Coronary Angioplasty or Percutaneous Coronary Intervention (PCI)

PCI is performed to treat coronary artery disease. Your Cardiologist has weighed out the benefits and risks of the procedure and determined that there is a net benefit of you undergoing PCI.

Although percutaneous coronary intervention is generally a very safe procedure, complications can very occasionally arise. Major complications include: • Stroke (very rare). During the procedure, blood clots can travel to the brain to cause either temporary or permanent disability • Death (very rare). The risk of death from undergoing non-emergency PCI is extremely low. • Heart attack. PCI involves manipulation of coronary arteries and there is a very small risk that injury (perforation, dissection) can be caused to the arteries during the procedure. This can lead to heart attack and damage to the heart muscle. Complications as a result of this injury requiring emergent heart surgery to correct this is very rare. Also very rarely, a tube (drain) may be inserted emergently to the sac around the heart (pericardium) to drain off blood as a result of injury to the coronary vessels. • Major bleeding. During the procedure, blood thinners will be given to prevent blood clots. However, uncommonly, complications like major bleeding in the brain, abdomen or puncture site may occur. Medicine antidotes are available to reverse or stop major bleeds. • Heart rhythm abnormalities (arrhythmias) requiring cardioversion. Very uncommonly, life-threatening arrhythmias may occur as a result of injection of dye into the coronary arteries or during manipulation of the coronary arteries. Normal rhythm of the heart will immediately be restored via a brief electrical current to the heart (electrical cardioversion) Minor complications • Bleeding and bruise around puncture site (<5%) • Allergic reaction to contrast (minimal risk) • Major bleeding and bruising (<1%) • Injuries to blood vessels at puncture site (pseudo-aneurysm, dissection etc) <1%

You must fast (nothing to eat or drink) for at least 6 hours prior to the procedure. For diabetics: • Please do not take your diabetic medications in the morning of your procedure. • Please do not take metformin for 48hrs after the procedure.

• The cath lab is a specialised X-ray suite where your coronary angiogram is performed by your Interventional Cardiologist, assisted by specialized cardiac scrub nurses. • You may occasionally be given a sedative, either orally or through an intravenous line just before the procedure to help you relax. You will however still be awake during your procedure. • The puncture site (your wrist and/or groin) will be cleaned with an antiseptic solution and thereafter, a sterile drape will be used to cover you. • Your Interventional Cardiologist will inject local anaesthetic around the puncture site (wrist or groin). This puncture site is where catheters (long tube) will be inserted via a small tubing (sheath) after a small cut in the skin. • The catheter will be passed to the coronaries in your heart via arteries in the arm, or via the aorta if the groin approach is taken. • If your artery in your arm is considered to be small or tortuous, there is a chance that the groin approach will be taken rather than using the wrist as an access. In this situation, groin approach would be then converted from radial approach. • It is generally a painless procedure, but you may feel some discomfort in your arm while the catheters pass through. • You will also notice that the X-ray machines be rotating around you during the procedure. This is to ensure the appropriate coronary images are taken during the study. • When your Interventional Cardiologist positions the catheter at the origin of your coronary arteries, contrast (dye) will be injected into your arteries to identify the narrowings or blockages. • A very thin and long wire (guidewire) will be inserted through the catheter across the narrowings or blockages in the coronary artery in question. Very small balloons and/or stents will be delivered via the guidewire to treat the narrowings and blockages. • You may feel some chest discomfort or shortness of breath when the balloons are inflated or when the stents are implanted as this technique will cause a temporary cessation of blood in your coronary artery. • A special device (Rotational atherectomy) is occasionally required to treat hardened and calcified narrowings and blockages. It will produce a distinct “spinning” noise when the device is being used. • Occasionally, when necessary, your Interventional Cardiologist may deliver imaging devices into the coronary artery via the guidewire to obtain accurate information of the artery in question or ensure optimal results after treating the narrowings and blockages.

• The nurse caring for you will instruct you to rest in bed for up to 4hrs, depending on whether the wrist or the groin is used as the puncture site. • Your nurse will also monitor your blood pressure, heart rate and puncture site for bleeding closely. • You will be monitored closely for any chest discomfort or shortness of breath that may arise post procedure. • You will likely be advised to stay overnight for observation and your heart rhythm being monitored closely. • Your doctor may discharge you the next day when there are no further issues. • Do make prior arrangements for someone to send you home especially if you have been given sedatives. Please do not drive for the next 24hrs post procedure if you have been given sedatives.

• You are encouraged to drink lots of fluids. • Please rest with minimal walking if the groin procedure was done. Use your arm minimally with minimum wrist flexion for the next 24-48hrs if you have a wrist puncture. • You are discouraged from lifting heavy weights for 7 days after procedure. • You can remove the plastic bandage dressing the day after the procedure. • Please make an appointment to see either your Cardiologist or General Practitioner 1 week after your procedure to check on your puncture site. • Please take note: • If you notice that your puncture site (groin or wrist) becomes painful and develops a large lump, you are advised to lie down immediately and apply pressure on the puncture site with the help of someone. • Please seek medical attention (calling an ambulance or proceed to nearest hospital) immediately as this could be bleeding from your artery.

There are currently three type of stents in the market, and you are likely to receive one of them. • Bare Metal Stents (BMS) are non-drug coated stents. • Drug Eluting Stents (DES) are drug-eluting stents • Bioresorbable Vascular Scaffolds (BVS) • The type of the stent used will determine the duration of your blood thinning medications (aspirin, ticlodipine clopidogrel, ticagrelor or prasugrel). • Over a period of time, the coronary vessel tissue will grow over the stent and the stent will be part of your artery. This is part of the healing process. However, if there is excessive growth of tissue around the stent, this will lead to narrowing or blockages of the stent (also known as restenosis). This may require another repeat coronary angioplasty to treat this condition. This condition occurs in about 10-20% of the patients that receive BMS. • This is a lesser issue with DES as it has been engineered to counter this problem. DES is known as the 2nd generation of coronary stents. It serves a similar function as the BMS except that its surface is coated with a drug to inhibit the excessive growth of smooth muscle cell. The drug that elutes from the DES will, therefore, reduce the incidence of restenosis to 5% of patients. However, because the healing process of the coronary artery has been slowed down, this increases the chance of clot formation inside the DES (stent thrombosis). Therefore if you have received a DES, you will be required to take a combination of blood thinners for at least twelve months to reduce the chance of stent thrombosis, compared to one month only if you have a BMS implanted. • A BVS has similar drug eluting properties as a DES, except that it is a not a metallic stent, but made up of a synthetic polymer that biodegrade (or dissolve) after two years, leaving nothing behind in the area of the coronary artery that was initially treated by this particular device. It may eliminate the risks associated with a permanent implant (BMS or DES). However, it may not be suitable for certain patients with vessels that have difficult anatomy. • The decision to implant certain type of stents will be determine by your Interventional Cardiologist, depending on your condition and situation.