Initial and long-term results of directional coronary atherectomy in unprotected left main coronary artery

Angioplasty in the unprotected left main coronary artery (LMCA) has been controversial. Recently, several studies have suggested that new procedures and devices such as directional coronary atherectomy (DCA) and stents may change this situation. Although there are many reports of unprotected LMCA stenting, there are few reports of DCA of this lesion. Therefore, initial and long-term results were evaluated in 101 patients who underwent DCA for unprotected LMCA in our hospital. Emergency procedures were performed in 15 patients and electively in 86 patients. Scheduled angiographic follow-up was routinely performed, and all patients were clinically followed for >4 months after DCA. Technical success was achieved in 99%, and in-hospital outcomes were cardiac death (2%), noncardiac death (4%), Q-wave myocardial infarction (1%), non-Q-wave myocardial infarction (8.9%), coronary artery bypass grafting (0%), and repeat angioplasty (4%). In-hospital results varied considerably, depending on presentation. In-hospital mortality was significantly higher in the emergency, left ventricular ejection fraction < or =35%, and high-risk surgical subgroups. The angiographic restenosis rate was 20.4% at follow-up, and its predictor was postminimal lumen diameter by multivariate analysis. Mean clinical follow-up was 2.8 years; estimated 1- and 3-year survival rates were 87% and 80.7%, respectively. The cardiac survival rate of the low-risk surgical subgroup was significantly higher than that of the high-risk surgical subgroup (p <0.05). Thus, our data show that DCA can be performed safely and effectively in unprotected LMCA with an acceptable low restenosis rate and high survival rate.     

Clinical outcomes following "rescue" administration of abciximab in patients undergoing percutaneous coronary angioplasty

Pre-intervention administration of abciximab in patients at "high risk" for coronary angioplasty has been shown to reduce acute and long-term cardiac outcomes. The role of intra-procedural ("rescue") administration of abciximab has not been fully elucidated. We assessed the clinical outcomes associated with rescue administration of abciximab during complex percutaneous coronary interventions. We studied in-hospital and long-term (1-year) outcomes (death, myocardial infarction and target lesion revascularization) of 298 consecutive patients (78% male; age, 62 +/- 11 years; 83% with acute coronary syndrome) treated with abciximab for thrombus-containing lesions, sub-optimal angioplasty results, procedural dissections or other complications. Stents were used in 73% of procedures. Procedural success was 97.0% and overall major in-hospital complication rate was 3.0% (death, 1.3%; Q-wave myocardial infarction, 0.7%; and emergent bypass surgery, 1.0%). Most frequent angiographic complications included visible thrombus (17%), dissections (17%), threatened closure (7%), and distal embolization (7%). In-hospital non-Q wave myocardial infarction (defined as CK-MB 5 times normal) occurred in 31.0%. Out-of-hospital to one-year events included death (1.7%), Q-wave myocardial infarction (2.7%), and target lesion revascularization (15.1%); cardiac event-free survival was 82.9%. We conclude that rescue administration of abciximab is associated with relatively low in-hospital complications and favorable long-term outcome in patients with sub-optimal angioplasty results and/or procedure-related complications, although peri-procedural non-Q wave myocardial infarction rate is high. A clinical and cost-effective comparison between provisional and rescue administration of abciximab may be warranted.     

Clinical success, complications and restenosis rates with excimer laser coronary angioplasty. The Percutaneous Excimer Laser Coronary Angioplasty Registry.

The role of excimer laser angioplasty in treating complex coronary artery disease remains uncertain. A randomized trial comparing this new technology with balloon angioplasty cannot be designed until systematic analysis identifies the lesion types that are likely to benefit from treatment with excimer laser angioplasty. In a cohort of 764 patients who had 858 coronary stenoses treated with excimer laser-facilitated angioplasty, relative risk analysis was used to examine acute success, complications and restenosis rates, and the results were compared with those of balloon angioplasty to identify the lesion types that show the greatest benefit with the new treatment. Clinical success was achieved in 657 patients (86%), as indicated by < or = 50% residual stenosis and no in-hospital complication. A major in-hospital complication (death, bypass surgery, or Q-wave or non-Q-wave myocardial infarction) occurred in 58 patients (7.6%). Follow-up angiography was obtained in 70% of eligible patients. Combining angiographic and noninvasive restenosis rates yielded an overall restenosis rate of 46%. Relative risk analysis showed that major complications occurred frequently in lesions at an arterial bifurcation (odds ratio [OR] 5.96 [2.76, 12.6]; p = 0.001). However, certain complex lesions that are difficult to treat with balloon angioplasty (saphenous vein graft lesions, lesions > 10 mm, ostial lesions, calcified stenoses, total occlusions and unsuccessful balloon dilatations), analyzed together as a group, had lower complication rates by univariate (OR 0.59 [0.35, 1.00]; p = 0.051) and multivariate logistic regression (p = 0.006) analyses.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of directional coronary atherectomy and stenting versus stenting alone for the treatment of de novo and restenotic coronary artery narrowing

Late lumen loss after directional coronary atherectomy (DCA) is mainly determined by arterial remodeling. We hypothesized that stent implantation after optimal lesion debulking could be an effective approach to reduce restenosis. A total of 753 patients with de novo or restenotic coronary lesions were prospectively randomized to DCA plus stenting (n = 381) or stenting alone (n = 372). The patients were followed for 12 months. Procedural success was achieved in 91.5% versus 97.3% (p = 0.0007) of patients treated with DCA plus stent versus stent alone. Optimal atherectomy (<20% residual stenosis) was achieved in 26.5% of patients. The final minimal luminal diameter and the acute gain were similar in the 2 groups. There was no increase in 30-day major adverse cardiac events in the DCA plus stent group (3.9% vs 2.4%, p = 0.30). The primary end point, angiographic restenosis at 8 months, occurred in 26.7% of patients treated with DCA plus stents and in 22.1% of patients treated with stents alone (p = 0.237). Clinical follow-up to 1 year showed no difference in mortality (1.3% vs 0.8%, p = 0.725), acute myocardial infarction (4.2% vs 3.5%, p = 0.706), and target vessel failure (composite of death, Q-wave myocardial infarction, and target vessel revascularization) (23.9% vs 21.5%, p = 0.487) between patients with DCA plus stents and those with stents alone. This study failed to support the hypothesis that DCA before stenting lowers the angiographic restenosis rate compared with stents alone. At 12-month follow-up, there were no significant differences between the 2 groups in rates of death, reinfarction, or target vessel failure.     

Initial management and long-term clinical outcome of restenosis after initially successful percutaneous transluminal coronary angioplasty.

Restenosis remains a critical limitation after percutaneous transluminal coronary angioplasty (PTCA). The clinical experience with restenosis was reviewed in 1,490 patients who had restenosis of at least 1 site within 1 year of their PTCA. The source of data was the clinical database at Emory University. Patients who had previous coronary bypass surgery or PTCA and patients who underwent PTCA in the setting of acute myocardial infarction were excluded. When restenosis was angiographically documented, 363 were treated medically, 1,051 with repeat PTCA, and 76 with coronary bypass surgery. In the repeat PTCA group there were 778 patients who originally had 1-vessel disease and 273 with multiple vessel disease. Re-dilatation of restenotic sites was performed in 95%. Angiographic success of all lesions dilated was achieved in 99%. Coronary bypass surgery was required in 2.5% of patients with restenosis first treated with repeat PTCA. One patient with multiple vessel disease died. Coronary bypass surgery was performed in fewer patients aged greater than or equal to 65 years, but more patients with multiple vessel disease. Two (2.6%) of the coronary bypass surgery patients had Q-wave myocardial infarction and there were no deaths. In the PTCA group, 5-year actuarial survival was 95%, and cardiac survival 96%. Freedom from cardiac events or further revascularization procedures was 51% at 5 years. Patients treated with PTCA and medically treated patients had similar cardiac survival rates. The most important correlates of cardiac survival were age and the presence of diabetes mellitus. At 5 years, cardiac survival without diabetes was 97 and 83% with diabetes (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Coronary angioplasty in patients aged 70 and over. Immediate results and later outcome

One hundred and ninety one consecutive patients over 70 years of age (127 men and 64 women, average age 75.6 years) underwent percutaneous transluminal coronary angioplasty (PTCA) between January 1986 and February 1989. One hundred and sixty patients had severe angina (20 Class III and 140 Class IV), 72 patients had previous myocardial infarction, 36 of which were recent (less than 1 month), and 6 patients had previously undergone coronary bypass surgery. The coronary lesions affected one vessel in 67 patients and more than one vessel in 124 patients. The left ventricular ejection fraction was less than 50% in 15 patients. Angioplasty was attempted on 245 lesions (228 stenoses and 17 occlusions): 1 lesion in 141 patients, 2 lesions in 46 patients, 3 lesions in 4 patients, with a primary success rate of 81% in stenotic and 41% in occluded arteries. There were 9 deaths (4.7%) 6 of which occurred in patients with multivessel disease and unstable angina; there were 6 Q-wave infarctions (3.1%), 8 non Q-wave infarctions (4.2%) and 3 emergency coronary bypass operations (1.6%). The first 123 patients of this series were followed up for an average of 18.8 months (7 to 37 months). Follow-up of the 100 patients successfully dilated (4 lost to follow-up) showed that 55 remained improved (53 asymptomatic), 25 had recurrent angina after the initial improvement due to restenosis in 19, progression of coronary athero-sclerosis in 3, restenosis and an evolution of coronary atherosclerosis in 1 and a lesion which had been neglected in 2 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term outcome of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting in patients with end-stage renal disease

This study was conducted to investigate therapeutic methods for end-stage renal disease (ESRD) by retrospectively analyzing in-hospital outcome and long-term outcome in patients who underwent either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). Ninety-two patients underwent PTCA and 47 underwent CABG, and the initial success rates were 87% and 85%, respectively. As major in-hospital complications, in the PTCA group 1 died (1%), 2 required emergency CABG (2%), and 2 had Q-wave myocardial infarction (2%); in the CABG group, 7 died (15%) and 3 had Q-wave myocardial infarction (6%). As for the long-term outcome, although there were no differences in the incidence of death or the incidence of cardiac death between the 2 groups, the cumulative proportion of patients free of death, myocardial infarction, CABG and repeat PTCA was lower in the PTCA group, which was mainly due to a higher incidence of repeat PTCA in that group. The incidence of cardiac death was low for both groups among the patients attaining complete revascularization. Twenty-three percent of the patients required cross-over implementation of PTCA and CABG. In conclusion, it is necessary to aim for complete revascularization using both treatments for a better prognosis in patients with ESRD.     

Clinical and angiographic outcomes after placement of multiple overlapping drug-eluting stents in diffuse coronary lesions

Multiple overlapping drug-eluting stents have increasingly been used to treat diffuse coronary disease, but the safety and efficacy of this approach remains unclear. We assayed the clinical and angiographic outcomes after placement of "full metal jacket" stents (stented length >or=60 mm) in 347 consecutive patients (352 lesions) with very long de novo coronary lesions. Mean age was 61.0 +/- 10.1 years, and the mean stented length was 71.9 +/- 13.7 mm. The procedural success rate was 97.7%. Major in-hospital complications (1 death, 2 cases of acute stent thrombosis) occurred in 3 patients (0.7%). Angiographic follow-up data, obtained for 230 (234 lesions) of the 328 eligible patients (70.1%), showed that the restenosis rate was 13.7%. Multivariate analysis found that the reference artery diameter (odds ratio 0.05, 95% confidence interval [CI] 0.01 to 0.33, p = 0.002) and the use of Taxus stents (odds ratio 2.88, 95% CI 1.03 to 8.04, p = 0.043) were significant predictors of restenosis. During follow-up (16.6 +/- 6.9 months), 9 deaths (6 cardiac and 3 noncardiac), 1 nonfatal myocardial infarction, and 13 target lesion revascularizations occurred. The cumulative probability of survival without major adverse cardiac events (cardiac death, Q-wave myocardial infarction, and target lesion revascularization) was 95.4 +/- 1.1% and 91.4 +/- 2.1% at 1 and 2 years, respectively. Left ventricular dysfunction (ejection fraction <45%) was the only predictor of stent thrombosis (hazard ratio 18.24, 95% CI 1.65 to 201.19, p = 0.018) and cardiac death/Q-wave myocardial infarction (hazard ratio 5.37, 95% CI 1.28 to 22.49, p = 0.021). In conclusion, full metal jacket drug-eluting stents may be a safe and effective method to treat diffuse coronary disease and may be a useful treatment option for complex long lesions.     

药物洗脱支架与冠状动脉旁路移植术治疗冠状动脉多支病变的比较

目的比较药物洗脱支架与冠状动脉旁路移植术治疗冠状动脉复杂多支病变的疗效。方法连续入选行血运重建治疗的冠心病多支病变患者200名,随机分为经皮冠状动脉介入(PCI)组和冠状动脉旁路移植术(CABG)组,每组100例。PCI组和CABG组中分别有合并糖尿病者(糖尿病亚组)27例和25例。观察术后1年内主要心脑血管不良事件(死亡、脑卒中、非致死性心肌梗死、靶血管再次血运重建)、再狭窄、心绞痛复发发生率,血浆肌酸激酶水平和PCI组支架内血栓形成发生率。结果两组患者的基线特征差异无统计学意义。PCI组与CABG组1个月、6个月和1年的主要心脑血管不良事件发生率分别为4.0%、7.0%、12.0%比6.0%、9.0%、15.2%(P>0.05);心绞痛复发率分别为2.0%、4.0%、6.0%比1.0%、3.0%、5.1%(P>0.05)。术后1年再狭窄率分别为11.3%比13.2%(P>0.05)。PCI组术后亚急性血栓形成率1.0%。PCI组和CABG组术后肌酸激酶MB型同工酶升高的患者比例分别为26%比82%(P<0.05)。PCI组糖尿病亚组与CABG组糖尿病亚组1个月、6个月和1年的严重心脑血管不良事件发生率分别为7.4%、11.1%、18.5%比8.0%、16.0%、24.0%(P>0.05)。结论药物洗脱支架时代PCI与CABG治疗冠状动脉多支病变的近、远期疗效相近,对于合并糖尿病的患者同样有效。     

Directional coronary atherectomy at the Toronto and Mount Sinai Hospitals: report of the initial 120 procedures.

OBJECTIVE: To assess the procedural success and complication rates of the first 120 directional coronary atherectomy cases performed at two Toronto hospitals. DESIGN AND SETTING: Case series in tertiary referral centres. PATIENTS: One hundred and thirteen patients in whom 120 atherectomy procedures were attempted between July 1990 and April 1992. INTERVENTION: Directional coronary atherectomy. MAIN RESULTS: Angiographic success was obtained in 115 of 120 procedures (96%) involving 117 of 123 lesions (95%). Procedural success (angiographic success without death, myocardial infarction or coronary bypass surgery) was obtained in 110 of 120 procedures (92%). Adjunctive balloon angioplasty was required in 20 procedures (17%). There was one death at 36 h in an elderly patient who underwent an emergency procedure while in cardiogenic shock. Periprocedural non-Q wave myocardial infarction occurred in five patients. There were no Q wave myocardial infarctions. Three patients required coronary bypass surgery prior to discharge and vascular complications occurred in five patients. CONCLUSIONS: Directional coronary atherectomy can be performed with procedural success and complication rates comparable to conventional balloon angioplasty. Randomized trials are underway to determine if atherectomy results in a lower restenosis rate.     

Initial Experience with the ACS Multi-Link Stent: Serial Angiographic Follow-Up and Comparison with the Palmaz-Schatz Stent in Matched Lesions

To evaluate the efficacy of the more flexible ACS Multi-Link stent, a prospective angiographic follow-up study was performed. Implantation of the ACS Multi-Link stent was attempted in 70 consecutive patients with 79 coronary lesions from April to November 1995. Clinical success defined as final % diameter stenosis of < 50% without death, bypass surgery or Q-wave myocardial infarction was achieved in 95% of the patients. There was 1 in-hospital death due to acute pulmonary embolism. In-hospital subacute stent occlusion occurred in 2 cases. Follow-up angiograms were obtained in 62 (83%) eligible lesions. The minimal luminal diameter improved from 0.97 +/- 0.41 to 2.72 +/- 0.30 mm, but started to decrease at 1 month (2.38 +/- 0.42 mm), and continued to decrease throughout the 6 months (1.96 +/- 0.41 mm). Angiographic restenosis (stenosis 3 50%) occurred in 16% of the lesions, a rate smaller though not significantly different from the 25% with the Palmaz-Schatz stent. A revascularization procedure of the target lesion was required in 6% of the patients. Multivariate analysis identified lack of post-dilatation, type of lesion, lesion length and pre-procedural reference diameter to be predictors of angiographic restenosis. In conclusion, the ACS Multi-Link stent can be implanted successfully with a low complication rate and a clinical outcome at least comparable to the Palmaz-Schatz stent.     

Results of percutaneous transluminal coronary angioplasty for angina pectoris early after acute myocardial infarction

Between May 1980 and July 1985, 70 patients underwent percutaneous transluminal coronary angioplasty (PTCA) for angina occurring 24 hours after and within 30 days of acute myocardial infarction (32 with Q-wave infarction and 38 with non-Q-wave infarction). One-vessel disease was present in 42 (60%) and multivessel in 28 (40%); the mean ejection fraction was 0.56 (greater than or equal to 0.50 in 77% of patients). PTCA was successful in 56 patients (80%) and after introduction of steerable dilating systems in February 1983 this rate became 86%. The success rate for complete occlusions was 76%. The interval from myocardial infarction to PTCA was similar in patients with successful dilation (12.7 +/- 8.1 days) and those without (13.4 +/- 8.0 days). PTCA failed in 14 patients (20%); 8 underwent emergency coronary artery bypass for acute occlusion and 4 of 6 patients whose lesions could not be crossed had elective bypass surgery. There was 1 operative death. No patient sustained a Q-wave infarction. Three patients had non-Q-wave infarctions after technically successful PTCAs. Mean follow-up was 27 months (6 to 67 months). Of the 56 patients successfully dilated, 14 (25%) had 15 cardiac events during follow-up: death (1), non-Q-wave infarction (2), repeat PTCA (7), coronary bypass (4) and recurrence of severe angina (1). The cumulative mortality was 3% and the reinfarction rate was 7% (no Q-wave reinfarctions). Forty-two (60%) of the 70 patients were free of complicating events acutely and during follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)     

Technical feasibility,safety, and clinical outcome of stenting of unprotected left main coronary artery bifurcation narrowing

This study was performed to evaluate the acute and long-term results of stenting for unprotected left main coronary artery (LMCA) bifurcation lesions. Sixty-three consecutive patients with an unprotected LMCA bifurcation lesion and normal left ventricular function were included. Stenting was performed with (n = 32) or without debulking atherectomy (n = 31) at the operator's discretion. Slotted-tube stents, coil stents, or bifurcation stents were used. The procedural success rate was 100%. In-hospital events including stent thrombosis, Q-wave myocardial infarction, and emergency bypass surgery did not occur in any patients. The angiographic follow-up rate was 86% (43 of the 50 eligible patients), and the restenosis rate was 28% (parent vessel only 14%, side branch only 9%, and both 5%). Restenosis at the parent vessel occurred less frequently in the debulking group than in the nondebulking group (5% vs 33%, respectively, p = 0.02). In multivariate analysis, the debulking procedure was an independent predictive factor of restenosis for the parent vessel (odds ratio 0.10, 95% confidence intervals 0.01 to 0.91, p = 0.04). Clinical follow-up was obtained in all patients at 19.9 +/- 13.7 months. There were 2 deaths (noncardiac origin), but no myocardial infarction during follow-up. Target lesion revascularization was required in 6 patients. The event-free survival rate (death, nonfatal myocardial infarction, and repeat revascularization) was 86% at the end of the follow-up period. In conclusion, stenting for an unprotected LMCA bifurcation lesion may be performed with a high procedural success rate and a favorable clinical outcome in selected patients with normal left ventricular function, suggesting that stenting would be an effective alternative to surgery in these patients.     

Acute results and long-term outcome of transluminal extraction catheter atherectomy for saphenous vein graft stenoses

Distal embolization of atheroma and thrombus is a major concern when performing balloon angioplasty in coronary saphenous vein grafts (SVGs). The transluminal extraction catheter (TEC) is designed to remove this material and may improve the safety of percutaneous treatment of SVG disease. We assessed the acute results and long-term outcome of 67 patients (mean age 65.6 ± 8.1 years; range 47–83 years) who underwent 73 separate TEC atherectomy procedures. Eighty-eight SVG lesions were treated (mean age 8.7 ± 3.8 years from bypass surgery). Procedural success (< 50% final diameter stenosis and absence of major complications) was obtained in 63 patients (86%). Adjunctive balloon angioplasty and/or directional coronary atherectomy was required in 69 of the procedures (95%). Major complications, occurring in 8 patients (ll%), were acute closure in 4 (5%), resulting in Q-wave myocardial infarction in 3 and urgent bypass surgery in 1, and distal embolization in 4 (5%; 1 associated with Q-wave myocardial infarction). Angiographic follow-up was available for 50 patients and restenosis was present in 26 (52%). These data suggest TEC atherectomy can be performed in SVGs with an acceptable procedural risk, but restenosis remains a significant limitation which will require other strategies to overcome. o 1994 Wiley-Liss, Inc.     

Usefulness of coronary angioplasty in asymptomatic patients

Of 6,545 patients who had elective coronary angioplasty procedures performed over a 7.5-year period from June 1980 through December 1987, 114 (1.7%) never had symptoms of myocardial ischemia. Exercise-induced silent myocardial ischemia was documented before angioplasty in 94% of these asymptomatic patients. Angioplasty was successful in 87%, whereas emergency coronary artery bypass grafting was required in 4%, and a further 2% had myocardial infarctions after the procedures. The remaining 7% had unsuccessful angioplasty procedures but experienced no in-hospital cardiac events. The follow-up period after hospital discharge averaged 43 +/- 20 months (range 5 to 93). There were no deaths. In the group of 99 patients with initially successful angioplasty procedures the follow-up interval ranged from 5 to 92 months. During that period, 7 patients underwent coronary bypass surgery, 4 patients had myocardial infarction and 30 patients had repeat angioplasty procedures for restenosis. The cumulative probability of event-free survival over 5 years for the group with successful angioplasty was: 100% freedom from death, 95% freedom from myocardial infarction, 87% freedom from myocardial infarction or coronary bypass surgery and 61% freedom from myocardial infarction, coronary bypass surgery or repeat angioplasty. Thus, coronary angioplasty performed in 114 asymptomatic patients, most with exercise-induced silent myocardial ischemia, achieved very good primary success and was accompanied by low cardiac event rates and no deaths over several years of patient follow-up.     

Initial experience with the Cordis stent: Analysis of serial angiographic follow-up

To evaluate the efficacy of the more flexible Cordis stent, a prospective angiographic follow-up study was performed. Implantation of the Cordis stent was attempted in 99 consecutive patients with 103 native coronary lesions from January 1994 to July 1995. Clinical success, defined as final diameter stenosis of <50% without death, bypass surgery, or Q-wave myocardial infarction, was achieved in 88% of the patients. There were no in-hospital deaths. In-hospital subacute stent occlusion occurred in only one case. Follow-up angiograms were obtained in 86 (95%) eligible lesions. The minimal luminal diameter improved from 1.03 ± 0.31 to 2.82 ± 0.31 mm, but started to decrease at 1 mon (2.57 ± 0.24 mm), and continued to decrease throughout the 6 mon (2.00 ± 0.61 mm), the biggest reduction being between 1 and 3 mon (−0.57 ± 0.50 mm). Angiographic restenosis (stenosis ≥50%) occurred in 23% of the lesions; a revascularization procedure of the target lesion was required in 12% of the patients. Multivariate analysis identified age, diabetes mellitus, and preprocedural reference diameter to be predictors of angiographic restenosis. In conclusion, the Cordis stent can be implanted successfully with a low complication rate and a clinical outcome at least comparable to other stent studies. Cathet. Cardiovasc. Diagn. 42:166–172, 1997. © 1997 Wiley-Liss, Inc.     

Comparison of immediate and one-year outcome after coronary angioplasty of narrowing < 3 mm with those > or =3 mm ( the National Heart, Lung, and Blood Institute Dynamic Registry)

Balloon angioplasty of small coronary artery lesions has been associated with lower success and higher complication rates than large coronary artery lesions. This study evaluates the in-hospital and 1-year outcome of the treatment of small coronary artery lesions in the modern era of interventional cardiology and compares it with the outcome of treating large coronary artery lesions. Of 1,658 patients with a single lesion treated from July 1997 to February 1998 in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry, there were 587 patients with small coronary artery lesions (<3 mm) and 1,071 patients with large coronary artery lesions (> or =3 mm). Success, in-hospital, and 1-year outcomes between both groups were compared. Patients with lesions in small coronary arteries were more often women, insulin-treated diabetics, and had undergone more prior coronary bypass graft surgery. Conventional angioplasty alone was performed more often and angioplasty with stents was performed less often in the small coronary artery than in the large coronary artery group. Angiographic success was slightly lower in the small coronary artery group (94.2% vs 96.9%, p <0.05). Periprocedural and in-hospital complication rates were similar in both groups. Likewise, at 1-year follow-up, major adverse cardiac events including death, myocardial infarction, and coronary artery bypass graft surgery were relatively low and comparable between the 2 groups, although patients with small coronary arteries were more likely to undergo repeat revascularization (17.4% vs 13.6%, p <0.05). Treatment of lesions in small coronary arteries in the modern era is associated with high success and low complication rates, comparable to the treatment of large coronary artery lesions, although the incidence of repeat revascularization was significantly greater at follow-up even if stents were used.     

The Magnum wire for percutaneous coronary balloon angioplasty in 723 patients

The experience of the use of the Magnum wire in a single center is reported. Percutaneous balloon coronary angioplasty, using the Magnum 0.021 inch wire, was attempted in 723 patients with 850 lesions; of these, 453 (53%) were chronic total occlusions and 50 (7%) recent occlusions of less than 24 hours (patients presenting with acute myocardial infarction). The overall technical success rate per lesion was 655/850 (77%). It was 255/280 (91%) for non-total lesions, 311/453 (69%) for chronic total occlusions, 53/67 (79%) for functional (TIMI grade I) occlusions, and 36/50 (72%) for recent occlusions. Clinical success was achieved in 196/232 patients (84%) with non-total lesions, in 292/436 (67%) with total chronic occlusions, in 49/65 (75%) with functional occlusions, and in 34/50 (68%) with recent occlusions. Complications (significant creatine kinase rise, new Q-wave infarction, need for coronary bypass surgery or in-hospital death) occurred in 7% (3% if patients presenting with unstable ischemic syndromes were excluded from the analysis). These data confirm that the use of the Magnum wire has success rates competitive with other systems both in setting of chronic total occlusion and in that of routine percutaneous transluminal coronary angioplasty.     

Repeat coronary angioplasty as treatment for restenosis.

Repeat coronary angioplasty has become the standard approach to a first restenosis. However, the long-term outcome of such a strategy is not well defined. In the present study, 465 patients (mean age 58 years [range 27 to 79], 53% with multivessel disease) underwent a second angioplasty procedure at the same site. The procedure was successful in 96.8% with a 1.5% rate of in-hospital bypass surgery, a 0.9% incidence rate of myocardial infarction and no procedural deaths. Four hundred sixty-three patients (99.6%) were followed up for a mean of 40.5 months. Forty-nine patients (10.6%) underwent a third angioplasty procedure at the same site, 55 (11.8%) had coronary bypass surgery and 33 (7.1%) underwent angioplasty at a different site. During follow-up, 12 patients (2.6%) sustained a myocardial infarction and 21 (4.5%) died including 13 (2.8%) with cardiac death. Of the 442 surviving patients, 88% experienced sustained functional improvement and 78% were free of angina. The actuarial 5-year cardiac survival rate was 96% and the rate of freedom from cardiac death and myocardial infarction was 92%. For the subgroup of 49 patients who had a third angioplasty procedure at the same site, the success rate was 93.9% with a 2% incidence rate of myocardial infarction. There were no in-hospital deaths or coronary artery bypass operations. The mean follow-up interval for this subgroup was 30.5 months with a 22.4% cross-over rate to coronary bypass surgery, a 4.1% incidence rate of myocardial infarction and a 2% cardiac mortality rate. At last follow-up, 89% of patients had sustained functional improvement and 76% were free of angina. The combined angiographic and clinical restenosis rate was 48%. Repeat angioplasty as treatment for restenosis is an effective approach associated with a high success rate, low incidence of procedural complications, and sustained functional improvement in combination with an acceptable rate of bypass surgery. However, there is a trend toward diminished angioplasty efficacy after a second restenosis. Thus, decisions for further revascularization should be made after careful review of available options.