Reperfusion through balloon catheter to minimize myocardial infarction during the interval between failed percutaneous transluminal coronary angioplasty and emergency coronary artery bypass grafting

Summary A 65-year-old man was admitted with chest pain. A diagnosis of spastic angina was made because of symptoms of recurrent anginal attacks associated with ST-segment elevations in the electrocardiogram. A selective coronary arteriogram revealed a 90% diameter narrowing of the proximal left anterior descending coronary artery (LAD). No angiographically visible collaterals from the right coronary artery to the LAD were observed. The ventriculogram showed normal contraction of the left ventricle with an ejection fraction of 65%. Percutaneous transluminal coronary angioplasty (PTCA) failed resulting in total occlusion of the stenosis. Repeat PTCA at a higher pressure and of longer duration failed to redilate the artery. Reperfusion with the blood from the femoral artery through the balloon catheter, which was used for the PTCA, was carried out until coronary artery bypass grafting (CABG). Blood flow rate of perfusion was approximately 25 ml/min. Reperfusion through the balloon catheter reduced chest pain and ST-segment elevations in the electrocardiogram. The patient tolerated the operative procedure well and his post-operative course was uncomplicated. The interval between the acute occlusion and revascularization by CABG was approximately 4 1/4 h. The ventriculogram taken 56 days after the CABG demonstrated normal contraction of the anterior wall of the left ventricle with an ejection fraction of 63%. Abnormal Q waves did not appear in precordial leads of the electrocardiogram after the surgery. The thallium scintigram showed no perfusion defects.In conclusion, this case suggested that autologous blood reperfusion through balloon cathether would be worth attempting in some cases for minimization of myocardial infarction during the interval between failed PTCA and emergency CABG.     

经皮冠状动脉内切割球囊成形术的临床应用

目的评价经皮冠状动脉内切割球囊成形术的临床疗效.方法使用切割球囊导管对20例冠心病患者(男18例、女2例,年龄53.4±6.3岁)的24支冠状动脉进行扩张.结果手术成功率为90%(18例),病变成功率为91.7%(22支).未出现死亡、急性Q波型心肌梗死和急性心包填塞等并发症.病变部位狭窄程度由术前的(85.6±7.3)%降至术后的(28.5±9.4)%.术后随访1～10个月,有3例复发心绞痛,其中1例经血管造影证实为再狭窄.结论切割球囊成形术是一种安全、有效的介入性治疗技术,其成功率高、并发症少.     

Acute closure during coronary excimer laser angioplasty and conventional balloon dilatation: a comparison of management outcome and prediction

Of 523 consecutive patients undergoing elective percutaneoustransluminal coronary angioplasty (PTCA) and 83 patients treatedwith coronary excimer laser angioplasty (ELCA), 17 (3.3%) hadin-laboratory occlusion following PTCA and 25 (30%)followingELCA; they were enrolled into a prospective study. Successfulmanagement (reopened vessel, patency at repeat angiography within24 h, no death, no myocardial infarction (MI), no emergencybypass surgery) including repeat lasing, subsequent PTCA, useof intracoronary nitroglycerin or streptokinase was achievedin 24 (96%) of the 25 patients with acute occlusion during ELCA.An anterior MI occurred in one patient of the laser group. Repeatballoon dilatation was successfully performed in seven of the17 patients (41%) with acute closure during PTCA. Among the10 patients with persistent occlusion after PTCA, five developeda limited myocardial infarction (35%). One patient requiredemergency CABG, and died peri-operatively. Severe spasm priorto occlusion defined by a new coronary flow depression withoutevidence of dissection or thrombus showed a significant positiveassociation with acute occlusion during ELCA (P =0.0008). Thus, in contrast to occlusion during PTCA, subsequent balloondilatation was successfully performed in the majority of patientswith acute occlusion during ELCA, implying that different underlyingmechanisms are responsible for this complication. In this limitedpatient group, occlusion after excimer laser angioplasty wasmuch more frequent than closure during PTCA, but was infrequentlyassociated with major events such as myocardial infarction ordeath.     

Diffuse spasm of a free gastroepiploic artery graft during percutaneous balloon angioplasty

Percutaneous transluminal balloon dilation of an 8-month-old free graft of the gastroepiploic artery was followed by diffuse and profound graft spasm. Because free arterial grafts are more prone to spasm, suitable precautions, such as administration of calcium channel antagonists, should be taken before attempting any interventions on these vessels. © Wiley-Liss, Inc.     

切割球囊血管成形术的作用机制及其在冠心病治疗中的应用

经皮腔内冠状动脉成形术后急性冠脉综合征和再狭窄等并发症是困扰冠心病介入治疗效果多年的难题 ,切割球囊血管扩张术是为解决这一难题出现的众多新技术中的一种。作者就切割球囊的结构、作用机制和临床应用等作一简要综述     

缺血预适应在经皮冠状动脉腔内成形术中的应用

对２６例冠心病患者随机分为预适应组（１４例）和对照组（１２例），分别观察经皮冠状动脉腔内成形术（ＰＴＣＡ）中心绞痛及心电图变化和术后心绞痛及运动心电图。结果显示：预适应组术中心绞痛积分和ＳＴ段抬高幅度均显著低于对照组（均Ｐ＜０．０５），心绞痛及ＳＴ段抬高出现时间均显著迟于对照组（均Ｐ＜０．０５）。术后随访６个月，预适应组心绞痛及运动心电图阳性例数显著低于对照组（均Ｐ＜０．０５）。表明缺血预适应不但可以减轻ＰＴＣＡ中心肌缺血的程度，而且也能降低术后心肌缺血的复发。     

Hugging balloon angioplasty of right coronary artery

We report a case of “hugging balloon” dilatation of a giant right coronary artery using two dilatation catheters, a balloon “on a wire” and a balloon “rapid exchange” systems via a single guiding catheter. The necessity of larger PTCA balloon catheter (>4.0 mm) was stressed.     

Physiological aspects of percutaneous transluminal coronary angioplasty

Summary Percutaneous transluminal coronary angioplasty (PTCA) can serve as a model for controlled coronary artery occlusion and reperfusion, which enable the dynamic physiological alterations related to PTCA to be assessed. In this review, physiologically related changes pertinent to PTCA in human subjects will be discussed.     

冠状动脉旋磨术及经皮冠状动脉成形术在复杂病变介入治疗中的应用

目的　探讨冠状动脉旋磨术 (Rotational atherectomy)及经皮腔内冠状动脉成形术 (Percutaneous translum i-nal coronary angioplasty PTCA)治疗复杂冠脉病变的临床效果。方法　对 15例患者的 2 0处病变行冠脉旋磨术及经皮腔内冠状动脉成形术 (PTCA)治疗 ,部分病例并在血管内超声指导下进行 ,观察其治疗的即刻成功率及并发症率。结果　 15例施行冠状动脉旋磨术的患者 ,旋磨头均成功地通过了病变 ,平均狭窄程度由 88.30 %± 7.5 4 %降至15 .6 0 %± 10 .75 %。其中 6 0 .0 0 %的病例选择了 1.5 mm的旋磨头 ,13.33%的病例使用了 2个旋磨头。全部病例均联合应用了 PTCA,13例在行旋磨术后置入冠脉内支架 (余下 2例为支架内再狭窄病例 )。 1例患者术中发生较严重的冠状动脉痉挛 ,经冠状动脉内给予硝酸甘油后缓解 ;2处 (10 .0 0 % )病变出现了 B型以上的内膜撕裂 ,出现缓慢血流现象发生率为 3.8%。无急诊冠状动脉搭桥及死亡病例。结论　冠状动脉旋磨术及 PTCA可选择性用于复杂冠状动脉病变 ,尤其是严重钙化病变 ,小血管长节段病变     

Preliminary experience with drug-coated balloon angioplasty in primary percutaneous coronary intervention

We evaluated the clinical feasibility of using drug-coated balloon (DCB) angioplasty in patients undergoing primary percutaneous coronary intervention (PPCI). Between January 2010 to September 2014, 89 ST-elevation myocardial infarction patients (83% male, mean age 59 ± 14 years) with a total of 89 coronary lesions were treated with DCB during PPCI. Clinical outcomes are reported at 30 d follow-up. Left anterior descending artery was the most common target vessel for PCI (37%). Twenty-eight percent of the patients had underlying diabetes mellitus. Mean left ventricular ejection fraction was 44% ± 11%. DCB-only PCI was the predominant approach (96%) with the remaining 4% of patients receiving bail-out stenting. Thrombolysis in Myocardial Infarction (TIMI) 3 flow was successfully restored in 98% of patients. An average of 1.2 ± 0.5 DCB were used per patient, with mean DCB diameter of 2.6 ± 0.5 mm and average length of 23.2 ± 10.2 mm. At 30-d follow-up, there were 4 deaths (4.5%). No patients experienced abrupt closure of the infarct-related artery and there was no reported target-lesion failure. Our preliminary experience showed that DCB angioplasty in PPCI was feasible and associated with a high rate of TIMI 3 flow and low 30-d ischaemic event.     

急诊冠脉介入治疗急性心肌梗塞的临床观察

目的：观察急诊冠脉介入治疗急性心肌梗塞（AMI）的安全性及有效性。方法：对42例AMI患者在发病0．5～12小时内行直接PTCA术，必要时联合临时心脏起搏技术及主动脉气囊反搏术，梗死相关血管（IRA）43支，TIMI血流0级：30例（71．4％），Ⅰ级：9例（21．4％），Ⅱ级：3例（7．2％）。结果：43支IRA中39支获得再通（90．9％），均达TIMI Ⅲ级血流，再通血管残余狭窄〈20％，5例合并左心功能不全（killip分级Ⅱ～Ⅲ级）及3例合并心源性休克患者，术后症状明显改善，1例死亡（2．5％）。术后6例（15％）直接PTCA成功患者心绞痛再发，再次PTCA后血管再通。结论：直接PTCA治疗AMI成功率高，病死率低，近期预后良好，是一种安全有效的治疗方法。     

急性心肌梗塞急诊PTCA后ST段改变及其临床意义

目的　对９５ 例急性心肌梗塞（ＡＭＩ）患者急诊经皮冠状动脉腔内成形术（ＰＴＣＡ）后３０ 分钟体表心电图ＳＴ 段改变进行分析，探讨此时ＳＴ 段改变与ＰＴＣＡ 效果、心肌损害程度及心功能预后的关系。方法　根据ＳＴ 段改变分三组。组Ⅰ：ＳＴ 段明显下降（≥５０％ ）组５５ 例，组Ⅱ：ＳＴ 段下降（＜ ５０％ ）组３２ 例，组Ⅲ：ＳＴ 段无变化或抬高者组８ 例。测定术后肌酸激酶（ＣＫ）的变化，同时测定术前及术后心功能。结果　组Ⅰ与组Ⅱ为ＰＴＣＡ 成功者，术后组ⅡＣＫ 明显高于组Ⅰ。术后４～６ 周组Ⅱ射血分数（ＥＦ％ ）明显低于组Ⅰ。结论　急性心肌梗塞患者ＰＴＣＡ 术后３０ 分钟体表心电图ＳＴ 段的改变能间接反映ＰＴ－ＣＡ 疗效。较准确早期了解心肌细胞灌注情况并判定预后     

Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty

Coronary angioplasty with 6F guiding catheters via the radial artery is associated with a minimal risk for major entry site-related complications. Although the incidence of radial artery occlusion (RAO) in the literature is approximately 30% after prolonged cannulations, little is known about the incidence and its clinical consequences of RAO following transradial percutaneous coronary angioplasty. In a prospective study, 563 patients with a normal Allen test were evaluated on patency and function of the radial artery after transradial angioplasty, by physical and ultrasound examination at discharge, and at 1 month follow-up. At discharge, 30 patients (5.3%) had clinical evidence of RAO. At follow-up, persistent RAO was found in 16 patients (2.8%). In this study we found a low incidence of RAO after transradial percutaneous coronary angioplasty. None of the patients with temporary or persistent RAO had any major clinical symptoms. Therefore, the occurrence of RAO can be considered a minor complication in patients with a previously good double blood supply to the hand. Cathet. Cardiovasc. Diagn. 40:156–158, 1997. © 1997 Wiley-Liss, Inc.     

Hugging perfusion balloon salvage of a right coronary artery angioplasty

A case is described in which hugging balloons, one a perfusion and the other a non-perfusion balloon, were used to salvage a failed coronary angioplasty. A discussion concerning balloon combinations, techniques, and therapeutic options is included. (This article is a U.S. Government work and, as such, is in the public domain in the United States of America.) © 1996 Wiley-Liss, Inc.     

Probe™ angioplasty of total coronary occlusion using the probing catheter™ technique

Coronary angioplasty (PTCA) of total coronary occlusion is limited by the inability of guidewires and conventional dilating catheters to cross all such lesions. A new technique was therefore prospectively evaluated for PTCA of these lesions using the ultra-low-profile Probe? “balloon on a wire” device. An intracoronary Probing Catheter? was used to facilitate crossing the stenosis with a guidewire and then to deliver a Probe? Into the obstruction for balloon dilatation. This technique was utilized in 64 consecutive patients with “absolute” coronary occlusions demonstrating no angiographically detectable antegrade coronary flow. Successful dilatation was achieved in 47 (73%). Among 33 occlusions of less than 3 mo duration 31 (94%) were successfully dilated whereas only 16 of 31 more chronic occlusions were dilated (P<.01). Chronic occlusions with a tapered morphology and those located more than 1 cm from a branch point were more frequently dilatable. There were no Serious complications including no vessel perforations with this technique. The Probing Catheter? technique offers a safe and effective method for the dilatation of recent coronary occlusions by using balloon on a wire technology.     

Evaluation of the long-term functional outcome assessed by myocardial perfusion scintigraphy following excimer laser angioplasty compared to balloon angioplasty in longer coronary lesions

Objectives: Evaluation of the long-term functional outcome assessed by exercise myocardial perfusion imaging following excimer laser angioplasty compared to balloon angioplasty in coronary lesions >10 mm in length. Background: Previous randomized studies evaluating the effect of coronary interventions mainly focused on the long-term clinical and angiographic outcome. The functional outcome, assessed by myocardial perfusion scintigraphy, has not been evaluated in a randomized setting. Methods: A total of 308 patients with stable angina and a longer coronary lesion (>10 mm) were randomized to excimer laser angioplasty or balloon angioplasty. A ^99mTechnetium-2-methoxy isobutyl isonitrile (MIBI) single-photon emission computed tomography (SPECT) study was performed in 139 patients before the initial angioplasty procedure and at 6 months follow-up (73 patients in the laser group versus 66 patients in the balloon group, respectively). Exercise tolerance at follow-up was compared to baseline values by means of exercise duration and double product at peak exercise. Myocardial perfusion of the randomized vascular bed was assessed semi-quantitatively on the MIBI SPECT images. The reversible defects were graded as mild, moderate or severe. Myocardial perfusion at follow-up was expressed as a percentage reduction in incidence and grading of the reversible defects compared to baseline values. Results: Forty-four (61%) patients assigned to laser angioplasty were asymptomatic at 6 months follow-up compared to 34 (52%) patients assigned to balloon angioplasty (p = NS). Improvement in exercise duration and double product were 0.7 ± 2.1 min and 4.3 ± 6.2 min/mmHg/1000, respectively, in the laser group, versus 0.3 ± 2.5 min and 3.1 ± 5.5 min/mmHg/1000, respectively, in the balloon group (both p = NS). The percentage reduction of reversible defects was 23% in patients assigned to laser angioplasty vs. 29% in patients assigned to balloon angioplasty (Relative risk [RR]: 0.79, 95% confidence interval [CI]: 0.40–1.57; p = 0.50). The mild, moderate and severe reversible defects improved in 44.4, 63.6 and 66.6%, respectively, in the laser angioplasty group vs. 66.6, 53.8 and 90%, respectively, in the balloon angioplasty group. None of the comparisons were significantly different. Conclusion: Excimer laser angioplasty compared to balloon angioplasty in coronary lesions >10 mm in length yields a similar long-term functional outcome assessed by anginal status, exercise tolerance and myocardial perfusion.     

Comparison of acute results of prophylactic intraaortic balloon pumping with cardiopulmonary support for percutaneous transluminal coronary angioplasty (PTCA)

High-risk patients not eligible for coronary artery bypass grafting (CABG) are being considered for percutaneous coronary interventions, using cardiopulmonary support (CPS) or intraaortic balloon pump (IABP). However, few data are available regarding case selection and outcome with various support devices. Over a 4-yr period, 149 patients underwent high-risk coronary angioplasty, using elective placement of support devices. Based on physician preference, 58 patients underwent CPS and 91 underwent IABP support prior to the angioplasty. Patients selected for CPS-assisted angioplasty were more likely to be males, and to have a history of chronic angina, congestive heart failure, and lower ejection fraction (26 ± 13% vs. 32 ± 14%, P = 0.01). Multivessel disease was present in 95% of CPS patients and 89% of IABP patients (P = 0.35). Multivessel angioplasty was performed more frequently in the CPS group (40% vs. 20%, P = 0.01), and angioplasty success was higher in the CPS groups (99% vs. 87%, P = 0.005). Major cardiac events such as myocardial infarction, bypass surgery, stroke, and death did not differ between the groups. Peripheral vascular complications such as hematomas (36% vs. 24%, P = 0.16), vascular repair (14% vs. 3%, P = 0.03), and transfusions (60% vs. 27%, P = 0.0001) were higher in the CPS group. In conclusion, despite a higher risk profile, CPS allowed longer balloon inflations and higher PTCA success rates compared to IABP. However, peripheral vascular complications were higher in the CPS group, and major cardiac events were similar to those in IABP-treated patients. These data suggest that either method of support may be acceptable during high-risk PTCA. Cathet. Cardiovasc. Diagn. 45:115–119, 1998. © 1998 Wiley-Liss, Inc.     

Sequential vs. kissing balloon angioplasty for stenting of bifurcation coronary lesions.

Coronary angioplasty of bifurcation lesions remains a technical challenge and is believed to result in low procedural success associated with the risk of side-branch occlusion. Furthermore, long-term results are associated with a high rate of reintervention. The aim of the study was to evaluate the immediate and long-term clinical and angiographic results of sequential vs. simultaneous balloon angioplasty (kissing balloon technique) for stenting of bifurcation coronary lesions. Between December 1999 and January 2001, 59 patients underwent coronary angioplasty because of symptomatic bifurcation lesions type III (i.e., side branch originates from within the target lesion of the main vessel, and both main and side branch are angiographically narrowed more than 50%). Twenty-six patients were treated with simultaneous and 33 patients with sequential balloon angioplasty. Main-vessel stent placement was mandatory; side-branch stenting and platelet IIb/IIIa antagonists were allowed at the discretion of the operator. Kissing balloon technique offered no advantage in terms of procedural success or need for repeat target vessel revascularization due to restenosis at 6-month follow-up. Using sequential balloon angioplasty, permanent or transient side-branch compromise rate (TIMI flow < 3) was significantly higher than after kissing balloon technique (33% vs. 0%, respectively; P = 0.003). Major clinical events in-hospital or at 6-month follow-up, however, showed no significant differences. Kissing balloon angioplasty reduces the rate of transient side-branch occlusion compared to sequential PTCA but does not improve immediate or long-term outcome compared to sequential PTCA for stenting of bifurcation lesions.     

单光子发射型计算机断层心肌灌注显像对PTCA的疗效评估

用运动－静息单光子发射型计算机断层（SPECT）心肌灌注显像对18例经皮腔内冠状动脉成形术（PTCA）的患者追踪观察。结果显示，PTCA后患者运动耐量增加；放射性异常积分及靶心缺损范围明显降低，说明近期缺血明显改善。发现1例再缺血经冠状动脉造影提示再狭窄。8例多支病变中，有6例仅进行部分血运重建，SPECT显示缺血严重区域，相关血管多为严重病变血管。对12例心肌梗塞患者梗塞边线带99mTC－MIBI摄取比值测定表明，PTCA前摄取比值小于30％的室壁节段，术后摄取比值仍无增加，提示是否对其相应血管进行扩张应慎重考虑。表明SPECT对PTCA后近期疗效评估及探测再狭窄具有较高的实用价值。     

44例经皮冠状动脉腔内切割球囊成形术的临床评价

目的探讨经皮冠状动脉腔内切割球囊成形术(PTCBA)的手术适应证及临床疗效.方法我院自1999年1月至2000年10月,共有44例病人应用了经皮冠状动脉腔内切割球囊成形术(percutaneoustransluminalcuttingballoonangioplasty,PTCBA),观察了44例病人的一般临床特征、冠脉病变特点及过程相关因素、手术成功率、并发症和随访结果.结果44例病人中不稳定心绞痛和劳累型心绞痛占81.8%(36/44),切割球囊技术应用于支架术前预扩张占25%(13/52)、支架内再狭窄治疗占总例数的46.1%(24/52).前降支开口病变占前降支病变的40.6%(13/32).病变类型以B1、B2型病变为主.PTCBA术失败合并传统球囊和支架术的病例4例(4处病变),原因为切割球囊术后内膜撕裂1例、残余狭窄>30%的1例及切割球囊未通过病变的2例.2例球囊未通过的病变分别合并中度钙化、严重扭曲.总手术成功率达100%,切割技术手术成功率达90.1%(4/44),无围术期死亡、急性心梗及急诊冠脉移植术,均在术后10天内出院.平均随访(5.3±3.5)个月,随访率为95%(38/40).无死亡和急性心肌梗死心脏事件发生,临床心绞痛复发率21.1%(8/38).复查冠脉造影率为50.5%(21/38),被证实为支架内再狭窄5例(冠脉造影再狭窄率23.8%).结论有选择地应用PTCBA技术替代传统球囊扩张术是安全有效的;为支架内再狭窄病人的治疗提供了有效的手段.