Coronary angioplasty in patients with prior coronary artery bypass surgery: all prior coronary artery bypass surgery patients and patients more than 5 years after coronary bypass surgery

Percutaneous transluminal coronary angioplasty (PTCA) has been used successfully in patients who have had prior bypass surgery (CABG) as a means of revascularizing the myocardium and avoiding repeat myocardial revascularization. However, angioplasty has been considered inappropriate as a means of dilating old saphenous vein grafts. The first section of this article details the authors' experience with PTCA of prior CABG patients, and the second section discusses the results of PTCA in the subset of patients 5 or more years after their last coronary bypass surgery. These data may make individuals rethink the appropriateness of PTCA in old saphenous vein grafts.     

Coronary angioplasty for medically refractory unstable angina within 30 days of acute myocardial infarction

Percutaneous transluminal coronary angioplasty (PTCA) has been used with good results in selected patients with unstable angina. The population with recent (less than or equal to 30 days) infarction and unstable angina is a subject of controversy. This report reviews the results of angioplasty of 84 vessels in 66 patients with medically refractory unstable angina who had documented myocardial infarction within 30 days of the procedure. Of these 66 patients, 54 had rest angina. Of the 66 patients with angioplasties, 58 patients (88%) had successful procedures. Two patients had technically unsuccessful results in the only vessel attempted; one went to elective surgery and recovered uneventfully and the other patient was in cardiogenic shock at the time of the procedure and died 12 hours later. There were three acute occlusions of infarct-related arteries that were managed medically. There were two (3%) emergency coronary artery bypass graft (CABG) procedures. There were two (3%) deaths during the index hospitalization. Of the 58 of 66 patients with technically successful angioplasty, all 58 had no more rest angina, and 46 had a satisfactory predischarge exercise test. All 46 were without angina at exercise. In follow-up ranging from 4 months to 36 months (14 months mean), there have been six cases of restenosis with recurrence of angina treated successfully with repeat angioplasty. There have been five late bypass surgeries. There have been three late deaths. These data, generated by a single operator in a Veterans Administration (VA) center, support the use of angioplasty in patients with unstable angina and recent myocardial infarction. The data suggest that a VA prospective randomized trial of PTCA versus CABG for post-infarction angina may be feasible.     

Coronary angioplasty in patients with prior coronary artery bypass grafting

We studied the clinical and angiographic outcome of patients with prior coronary arterial bypass grafting who underwent percutaneous transluminal coronary angioplasty at the Royal Infirmary of Edinburgh. Over a 4 year period, 47 patients with prior bypass surgery underwent angioplasty of 23 stenotic graft sites and 37 stenotic sites of native vessels. The procedure was performed a mean of 31.3 months after surgery for recurrence of symptoms refractory to maximal medical treatment. Satisfactory angiographic results were achieved in 42 patients (58 stenotic grafts or native vessels). At a median follow up period of 18 months, 20 patients were symptomatically improved, but 22 patients experienced recurrence of symptoms a mean of 4.7 months after angioplasty, despite a good initial angiographic result. Overall, 4 patients had a repeat bypass grafting and 9 patients had a repeat angioplasty. Angioplasty can be used as an alternative to a repeat operation in patients with prior bypass grafting who experience recurrence of symptoms. Initial success rates are high and complication rates low. Restenosis or development of new lesions in the native circulation, and/or in the grafts, remain significant problems. Patients with a long asymptomatic interval (greater than 6 months) between the bypass operation and recurrence of symptoms are more likely to have better long-term results after successful angioplasty, perhaps because of slower progression of atherosclerotic heart disease.     

Coronary bypass surgery for stable angina and unstable angina pectoris

Large randomized trials have shown that surgical revascularization is more effective than medical therapy in relieving angina and improving exercise tolerance. Development of atherosclerosis in the vein grafts plus progression of disease in the native vessels, however, results in a return of angina in a substantial proportion of patients 5 to 10 years after the procedure. The better myocardial protection, more complete revascularization, and improved graft patency rates that have occurred in the last decade imply that survival following coronary artery bypass may be improved in a broader spectrum of coronary artery disease patients than documented in the randomized trials. Patients with unstable angina have higher operative mortality but clearly benefit symptomatically from revascularization. There is a need for randomized trials to compare the relative risks and benefits of angioplasty versus surgical revascularization.     

Coronary angioplasty for unstable angina.

Coronary angioplasty is an effective treatment for subgroups of patients with unstable angina. The procedure has a high initial success rate but there is an increased risk of major complications resulting from a higher incidence of acute closure presumably related to additional injury of the underlying plaque with augmented platelet and clotting activity, and ensuing spasm. Newer agents that inhibit platelet aggregation or thrombin may provide a safer use of coronary angioplasty in patients with unstable angina. Coronary angioplasty is indicated if a stenosis, technically suitable for dilation, is found to be responsible for the unstable state. The decision in favor of coronary angioplasty in patients with single-vessel disease is easy to make. Patients with left main stem disease or severe multivessel disease should primarily be scheduled for bypass surgery. In the presence of other multivessel disease, uncertainty remains. However, in selected patients with multivessel disease, one might prefer dilation of the ischemia-related vessel "the culprit vessel" only, rather than total revascularization by multiple dilatations or bypass surgery, since this can be performed faster and thus shorten the hospital stay. Thrombolytic treatment in the management of patients with unstable angina may be indicated in patients with pre-existing intracoronary thrombi or when procedural acute closure occurs associated with intracoronary thrombus formation.     

Role of prolonged intravenous heparin in unstable angina patients prior to coronary angioplasty

BACKGROUND: The optimal timing of coronary angioplasty in unstable angina patients is controversial. Early reports suggested using 3-5 days of intravenous heparin and aspirin for plaque stabilization before angioplasty. There is no clearcut data in this regard from the published literature. The purpose of this study was to evaluate whether delaying the angioplasty in order to stabilize the plaque affected the outcome. METHODS: We reviewed the hospital course of patients who were admitted with unstable angina through the emergency room and ruled out for myocardial infarction, and who required angioplasty during the index hospitalization. To diminish the influence of coronary stenting and glycoprotein IIb/IIIa receptor blockade, we reviewed all patients admitted during 1994. RESULTS: Of the 305 patients, 166 patients received < or = 48 hours and 139 patients received > 48 hours of intravenous heparin infusion before angioplasty. Both groups were well-matched. The procedural success was similar in both the groups (98% vs 97%, P = 0.72). The complication rate was similar in both groups, including abrupt closure, emergency bypass surgery, myocardial infarction and death. Length of hospital stay was significantly prolonged in the group with > 48 hours of heparin infusion (4.4 +/- 3.0 vs 7.4 +/- 3.6 days; P < 0.001). CONCLUSION: In patients with unstable angina undergoing angioplasty, prolonged duration of heparin infusion influenced the procedural outcome or postprocedural complications, but prolonged the hospital stay. These data suggest that early angioplasty of unstable angina patients is safe and may be cost-effective, even in the absence of stenting and potent antiplatelet agents. However, prospective, randomized trials are needed to clarify the need for and duration of heparin infusion prior to angioplasty in unstable angina patients.     

Coronary angioplasty of 'complex lesions' in patients with unstable angina

Out of 55 patients subjected to coronary angioplasty over the past 12 months, there were 33 (60%) who had unstable angina. Amongst these, 22 patients had coronary lesions classified as 'complex' on coronary angiography. These included tandem lesions, branch stenoses, distal lesions, total occlusions, vein graft stenoses, lesions with ulceration and intraluminal clot and associated with valvular lesions. We describe our experience of coronary angioplasty in these 22 patients of unstable angina having 'complex lesions'. All were males with a mean age of 48.7 +/- 13 years. Fourteen patients had single vessel and 8 multivessel disease. A total of 35 lesions were subjected to dilatation. The angiographic primary success was achieved in 85.7% of the lesions attempted. Except total occlusions and very distal lesions, all other types of 'complex lesions' could be dilated with a success rate of greater than 75%. There were 4 (11.4%) failures because of inability to cross the lesion with the guidewire or balloon catheter. One patient developed non-Q wave inferior wall infarction. There were no deaths. We conclude that coronary angioplasty of various types of 'complex lesions' can be performed with a good primary success and negligible complications in our setting.     

顽固性不稳定性心绞痛的介入治疗

目的　探讨介入治疗顽固性不稳定性心绞痛的近、远期疗效。方法　回顾性分析连续 48例顽固性不稳定性心绞痛患者 ,入院后 (5 .2± 3.4)d介入治疗患者的临床资料。抗血栓治疗为 :阿司匹林、噻氯匹啶、皮下注射低分子量肝素。 48例患者中 ,有 46例 (95 .8% )植入支架。结果　介入治疗的病例、病变成功率分别为 95 .8% (4 6 48)和93.8% (75 80 )。无 1例发生死亡、急性心肌梗死、急诊冠状动脉旁路移植术。 46例介入治疗均获成功 ,心绞痛完全消失或明显缓解。随诊 2～ 2 4(12 .5± 8.0 )个月 ,8例 (17.4% )发生心脏事件 ,其中 2例 (4 .3% )发生心肌梗死 ,6例(13.0 % )再次行血管重建治疗 (介入治疗 5例 ,冠状动脉旁路移植术 1例 )。结论　在使用阿司匹林、噻氯匹啶、皮下注射低分子量肝素抗血栓疗法和广泛应用支架的前提下 ,介入治疗顽固性不稳定性心绞痛成功率高 ,近期疗效明显 ,远期疗效满意     

Troponin-T in patients with unstable and stable angina pectoris undergoing coronary bypass surgery

BACKGROUND: Troponin-T is a sensitive indicator of minor myocardial damage during coronary bypass surgery. METHODS: Troponin-T levels were assessed before and repeatedly for 64 hours after coronary bypass surgery in 100 patients with unstable and 100 with stable angina pectoris. RESULTS: Postoperative troponin-T levels rose significantly within 6 hours followed by a decline until 64 hours. In unstable patients who had pain within two days and an acute myocardial infarction within two weeks before the operation (Braunwald class IIIC), Troponin-T rose to high levels that persisted for 64 h. Sixty-seven percent of these patients had an elevated troponin-T >0.10 microg/l already before the operation and a perioperative myocardial infarction was recorded in 27%. In contrast, postoperative troponin-T levels in remaining patients classified as unstable were similar to those in patients with stable angina. Elective operations in the control group were performed with a low risk of adverse postoperative events. CONCLUSIONS: Patients with Braunwald class IIIC unstable angina suffered to a great extent myocardial cell damage following coronary bypass surgery.     

Percutaneous transluminal coronary angioplasty and coronary bypass grafting for refractory angina in chronic dialysis patients]

Between June 1983 and July 1989, 25 consecutive chronic dialysis patients with medically refractory angina pectoris underwent revascularization, either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) (21 males and 4 females, mean age of 57 +/- 10 years, and mean duration of dialysis of 3.7 +/- 5.0 years). Patients with single-vessel disease and/or mildly calcified lesions received PTCA (n = 15), while those with multi-vessel disease and/or severely calcified lesions received CABG (n = 10). As controls for PTCA-treated dialysis patients, 208 non-dialysis patients who received initial PTCA in 1988 were used. The mean number of diseased vessels was 2.7 +/- 0.7 for CABG group, and 1.5 +/- 0.8 for PTCA group (p < 0.01). In both groups, 80% of patients were successfully revascularized. In CABG group, however, 7 of 10 patients had major complications including 2 hospital deaths, while no complications occurred in the PTCA group. During the follow-up period after CABG (35 +/- 30 months), recurrent angina developed in one patient, who was successfully treated with PTCA. In the PTCA group, angiographic success was initially obtained in 16 of 21 lesions (76%), which was significantly lower than that in the control group (92%, p < 0.05). Follow-up angiography revealed restenosis in 6 of 16 lesions with successful PTCA (38%), similar to that observed in the control group (32%, p = ns). A second PTCA was successful in 5 of 6 patients with restenosis, however, 4/5 patients developed recurrent angina. Three of 4 patients with a second episode of restenosis underwent a third PTCA, and angina recurred in 2.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary angioplasty at the time of initial diagnostic coronary angiography in patients with unstable angina

Of the last 200 consecutive patients undergoing PTCA procedures at our institution, 29 (15%) had unstable angina; and angioplasty was performed at the time of diagnostic coronary arteriography. There were 26 males and three females with an age range of 31-82 (mean 57) years. Factors favoring PTCA at the time of initial coronary arteriography included clinical indications for revascularization, appropriate anatomy based on high-quality fluoroscopy, and availability of emergency surgery if required. Of 34 coronary lesions in 29 patients, 19 involved the anterior branch of the left anterior descending coronary artery (LAD), eight the circumflex branch (Cx); and seven the right coronary artery (RCA). Five patients had two vessels dilated (one LAD + RCA, two LAD + Cx, and two RCA + Cx). Of the coronary artery lesions, 19 were concentric, seven were eccentric, 20 were single and discrete, six were long or multiple in the same vessel; eight vessels were totally occluded, and in nine patients there was good collateral circulation. Twenty-nine (85%) arteries were successfully dilated. Of the unsuccessful cases, one was from failure to cross a totally occluded lesion, and three residual lesions and/or postdilatation pressure gradients remained significant. One patient required emergency aortocoronary bypass surgery because of total occlusion of the LAD immediately post-PTCA. There were no postprocedural myocardial infarcts or deaths. It is concluded that, in selected patients with unstable angina, PTCA can be performed successfully and with low risk at the time of initial diagnostic coronary arteriography. This approach offers certain clinical financial advantages.     

Coronary angioplasty for early postinfarction unstable angina

Coronary angioplasty was performed in 53 patients in whom unstable angina had reoccurred after 48 hr and within 30 days after sustained myocardial infarction. Single-vessel disease was present in 64% of the patients and multivessel disease in 36%. The preceding myocardial infarction had been small to moderate in size in the majority of the patients. The left ventricular ejection fraction was more than 50% in 80% of the patients. Forty-five patients were refractory to pharmacologic treatment; eight were initially stabilized but once again became symptomatic with light exertion. Angioplasty was performed in 35 patients 2 to 14 days and in 18 patients 15 to 30 days after infarction (average 12 +/- 7 days after infarction). The initial success rate was 89% (47/53). The success rate of the patients treated at 2 to 14 days was lower (29/35, 83%) than that of patients treated at 14 to 30 days (18/18, 100%) but did not reach statistical significance (p less than .06). There were no deaths related to the procedure. In four of the six failures, emergency bypass surgery was performed and two patients sustained a myocardial infarction. Furthermore, a myocardial infarction complicated the angioplasty procedure in two other patients; thus the overall procedure-related myocardial infarction rate was 8% (4/53). At 6 months follow-up 26% (14/53) of all the patients who underwent angioplasty had recurrence of angina, which was successfully treated with repeat angioplasty, bypass surgery, or medical therapy. There were no late deaths. Late myocardial infarction occurred in two patients. Thus the total myocardial infarction rate after angioplasty at 6 months was 11% (6/53 patients).(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous transluminal coronary angioplasty for patients with unstable angina pectoris.

Percutaneous transluminal coronary angioplasty (PTCA) was successful in 91% of 76 patients with unstable angina pectoris refractory to pharmacological treatment. However, the rate of acute occlusion and reocclusion was rather high (95). Restenosis developed in 56.5% of successful cases after initial PTCA, and 29 patients underwent 2nd, and nine 3rd PTCA. Most refractory unstable angina can be controlled by PTCA, which may require repeating in some patients.