Case of spontaneous healing of occlusive dissection on percutaneous transluminal coronary angioplasty

A large pseudolumen due to dissection arose during percutaneous coronary angioplasty. The true lumen was compressed critically. However, no infarction took place because of good collaterals. During medical follow-up, the patient's angina vanished suddenly. The repeat angiography showed healing of the dissection and patency of the coronary artery.     

Aortic dissection as complication of percutaneous transluminal coronary angioplasty

We report two cases of aortic dissection during coronary angioplasty with a disparate evolution that was due to the different location of the entry port of the dissection. Aortic dissection occurring during coronary angioplasty may be self-limiting, but it may also be life-threatening and may call for urgent surgical repair. © 1992 Wiley-Liss, Inc.     

Left main coronary artery dissection during percutaneous transluminal coronary angioplasty

Acute dissection of the left main coronary artery during diagnostic cardiac catheterization with selective coronary arteriography is an uncommon but recognized complication of the procedure. That similar dissection may occur during percutaneous transluminal coronary angioplasty is less well recognized. This report describes two cases of left main coronary dissection resulting in acute occlusion that occurred during percutaneous transluminal coronary angioplasty and demonstrates that survival with essentially complete functional recovery may result if immediate surgical intervention is undertaken. Recognition and treatment of this potentially catastrophic complication of angioplasty is described.     

Extensive coronary dissection after percutaneous transluminal angioplasty. Apropos of a case

The authors report a rare case of very extensive dissection of the right coronary artery immediately after angioplasty; the lesion was totally asymptomatic. Coronary bypass was performed 4 months later without complications and with a satisfactory result at a 15-month follow-up. Coronary dissection during angioplasty is usually located at the site of dilatation: its incidence varies from 6 to 13 p. 100 depending on the series reported. Facilitating factors are analysed, and the management of this complication is discussed: repeat angioplasty and/or emergency or elective coronary bypass, depending on the presence or absence of coronary thrombosis and symptoms, on the importance of the territory threatened and on the quality of collateral circulation.     

Restenosis after multilesion percutaneous transluminal coronary angioplasty

Experience and new technical advances have resulted in an increasing number of patients with multivessel coronary disease who can be considered for percutaneous transluminal coronary angioplasty (PTCA). In selected patients with multivessel coronary disease, PTCA is a safe and effective procedure for the immediate relief of anginal symptoms. However, many questions remain regarding the long-term therapeutic benefit of the procedure. Few data are available on the incidence and clinical significance of restenosis after multilesion PTCA. Clearly, there is the potential for a higher rate of restenosis in patients who undergo dilatation of more than 1 lesion. Determination of restenosis rates after multilesion PTCA is important in the definition of expanded indications for this procedure. Because of the variations in definitions of restenosis and in patient selection factors, reported recurrence rates after multilesion PTCA are not easily compared between patient series. After multilesion dilatation the risk of developing at least 1 recurrent lesion ranges from 26% to 53% and appears to be greater than that reported for single lesion PTCA. Multilesion restenosis occurs in 7% to 21% of patients who undergo multilesion PTCA and is frequently observed in patients with recurrent symptoms. "Silent" multilesion restenosis (i.e., multiple lesion restenosis without symptoms) is rare. A higher risk of restenosis at one of several dilatation sites in a patient with extensive coronary disease should not be a deterrent in recommending multilesion PTCA to selected patients with multivessel coronary disease because the procedure provides important symptomatic relief to most. Further, recurrent narrowings are usually amenable to a second dilatation attempt if clinically indicated.     

Risk stratification after percutaneous transluminal coronary angioplasty

Summary Approximately 20–30% of patients who undergo elective percutaneous transluminal coronary angioplasty (PTCA) require a second angioplasty within 12 months. A significant proportion of patients develop clinical cardiac events during the first year following the initial procedure. The present investigation was undertaken to establish a statistical model for predicting such events. The study group consisted of 100 patients who underwent elective PTCA at the University of Alberta Hospital. All patients were prescribed nifedipine (10 mg tid) and aspirin (325 mg daily) in addition to other medications determined by the attending cardiologist. The patients were reviewed 10 weeks after the procedure and again at the end of 1 year.The follow-up was completed on 96 patients. Within the first year, forty-five experienced cardiac events (1 death, 5 myocardial infarctions, 4 bypass surgeries, 22 repeat PTCAs). These events occurred in 29 patients. An additional 16 patients experienced significant anginal symptoms. A statistical model based upon the patients' perception of symptoms immediately after the procedure, history of hypertension, vessel subjected to PTCA, ejection fraction pre-PTCA, and occurrence of intimal dissection during PTCA was used to identify patients likely to develop cardiac events. Overall, the model classified 72% of the patients (with and without events). Such a statistical model could be used to identify patients who should be subjected to an enhanced degree of cardiologic surveillance in a rehabilitation program.     

Pathological findings after percutaneous transluminal coronary angioplasty

Ten serial pathological cross sections at 1 mm intervals of both the left anterior descending artery at the site of a percutaneous transluminal coronary angioplasty and of the circumflex artery in the untreated stenotic area were studied at necropsy in a patient who died immediately after the procedure. The extent of calcification and atheroma were similar in both branches. Intimal or medial splitting, desquamation, and plaque fracture were present in the left anterior descending artery. No typical pathological findings were seen in the circumflex artery. This study suggests that the original stenotic lumen may have been enlarged as a result of plaque splitting.     

Coronary histology after percutaneous transluminal coronary angioplasty

This article describes previously unreported histologic changes in the vessels of a patient who was admitted with an evolving myocardial infarction due to subtotal occlusion of the left anterior descending coronary artery. The patient died of cardiogenic shock 15 hours after undergoing a technically successful percutaneous transluminal coronary angioplasty procedure. Upon early postmortem study, histologic sections from the proximal, middle, and distal thirds of the left anterior descending coronary artery were polymorphic in appearance. Sections from the most proximal angioplasty site revealed intimal proliferation of polymorphonuclear leukocytes, as well as intimal fibrosis with plaque cleavage. Sections from the more distal angioplasty sites revealed plaque cleavage, intimal polymorphonuclear infiltration, and intimal, medial, and adventitial fracture with dissecting hemorrhage, although mural integrity had been maintained. Intense subintimal proliferation with inflammatory cells has previously been described only in an experimental animal model. Our case also appears to be the first in which adventitial disruption has been observed after percutaneous transluminal coronary angioplasty; this finding provides new evidence that an atherosclerotic coronary artery can tolerate vigorous dilatation without rupture.     

Ischemic complications after percutaneous transluminal coronary angioplasty

The ischemic complications ofpercutaneous transluminal coronary angioplasty (PTCA) include abrupt closure, which occurs in 2% to 10% of patients and is associated with increased morbidity and mortality. Periprocedural myocardial infarction due to side branch occlusion or embolization of platelet aggregates or thrombus occurs in 5% to 20% of patients. Patients with acute coronary syndromes, older age, and complex lesions are at greater risk of periprocedural complications. Technical advances, primarily stenting, are useful in the prevention and management of acute closure, but are also accompanied by thrombotic complications. It remains to be seen whether the new antithrombin agents reduce the rate of periprocedural complications if used in combination with aspirin and new antiplatelet therapies. These new antiplatelet agents (ticlopidine, clopidogrel, abciximab, eptifibatide, and tirofiban) reduce the rate of ischemic complications and have become standard adjunctive therapy for patients who undergo PTCA.     

Aortic dissection as complication of percutaneous transluminal coronary angioplasty.

We report two cases of aortic dissection during coronary angioplasty with a disparate evolution that was due to the different location of the entry port of the dissection. Aortic dissection occurring during coronary angioplasty may be self-limiting, but it may also be life-threatening and may call for urgent surgical repair.     

Pathological findings after percutaneous transluminal coronary angioplasty.

Ten serial pathological cross sections at 1 mm intervals of both the left anterior descending artery at the site of a percutaneous transluminal coronary angioplasty and of the circumflex artery in the untreated stenotic area were studied at necropsy in a patient who died immediately after the procedure. The extent of calcification and atheroma were similar in both branches. Intimal or medial splitting, desquamation, and plaque fracture were present in the left anterior descending artery. No typical pathological findings were seen in the circumflex artery. This study suggests that the original stenotic lumen may have been enlarged as a result of plaque splitting.     

Early hospital discharge after percutaneous transluminal coronary angioplasty

To determine the safety and efficacy of early hospital discharge after percutaneous transluminal coronary angioplasty (PTCA), 100 patients were studied prospectively. A telemetry observation unit was established to monitor patients having uncomplicated procedures. A total of 170 lesions were dilated, with a procedural success rate of 96% and a clinical success rate of 91%. There were no deaths or patients who required emergency bypass surgery. Four patients developed abrupt vessel closure in the catheterization laboratory. No major complications developed in the telemetry observation unit or after discharge. Patients with high-risk lesion morphology, based on the American College of Cardiology/American Heart Association Task Force guidelines, tended to have a lower success rate and more procedural complications. Coronary dissections were angiographically detected in 33 patients and stratified into 6 types. To reduce possible adverse sequelae, all patients with complex dissections were triaged in the catheterization laboratory to an in-patient monitored unit for additional management. Accordingly, 20 patients were admitted to an in-patient unit for extended observation. Excluding 4 patients with myocardial infarction, 75% (12 of 16) were discharged the next day. Initial experience with early discharge suggests that under proper conditions the procedure is safe and effective. Patients with complex coronary dissections who are at high risk for abrupt vessel closure can be promptly identified after dilatation and triaged to an appropriate monitoring area. Early discharge after PTCA offers more efficient use of hospital facilities and the opportunity to reduce hospital costs.