| Patient risk: expected clinical risk in case of occlusion caused by procedure |
High patient risk: Patients with any of the following:
- Decompensated congestive heart failure (Killip Class 3) without evidence for active ischemia, recent CVA, advanced malignancy, known clotting disorders
- LVEF <25 percent
- Left main stenosis (≥50 percent diameter) or 3-vessel disease unprotected by prior bypass surgery (>70 percent stenoses in the proximal segment of all major epicardial coronary arteries)
- Single-target lesion that jeopardizes >50 percent of remaining viable myocardium
|
| Lesion risk: probability that procedure will cause acute vessel occlusion |
Increased lesion risk: lesions in open vessels with any of the following characteristics:
- Diffuse disease (>2 cm in length) and excessive tortuosity of proximal segments
- More than moderate calcification of a stenosis or proximal segment
- Location in an extremely angulated segment (>90 percent)
- Inability to protect major side branches
- Degenerated older vein grafts with friable lesions
- Substantial thrombus in the vessel or at the lesion site
- Any other feature that may, in the operator's judgment, impede successful stent deployment
Aggressive measures to open CTOs are also discouraged because of an increased risk of perforation |
| Strategy for surgical backup based on lesion and patient risk: |
- High-risk patients with high-risk lesions should not undergo nonemergency PCI at a facility without on-site surgery
- High-risk patients with non-high-risk lesions: Nonemergency patients with this profile may undergo PCI, but confirmation that a cardiac surgeon and operating room are immediately available is necessary
- Non-high-risk patients with high-risk lesions require no additional precautions
- Non-high-risk patients with non-high-risk lesions require no additional precautions. Best scenario for PCI without on-site surgery.
|
