Treatment

Angioplasty and Stenting

Inside the cardiac catheterization lab, specialists use advanced imaging to visualize coronary arteries

Percutaneous coronary intervention — commonly known as coronary angioplasty and stenting — is a catheter-based procedure that restores blood flow through narrowed or blocked coronary arteries caused by atherosclerotic plaque. Performed under local anaesthesia through wrist (radial) or groin (femoral) access, PCI avoids open-chest surgery and enables rapid recovery. It is used to treat stable angina, acute coronary syndromes (NSTEMI and unstable angina), and as emergency primary PCI for STEMI — where rapid restoration of coronary flow directly reduces mortality and preserves heart muscle.

The PCI Procedure

A thin catheter is advanced under fluoroscopic guidance from the access site to the blocked coronary artery. A guidewire crosses the stenosis, followed by a balloon catheter that inflates to dilate the narrowing — a process called balloon angioplasty. A drug-eluting stent (DES) — a metal mesh scaffold coated with antiproliferative medication — is then deployed at the lesion site to maintain vessel patency and prevent elastic recoil. DES significantly reduces the risk of in-stent restenosis compared to bare metal stents and is the standard device for most coronary lesions. Radial artery access (via the wrist) is the preferred approach — associated with lower bleeding risk, earlier ambulation, and improved patient comfort compared to femoral access.

Intracoronary Imaging & Physiological Assessment

Optimal PCI outcomes require precise lesion assessment and stent deployment verification. Fractional flow reserve (FFR) — a pressure wire measurement across a stenosis — determines haemodynamic significance before stenting, ensuring only flow-limiting lesions are treated. Intravascular ultrasound (IVUS) provides cross-sectional imaging of plaque distribution and vessel dimensions, guiding stent sizing and deployment. Optical coherence tomography (OCT) — a higher-resolution intracoronary imaging modality — identifies stent underexpansion, malapposition, and edge dissection with precision not achievable with IVUS, enabling stent optimisation that reduces long-term adverse events. Use of intracoronary imaging is associated with improved clinical outcomes compared to angiography-guided PCI alone.

Complex PCI Techniques

Rotational atherectomy uses a high-speed diamond-coated burr to debulk heavily calcified plaque — preparing the vessel for adequate stent expansion in lesions that balloon angioplasty alone cannot effectively dilate. Intravascular lithotripsy (IVL) is a newer calcium-modifying technique using sonic pressure waves to fracture calcified plaque prior to stenting. Bifurcation PCI addresses lesions at coronary branch points using dedicated techniques including provisional single-stenting or two-stent strategies depending on side branch anatomy. Chronic total occlusion (CTO) PCI opens completely occluded coronary arteries using specialised guidewire and microcatheter techniques, restoring perfusion to viable but hibernating myocardium.

Primary PCI for STEMI

Primary PCI is the treatment of choice for ST-elevation myocardial infarction (STEMI) — emergency balloon angioplasty and stenting to restore coronary flow as rapidly as possible following complete arterial occlusion. Every minute of delay increases irreversible myocardial damage. Door-to-balloon time — the interval from hospital arrival to coronary reperfusion — is the key performance benchmark, with targets of below 90 minutes in guidelines. Primary PCI achieves superior outcomes to thrombolysis in reducing mortality, recurrent infarction, and stroke when performed promptly at an experienced centre.

PCI vs. CABG — Choosing the Right Revascularisation Strategy

The choice between PCI and coronary artery bypass grafting (CABG) is determined by coronary anatomy complexity, number of diseased vessels, left ventricular function, diabetes status, and patient preference — guided by Heart Team discussion. SYNTAX score quantifies coronary anatomy complexity: low SYNTAX scores favour PCI; intermediate and high scores generally favour CABG, particularly in diabetic patients with multi-vessel disease. Left main coronary stenosis may be treated by PCI or CABG depending on anatomical complexity — an evolving area with landmark evidence from the EXCEL and NOBLE trials informing current practice.

After PCI — Medications & Follow-Up

Dual antiplatelet therapy (DAPT) — combining aspirin with a P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel) — is mandatory after drug-eluting stent implantation to prevent stent thrombosis. Standard DAPT duration is 6–12 months for stable CAD and up to 12 months following ACS, with duration adjusted based on bleeding risk, ischaemic risk, and clinical context. Long-term aspirin and high-intensity statin therapy continue indefinitely. Post-PCI surveillance with stress testing or CTCA is performed as clinically indicated to monitor for restenosis or disease progression.

Diagnosed with coronary artery disease, angina, or referred for coronary intervention in Singapore? Dr. Peter Chang consults at Paragon Medical Centre, Orchard Road. Book a specialist assessment today.