Coronary ischemia and percutaneous intervention

The interventional treatment of ischemia is a complex issue grounded on an understanding of basic pathophysiology, but translated and implemented in practice by extensive clinical trial data representing patients with a spectrum of ischemia-causing clinical syndromes and anatomical variations of coronary artery disease (CAD). Percutaneous coronary intervention (PCI) has evolved to treat ischemia within this matrix of clinical and anatomical subsets using a wide array of techniques. Initial techniques using balloon angioplasty were promising, but demonstrated significant rates of restenosis due to negative arterial remodeling. The advent of stent technology prevented arterial recoil and provided a viable treatment for flow-limiting coronary dissections, thereby facilitating improved long-term patency of coronary vessels without the need for repeat revascularization. In-stent restenosis has been successfully addressed with drug elution, but late stent thrombosis has emerged as a complex issue involving dual antiplatelet therapy, patient compliance, and reexamination of the delicate balance between reducing restenosis and promoting endothelial proliferation. Finally, complex coronary lesions associated with heavy calcification or extensive plaque/thrombus burden that introduce unique challenges in obtaining ideal angiographic results have led to the development of new debulking devices aimed at optimizing procedural outcomes. This review will describe a variety of percutaneous coronary interventional techniques and technologies that are employed in the invasive treatment of ischemia under the guidance of clinical guidelines and evidence-based medicine.