Immediate and short-term results of a 1988-1989 coronary angioplasty registry

To determine the relevance of recent refinements in angioplasty technology to our particular practice, the records of 507 consecutive patients undergoing a first percutaneous transluminal coronary angioplasty (PTCA) at our center between October 1988 and May 1989 were reviewed. At the time of PTCA, 41% of these patients had class IV angina and 44% were identified as having multivessel disease. Dilatation was attempted in 734 lesions (mean 1.5 per patient), of which 95 (13%) were chronic total occlusions. Overall, 69% of the 734 lesions were judged anatomically complex, and, in dilating these lesions, a rail-type device was used almost exclusively. Successful dilatation was achieved in 659 of the 734 (90%) attempted lesions. There were low incidences of the major complications of death (0.4%), myocardial infarction (1.8%) and emergency bypass surgery (1.8%). Acute rethrombosis occurred in 54 patients (11%). In these patients, initial strategy of repeat dilatation was successful in 38 of 47 patients (81%). Overall, primary clinical success at PTCA was achieved in 480 patients (95%). At a mean follow-up of 7.5 +/- 1.5 months in 497 of the study patients, the event-free rate (freedom from cardiac death, myocardial infarction, repeat PTCA or coronary bypass surgery or recurrence of severe [class III to IV] angina) was 71%. In conclusion, despite the often complex coronary disease in patients currently presenting to our center, a high initial success rate and acceptable short-term outcome of PTCA was achieved.     

Utility of routine functional testing after percutaneous transluminal coronary angioplasty: results from the ROSETTA registry

BACKGROUND: There is little consensus regarding the use of functional testing after percutaneous transluminal coronary angioplasty (PTCA). Some physicians employ a routine functional testing strategy, and others employ a symptom-driven strategy. OBJECTIVE: To examine the effects of routine post-PTCA functional testing on the use of follow-up cardiac procedures and clinical events. METHODS: The Routine versus Selective Exercise Treadmill Testing after Angioplasty (ROSETTA) Registry is a prospective multicenter observational study examining the use of functional testing after PTCA. A total of 788 patients (pts) were enrolled in the ROSETTA Registry at 13 clinical centers in 5 countries. The frequencies of functional testing, cardiac procedures and clinical events were examined during the first 6 months following a successful PTCA. RESULTS: Patients were predominantly elderly men (mean age, 61+/-11 years; 76% male) who underwent single-vessel PTCA (85%) with stent implantation (58%). During the 6-month follow-up, a total of 237 pts were observed to undergo a routine functional testing strategy (100% having functional testing for routine follow-up), while 551 pts underwent a selective (or clinically-driven) strategy (73% having no functional testing and 27% having functional testing for a clinical indication). Patients in the routine testing group underwent a total of 344 functional tests compared with 165 tests performed in the selective testing group (mean, 1.45 tests/patient versus 0.3 tests/patient; p<0.0001). There was little difference in the rates of follow-up cardiac procedures among the pts undergoing the routine and selective testing strategies [cardiac catheterization, 13.9% versus 17.5% (p=NS); percutaneous coronary intervention (PCI), 8.4% versus 8.7% (p=NS); coronary artery bypass graft surgery, 2.1% versus 3.3% (p=NS)]. However, clinical events were less common among pts who underwent routine functional testing, e.g., unstable angina (6.1% versus 14.4%; p=0.001), myocardial infarction (0.4% versus 1.6%; p=NS), death (0% versus 2.2%; p=0.02) and composite clinical events (6.3% versus 16.3%; p<0.0001). After controlling for baseline clinical and procedural differences, routine functional testing had a persistent independent association with a reduction in the composite clinical event rate (odds ratio, 0.45; 95% confidence interval, 0.24-0.81; p=0.008). CONCLUSION: Routine functional testing after PTCA is associated with a reduction in the frequency of follow-up clinical events. This association may be attributable to the early identification and treatment of pts at risk for follow-up events, or it may be due to clinical differences between pts who are referred for routine and selective functional testing.     

Immediate sheath removal after PCI using a Femostop is feasible and safe. Results of a registry

BACKGROUND: Due to antithrombotic therapy before, during, and after percutaneous coronary intervention (PCI), and due sometimes to the need for an urgent reintervention, the arterial femoral sheath is generally not removed immediately after PCI, unless a vascular closing device is used. This strategy causes discomfort to the patient, increases the workload for the nursing staff, and bears a risk of local complications. OBJECTIVE: The purpose of this registry is to demonstrate that immediate sheath removal after PCI is safe and feasible with the ultimate goal of enhancing patient care and hospital efficiency. METHODS: In patients undergoing PCI, the femoral arterial sheath was removed immediately after PCI in the cath lab, using a Femostop, without manual compression. The patient's discomfort and the complication rate were measured. The overall time given to haemostasis was assessed. RESULTS: A total of 339 patients were included. Patient discomfort during Femostop placement was assessed as follows: 85% suffered none, 2% slight, 3% moderate, and 10% severe discomfort. Complication rates were: 36% ecchimosis, 10% haematoma < 6 cm, 5% haematoma > or = 6 cm (literature data of manual compression--LDMC--5.1% to 9%), 1% pseudoaneurysm (LDMC 1% to 1.8%), 0.6% need for transfusion (LDMC 2.5%), 0.3% need for vascular repair (LDMC 1.5% to 2.7%). The patient's immobilisation time after PCI was reduced from at least 10 hours to 6 hours. The time given to haemostasis was also reduced. CONCLUSION: Immediate sheath removal using a Femostop is feasible, safe, and improves the patient's comfort. The complication rate is equal or even lower to that reported after classical manual compression. Early ambulation improves the patient's comfort, and reduced time given to haemostasis causes organisational benefit. If a vascular closing device is not routinely used after PCI (for example, for economical reasons), immediate sheath removal after PCI could be the routine strategy.     

Immediate protamine administration and sheath removal following percutaneous coronary intervention: a prospective study of 429 patients.

We tested the approach of reversing anticoagulation following PCI and immediate sheath removal in 429 consecutive patients. On completion of the PCI, protamine was administered, and the vascular sheath was immediately removed. Stents were used in 364 patients (85%) and GP IIb/IIIa inhibitors were used in 52 patients (12%). Time to achieve hemostasis was 30 +/- 17 min. Minor groin bleeding occurred in six patients. One patient required repair of femoral pseudoaneurysm. Mean creatine kinase at 8 and 16 hr post-PCI were 129 +/- 35 and 145 +/- 32 units, respectively. Creatine kinase rose to > 3 times normal in 12 out of 350 patients (3.4%). Prior to 48 hr, eight patients (1.9%) required emergency PCI or coronary bypass surgery. Follow-up at 30 days observed no deaths and only three target vessel revascularizations (0.7%). In conclusion, immediate reversal of anticoagulation and sheath removal after PCI is safe and feasible.     

Emergency coronary artery bypass surgery following coronary angioplasty and stenting: Results of a French multicenter registry

This study investigates the influence of coronary stenting on the risk of emergency bypass surgery performed within 24 hr of percutaneous tranluminal coronary angioplasty (PTCA) with particular concern for incidence and indication. Since 1995, coronary stenting has been increasingly performed in France during angioplasty procedures, altering significantly the role of emergency bypass surgery. The outcome of elective stenting and widespread use of coronary stenting and its influence on emergency surgery have not been evaluated so far. Through a retrospective (1995) and prospective (1996) registry, we analyzed the incidence, indication and results of emergency bypass surgery performed within 24 hr of PTCA in 68 and 57 centers, respectively, accounting for nearly half of all angioplasty procedures in France. Data were collected through questionnaires consisting of separate forms for every case report that were sent to every center. Over the two years, 26,885 and 27,497 procedures were investigated with a stenting rate of 46% and 64%, respectively. The observed need for emergency surgery was constantly low throughout this period (0.38% and 0.32%, respectively). Indications for surgery included complications directly due to stent in 37% of cases in the 2-year period. Outcome remained poor, with in-hospital mortality in 10% and 17% and myocardial infarction in 27% and 25% of cases, respectively. A comparison of the results in centers with and without surgical facilities showed no differences in outcome, despite a longer time to surgery (359 min ± 406 min vs. 170 min ± 205 min, P = 0.0001) and a lower incidence of emergency surgery (0.25% vs. 0.44%, P = 0.0001) in centers without on-site surgery backup. The French multicenter registry reveals an increase in the use of stents together with a dramatic decrease in the incidence of emergency bypass surgery (below 0.5 %) following PTCA. There has been a significant evolution in the indication, and stent implantation now accounts for a third of the indications for emergency bypass surgery. Cathet. Cardiovasc. Intervent. 48:441–448, 1999. © 1999 Wiley-Liss, Inc.     

A randomized trial of a fixed high dose vs a weight-adjusted low dose of intravenous heparin during coronary angioplasty

AIMS: Prospectively to compare success rate and complications in percutaneoustransluminal coronary angioplasty using two doses of heparin. METHODS AND RESULTS: Four hundred patients undergoing coronary angioplasty were randomlyassigned to receive 15 000 IU (group A) or 100 IU. kg ^–1(group B) of heparin. The angioplasty success rate was 95% inboth groups. Stents were placed in 28·5% and 26·5%of patients in groups A and B, respectively (P=0·73).The primary endpoint (freedom from death, myocardial infarction,unplanned revascularization or bailout stenting) occurred in91% vs 95% of patients in groups A and B, respectively (oddsratio: 1·88, 95% CI: 0·80—4·50, P=0·12).Haemoglobin loss was 0·36 ± 1 and 0·27± 0·9 g. dl ^–1 in groups A and B, respectively(P=0·37). The time to sheath removal (735 ± 265vs 558 ± 246 min) and the time to transfer to a stepdownunit (12·7 ± 4·5 vs 9·8 ±4·2 h) were longer in groups A (P=0·0001 for bothcomparisons). CONCLUSION: A weight-adjusted low dose of intravenous heparin is at leastas safe as a fixed high dose for coronary angioplasty. It allowsearlier sheath removal and discharge to a stepdown unit.     

Randomized prospective evaluation of prolonged versus abbreviated intravenous heparin therapy after coronary angioplasty

Objectives. This study was designed to prospectively evaluate the routine use of continuous heparin therapy after successful uncomplicated coronary angioplasty.Background. The use of such therapy varies among institutions and may increase the incidence of complications. Evaluation of the risks and benefits of abbreviated heparin therapy combined with early sheath removal after coronary angioplasty is necessary to determine optimal postprocedure care.Methods. We prospectively studied 284 patients who were scheduled for elective coronary angioplasty. Historical, clinical, physiologic and angiographic data were gathered. All patients received an initial bolus of heparin and then were randomized during the procedure to receive either no additional heparin therapy or an adjusted 24-h infusion. On the basis of specific criteria, additional heparin was not withheld if procedural results suggested an increased risk for complications.Results. Two hundred thirty-eight patients completed the study; 46 others were excluded in the catheterization laboratory because of unfavorable procedural results. The patients with abbreviated (n = 118) and 24-h (n = 120) therapy did not differ with respect to demographic and angiographic findings. However, the former had fewer bleeding complications (0% vs. 7%, p < 0.001) and were discharged earlier (mean ± SD 23 ± 11 h vs. 42 ± 24 h, p < 0.001). One patient in this group had a major complication shortly after angioplasty. The mean savings in hospital charges in the abbreviated therapy group was $1,370 ($6,093 ± $1,772 vs. $7,463 +- $1,782, p < 0.081).Conclusions. Omission of routine heparin therapy after successful coronary angioplasty reduces bleeding complications without increasing patient risk. Earlier discharge and significant cost savings are possible under proper conditions.     

Cardiopulmonary bypass support of high risk coronary angioplasty patients: registry results

Coronary angioplasty has been increasingly utilized in patients with extensive coronary disease, severe and acute chest pain syndromes, and poor ventricular function. This process has been facilitated in part by use of circulatory support, including perfusion balloons, intraaortic balloon pumps and cardiopulmonary bypass support systems. Percutaneous cannulation has facilitated elective and emergency application of cardiopulmonary bypass support in patients undergoing high risk coronary angioplasty. A National Registry of 25 centers has accumulated data on 801 elective and 210 emergency support angioplasty patients. Standby cardiopulmonary bypass support of elective high risk patients was associated with fewer complications and less in-hospital mortality in patients other than those with left ventricular ejection fraction < or = 20% and possibly older high risk patients. In elective cases, circulatory support was required in only approximately 7% of high risk patients, although need appeared to be unpredictable. Emergency use of cardiopulmonary bypass support, initiated < 20 minutes from the time of circulatory collapse, was associated with improved patient prognosis. Overall, patients undergoing circulatory cardiopulmonary bypass supported angioplasty had a marked reduction in anginal status, improvement in left ventricular ejection fraction and good (80%) 2-year survival. Although used only occasionally, circulatory support remains an important prophylactic interventional tool for the extremely high risk patient (left ventricular ejection fraction < or = 20%) and a lifesaving emergency technique for the occasional patient with circulatory collapse.     

Improved anticoagulation with a weight-adjusted heparin nomogram in patients with acute coronary syndromes: A randomized trial

The optimal heparin dosing schedule to achieve rapid and therapeutic anticoagulation has not been established. The objective of this study is to determine whether an intravenous heparin dosing nomogram based on body weight achieves adequate anticoagulation more rapidly than a standard-care nomogram. Sixty-four patients requiring intravenous heparin treatment for acute coronary syndromes, but who did not receive thrombolytic therapy, were randomized to a standard-care nomogram in which heparin was given as a 5000 unit IV bolus followed by 1000 U/hr, or a weight adjusted nomogram in which heparin was given as an 80 U/ kg IV bolus and 18 U/kg/hr. Activated partial thromboplastin time (APTT) values were checked at 6,12,18, 24, and 48 hours and adjusted either by 100–200 U/hr (standard-care nomogram) or by 2–4 U/kg/hr (weight-based nomogram). Activated partial thromboplastin times were measured using a widely generalizable laboratory method. The primary goal was to achieve and maintain the APTT between 60 and 90 seconds. The median APTT values were higher in the weight adjusted group compared with the standard-care group at 6, 12, 18, 24, and 48 hours: 150 versus 83 (p=0.001), 100 versus 79 (p=0.09), 66 versus 61 (p=0.005), 63 versus 56 (p = 0.09), and 64 versus 56 (p=0.11). At 18 hours only 11% of patients in the weight-adjusted group had an APTT <61 compared with 26% in the standard-care nomogram (p=0.007). No major bleeding complications were noted in either group. A weight-adjusted heparin nomogram offers improved anticoagulation in the first 24 hours after heparin initiation compared with a standard-care nomogram in patients with acute coronary artery syndromes.     

6 months' results of coronary angioplasty after thrombolysis of myocardial infarction

Transluminal coronary angioplasty (TCA) has become the treatment of choice of residual stenosis after thrombolysis for myocardial infarction, but the long-term results of TCA are imperfectly evaluated. Seventy patients underwent TCA after thrombolysis on account of a significant (greater than 50 p. 100) residual stenosis of the artery responsible for the infarction. TCA was performed less than 6 hours after the onset of symptoms in 15 patients who had neither clinical nor electrocardiographic evidence of reperfusion; 4 of these patients were in a state of cardiogenic shock. In the remaining patients TCA was performed 1 to 10 days (mean 3.2 days) after thrombolysis. A primary success was obtained in 64 patients (91 p. 100). Two patients had emergency aorto-coronary bypass. During their stay in hospital, 5 patients presented with symptoms of reocclusion which in 4 of them occurred less than 24 hours after TAC, and 2 of these 4 patients had to be reoperated upon; 2 patients died suddenly. During a 6 to 18 months' follow-up period (mean 10.5 months), the infarction recurred in 3 patients; the recurrence took place during the 3rd month in 2 of them (1 had another thrombolysis and later TAC) and during the 6th month in the third one. At 6 months, 4 patients were suffering from exertion angina and 2 asymptomatic patients had a positive exercise test. Fifty-two control coronary arteriographies were performed at 6 months. Thirteen patients (25 p. 100) had an occluded artery which was clinically silent in 11; 39 patients had a patent artery with restenosis in 7.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of routine functional testing after percutaneous transluminal coronary angioplasty: results from the ROSETTA Registry

BACKGROUND: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for exercise testing suggest that only selected groups of high-risk patients should undergo routine functional testing after percutaneous transluminal coronary angioplasty (PTCA) for the detection of restenosis. OBJECTIVES: Our purpose was (1) to document the patterns of use of post-PTCA functional testing and (2) to determine whether the choice of functional testing strategy is related to clinical characteristics of patients or whether physicians use a similar strategy for all their patients. METHODS: The Routine Versus Selective Exercise Treadmill Testing After Angioplasty (ROSETTA) Registry is a prospective study examining the use of functional testing among 788 patients at 13 centers in 5 countries. RESULTS: During the 6-month period after a successful PTCA, 49% of patients underwent functional testing (range among centers 10%-81%). Among patients who underwent functional testing, 39% had a clinical indication and 61% had functional testing as a routine follow-up. The first functional test was performed a median of 7 weeks after PTCA, with 13% of patients having second tests at a median of 14 weeks and 4% having additional tests at a median of 20 weeks. Univariate and multivariate analyses demonstrated that the chief determinant of the use of routine functional testing was clinical center. Aside from age (P <.0001), no baseline clinical or procedural characteristics were consistently associated with the use of routine functional testing after PTCA. CONCLUSIONS: Physicians do not appear to be adhering to the ACC/AHA guidelines for exercise testing regarding the routine use of post-PTCA functional testing. None of the clinical characteristics identified by the ACC/AHA guidelines were associated with the routine use of post-PTCA functional testing, and the primary determinant of functional testing was the location of the center at which the patient had the PTCA.     

Femoral artery hemostasis after coronary angioplasty with moderate dose of heparin

Early retraction of the arterial introducer facilitates patient management after coronary angioplasty. Closure systems permit rapid haemostasis, but are costly and do not avoid all serious vascular complications. Moderate doses of heparin, used often at the moment, could allow immediate retraction of the introducer with rapid and safe haemostasis by manual compression. METHODS: We evaluated prospectively in 350 consecutive patients the safety and efficacy of immediate retraction of the 6F introducer after coronary angioplasty performed by the femoral route with a moderate dose of heparin (70 IU. kg-1). Only procedures during acute infarction or using abciximab electively were excluded. RESULTS: Retraction of the introducer was immediate in 340 patients (97%). The dose of heparin administered was 5300 +/- 800 IU and the compression time was 11 +/- 4 minutes. The activated clotting time at retraction of the introducer was 254 +/- 46 s. Six (1.7%) serious vascular complications (4 significant haematomas and 2 false aneurysms) were noted during the hospital phase. A single patient (0.6%) was transfused and no vascular surgical procedure was necessary. The average duration of stay after angioplasty was 2.6 +/- 2.2 days and 73% of patients left before 48 hours. CONCLUSION: Immediate retraction of the arterial introducer is possible with simple manual compression, after coronary angioplasty performed with a moderate dose of heparin.     

Emergency coronary surgery after transluminal angioplasty. Immediate results and long-term outcome of 100 operations]

The increasing application of percutaneous transluminal coronary angioplasty (PTCA) requires evaluation of emergency coronary artery surgery for complications of this procedure. In a consecutive series of 2,576 angioplasties performed between April 1980 and January 1990, 100 patients (82 men and 18 women, average age 54 +/- 10 years, 3.9%) underwent emergency coronary artery surgery because of complications. The artery involved was the left anterior descending artery in 81% of cases. The causal lesion was a dissection and/or thrombus in 95% of cases; 85% of patients were referred for surgery with acute myocardial infarction. The average delay before surgery was 110 +/- 15 minutes (interval between coronary occlusion and starting cardiopulmonary bypass) and 155 coronary grafts were implanted (1.5 per patient). The hospital mortality was 19%; the infarction rate was 57%. The left ventricular ejection fraction decreased from 63 +/- 10% (preoperatively) to 52 +/- 9% (postoperatively), p less than 0.001. Hospital mortality was significantly related to three factors, old age, unstable angina before PTCA, and cardiogenic shock or the necessity for external cardiac massage. In the subgroup of patients developing cardiogenic shock (n = 7) or requiring external cardiac massage during transfer to the operating theatre (n = 16) the mortality was 44%. Among the 81 survivors, the global 7 year survival rate was 96% (Kaplan-Meier) with 3 cardiac deaths, 2 other patients developing myocardial infarction and 4 undergoing repeat angioplasty. After an average follow-up of 55 +/- 38 months, 80% of patients are asymptomatic, 34% have no antianginal drugs and 73% of those who were previously employed have returned to work.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary angioplasty of multivessel coronary diseases. Apropos of 1664 procedures. Immediate results and results following 6 months]

Between 1980 and 1990, 1,664 coronary angioplasty procedures were performed in 1,307 patients (86.6% male) with multivessel disease. The average age was 57 +/- 3 years (range 29 to 83 years). There was a previous history of infarction in 40.1% of patients and 22.4% of the procedures were performed for unstable angina. Catheter and 58.2%, 1,220 double vessel and 444 triple vessel diseases. A total of 2,509 lesions were dilated (1.5 stenoses/patient). The primary success rate was 81.9% with 3.2% of infarcts and 3.5% emergency bypass procedures and a global mortality of 2%. The factors responsible for death in the acute and hospital phases were unstable angina, age > 70 years, and ejection fraction < 35%. Complete revascularisation was achieved in 14.3% of cases: the only predictive factor for complete revascularisation on multivariate analysis was double vessel disease. A 6 months clinical and angiographic control was obtained for 83.8% of controllable procedures (965 dilatations). The restenosis rate was 47.9%. Univariate analysis of the factors of restenosis identified clinical parameters (age > 58 years, triple vessel disease, diabetes and unstable angina), parameters related to the lesion (length of stenosis > 1 cm, percentage stenosis > 80%) and to the procedure (residual stenosis > 20%): 68.4% of patients with restenosis underwent repeat angioplasty with a significantly superior primary success rate 88.7% vs 81.9% of global successes (p < 0.001). With a 82% primary success rate with few major complications, coronary angioplasty is a safe and effective therapeutic alternative. The extent of the lesions and the presence of chronic occlusion are the main limitating factors of revascularisation.(ABSTRACT TRUNCATED AT 250 WORDS)     

The 6Fr Angio-Seal arterial closure device: results from a multimember prospective registry

Femoral closure devices help early ambulation after cardiac catheterization without incurring additional risk to the patients. This report summarizes the safety and efficacy data of the 6Fr Angio-Seal device.     

Two hour ambulation after coronary angioplasty and stenting with 6 F guiding catheters and low dose heparin

OBJECTIVE: To evaluate the feasibility and safety of ambulation of patients two hours after elective coronary angioplasty or stenting, or both. METHODS: Coronary angioplasty and stenting were performed using 6 F guiding catheters by the femoral approach and a standard dose of heparin 5000 IU. There were no angiographic exclusion criteria except for planned atherectomy. Patients given oral anticoagulants or heparin were not eligible. All patients were given aspirin. Patients who underwent stent implantation also received ticlopidine 250 mg daily. The arterial sheath was removed immediately after the procedure. Haemostasis was achieved by manual compression and maintained with an inguinal compression bandage. Early ambulation was attempted after two hours of supine bed rest following removal of the bandage. MAIN OUTCOME MEASURES: The incidence of bleeding at or during ambulation requiring compression and additional bed rest, and puncture site complications documented 48 hours after the procedure. RESULTS: 300 of 359 consecutive eligible patients were included for two hour ambulation. Stent implantation was performed in 32% of the procedures. The mean (SD) time to haemostasis was 9.6 (3.2) minutes. Bleeding at ambulation occurred in five patients (1.7%), and nine patients (3.0%) reached the secondary end point of haematoma > 5 x 5 cm at 48 hour follow up. All were treated conservatively without further sequelae. There was no late bleeding or vascular complications. Conclusion: Ambulation two hours after elective balloon angioplasty or stent implantation with 6 F guiding catheters by the femoral route and low dose heparin is feasible and safe, with a low incidence of puncture site complications. This early ambulation protocol facilitates a short hospital stay.     

Percutaneous transluminal coronary angioplasty after thrombolytic therapy: a prospective controlled randomized trial

In 162 patients with acute transmural myocardial infarction, combined intravenous and intracoronary thrombolytic therapy with streptokinase was initiated. In vessels that remained occluded, mechanical recanalization was performed with a 3F recanalization catheter (group I, n = 79) or a 4F Grüntzig balloon catheter (group II, n = 83). After reperfusion, intracoronary streptokinase was administered superselectively. After termination of streptokinase infusion, angioplasty was performed only in patients in group II. There was no difference between the groups in relation to sex, age, infarct location, creatine kinase levels and time between onset of symptoms and start of treatment. Initial coronary angiography showed an open vessel in 27 (34%) of 79 patients in group I and 21 (25%) of 83 patients in group II. The final reperfusion rate was 90% (71 of 79) in group I and 86% (71 of 83) in group II. Angioplasty was attempted in 69 of the 71 patients in group II with a success rate of 65% and an occlusion rate of 3%. During the hospital stay, reocclusion occurred in 14 (20%) of 71 patients in group I. After thrombolytic therapy, coronary luminal narrowing in group I was 75 +/- 17% in patients without and 87 +/- 6% in patients with reocclusion (p less than 0.05). In group II, reocclusion was found in 10 (14%) of 71 patients. After angioplasty, the degree of coronary stenosis in group II was reduced from 82 +/- 12 to 51 +/- 30% (p less than 0.001). Reocclusion was found in 3 (7%) of the 45 patients with successful angioplasty and in 7 (32%) of the 22 patients with unsuccessful angioplasty (p less than 0.01). Improvement in regional left ventricular function was observed only in patients from group II with anterior myocardial infarction. In conclusion, by combined medical and mechanical recanalization, the rate of coronary reperfusion can be increased and infarct time shortened, providing the possibility of full revascularization by angioplasty, with improvement of regional wall motion and reduction of the rate of reocclusion.     

Immediate and chronic results of cutting balloon angioplasty: A matched comparison with conventional angioplasty

Background: At the initial stages of percutaneous transluminal coronary angioplasty (PTCA), several studies reported on the feasibility of coronary artery incision and dilatation leading to the extension of the PTCA technique. Hypothesis: This study was designed to determine the immediate and chronic results of cutting balloon (CB) angioplasty. Methods: This procedure was performed on 127 lesions in 110 patients (male 83%, age 61.8 ± 9.3 years). Results: The overall procedural success rates for the CB were 93.7% (119 lesions) and 92.7% (102 patients), while solitary CB without pre- and/or postdilatation was 76.4% (91 lesions). There was one major in-hospital complication (Q-wave myocardial infarction, 0.9%), but there were no deaths or emergency coronary artery bypass graftings. Significant angiographic dissections (≥ grade C) occurred in four patients, and coronary perforation occurred in one. The successfully treated CB group (95 lesions) was matched with the successful conventional angioplasty group (PTCA group) for chronic result assessment in regard to reference vessel size and lesion characteristics. In the CB group, postprocedural minimal luminal diameters were significantly larger and the percentage of stenosis at the stenotic site was significantly lower compared with the PTCA group. Restenosis occurred in 22 lesions (23.1%). This showed a significantly lower restenosis rate compared with the PTCA group (42.1%). In addition, the restenosis rate of the CB without inclusion of the pre- and/or postdilatation-treated lesions was 19.7%. Conclusions: (1) Cutting balloon angioplasty procedures can be performed with high success rates with few major in-hospital events. (2) The restenosis rate in the CB group was significantly lower compared with the PTCA group.     

Immediate coronary angioplasty in the acute phase of myocardial infarction. French multicenter study: December 1983

Following the introduction of intracoronary thrombolysis in the acute phase of myocardial infarction (AMI), transcutaneous coronary angioplasty (TCA) was originally conceived as a logical complementary procedure to treat residual stenosis and so prevent the frequent post-thrombolysis reocclusion (20-30 p. 100 of cases). With increasing experience TCA of first intent appeared rational, more rapid and effective, ensuring coronary recanalisation (CR), suppression of residual stenosis and the prevention of reocclusion in the same procedure with with the objective of reducing the number of coronary bypass grafts (CBG) in patients with single vessel disease. A French multicentre study of 22 cases was organised by 9 centres. The average period between onset of symptoms and intervention was 2 hours 10 mins (range 30 mins-5 hours 30 mins). The average duration of the procedure was only 30 mins. 16 patients had anterior and 6 patients inferior AMI. Coronary angiography showed 12 occlusions (54.5 p. 100) and 10 sub-occlusions with 6 cases of delayed opacification. All patients had successful initial TCA with no major complications. The arterial occlusions decreased from 100 p. 100 to 31 p. 100 and the subocclusions from 94 to 12 p. 100. 2 patients died in the hospital period, one at the 48th hour of controlateral AMI and the other one at the 5th day of reocclusion. Three patients developed reocclusion at the site of the original TCA. Complete regression of ECG changes was observed in 31.8 p. 100 of cases. Complete recovery of normal left ventricular function was observed in 8 of the 17 patients who underwent follow-up investigations (47 p. 100 of cases).(ABSTRACT TRUNCATED AT 250 WORDS)     

One center's experience of coronary angioplasty with a 5 French catheter guide by a femoral approach at the same time as coronary angiography

The object of this study was to assess the feasibility of so-called ad hoc 5 F percutaneous transluminal coronary angioplasty (PTCA). This monocentric register included 200 consecutive procedures (233 lesions) of 5F PTCA by a femoral approach after a bolus of standard heparin (50 to 70 IU/kg). The population included 15.4% of stable angina, 29.4% of unstable angina, 11% acute phase, 13.5% post-revascularisation angina and 30.7% post-infarction cases. A successful procedure was defined as a good angiographic result without ischaemic complications. A failed 5F procedure was defined by the need to fall back on a 6F PTCA. The peripheral vascular complications were recorded. The lesions were stented in 77.4% of cases including 13.4% of direct stenting. There were 200 successful procedures (87%). The failures (N = 26) were mainly explained by the inability to cross chronic obstruction (N = 11). The ischaemic complications included 2 coronary bypasses (2 retrograde dissections of the left anterior descending artery) and 7 enzymatic increases without ECG changes. Fall back to 6F PTCA was required in 4 cases (1.7%) always because of the instability of the 5F catheter guide before the procedure. The quality of coronary contrast was estimated to be good. The vascular complication rate was low with 2% of communicating haematomas (N = 4). Therefore, 5F PTCA is feasible with failure and complication rates comparable to those reported with catheters of larger dimensions. One of its principal advantages is "ad hoc" angioplasty after 5F coronary angiography.