Acute coronary occlusion during percutaneous transluminal coronary angioplasty

Two hundred and forty percutaneous transluminal coronary angioplasty procedures were performed in three centres over a two year period. Acute occlusion of the vessel undergoing angioplasty was seen on 20 (8%) occasions. The cause of occlusion was determined angiographically and in some cases confirmed at the time of emergency open heart surgery. The mechanism of coronary occlusion was arterial dissection in six cases, persisting coronary arterial spasm in seven, and coronary thrombosis in four. In three patients the mechanism could not be determined. Immediate reintroduction of a balloon dilatation catheter was attempted in 10 patients and resulted in restoration of adequate coronary flow in six. The remaining 14 patients underwent open heart surgery as an emergency procedure.     

Acute coronary occlusion during percutaneous transluminal coronary angioplasty.

Two hundred and forty percutaneous transluminal coronary angioplasty procedures were performed in three centres over a two year period. Acute occlusion of the vessel undergoing angioplasty was seen on 20 (8%) occasions. The cause of occlusion was determined angiographically and in some cases confirmed at the time of emergency open heart surgery. The mechanism of coronary occlusion was arterial dissection in six cases, persisting coronary arterial spasm in seven, and coronary thrombosis in four. In three patients the mechanism could not be determined. Immediate reintroduction of a balloon dilatation catheter was attempted in 10 patients and resulted in restoration of adequate coronary flow in six. The remaining 14 patients underwent open heart surgery as an emergency procedure.     

Acute coronary artery occlusion during percutaneous transluminal coronary angioplasty treated by redilation of the occluded segment

Acute occlusion of a coronary artery during percutaneous coronary angioplasty usually results in unremitting ischemia requiring emergency surgical intervention. Seven patients are described, in whom complete occlusion occurred during coronary angioplasty as a result of coronary artery dissection. Despite this, it was possible to reintroduce the balloon catheter immediately and redilate the vessel with abrupt reversal of clinical and electrocardiographic manifestations of ischemia. Six patients had no subsequent evidence of myocardial infarction. The seventh had a slight elevation of serum creatine kinase and transient electrocardiographic changes. All patients were discharged from the hospital without further intervention. Four patients had elective coronary artery bypass surgery (greater than 4 weeks after angioplasty) and three have remained asymptomatic or in improved condition since the coronary angioplasty. It is concluded that sudden occlusion of a coronary artery during coronary angioplasty can be safely treated by redilation in the acute stage.     

Early and late outcome of percutaneous transluminal coronary angioplasty for subacute and chronic total coronary occlusion

Percutaneous transluminal coronary angioplasty (PTCA) for nonacute total coronary occlusion was performed in 46 patients, with a 63% primary success rate (29 of 46 procedures). There were no acute myocardial infarctions and no deaths in the study group. There was no difference in success rate according to vessel dilated, prior myocardial infarction, or lesion morphology. The success rate with occlusions <2 weeks' duration was 14 of 19 (74%) vs 15 of 27 (55%) with occlusions >2 weeks' duration (p =NS). There was clinical recurrence in 14 of 29 (48%). Factors predictive of recurrence included a greater residual post-PTCA stenosis of 47 ± 6% in recurrences vs 31 ± 3% in nonrecurrences (p < 0.025), while estimated duration of initial occlusion was 1.1 ± 0.4 months for recurrences vs 3.1 ± 1 months for nonrecurrences (p = 0.07). PTCA for total occlusion has a lower success rate and higher recurrence rate than PTCA for nontotal stenoses. Recurrence appears to be related to a higher degree of post-PTCA residual narrowing and to a shorter duration of initial occlusion.     

Acute coronary thrombotic occlusion following exercise testing 6 weeks after percutaneous transluminal coronary angioplasty

Exercise stress testing is often performed following percutaneous transluminal coronary angioplasty (PTCA) in order to evaluate the efficacy of the procedure [1]. Together with thallium-201 (T1-201) scintigraphy, these noninvasive tests provide valuable data for predicting the recurrence of angina and restenosis [2]. However, concerns regarding the safe timing of exercise testing post-PTCA have been raised in 3 previous case reports [3–5]. Each case documents acute coronary occlusion shortly after stress testing performed within several days of successful angioplasty, leading to the recommendation that such testing be deferred up to 4 weeks following PTCA. This paper reports a patient in whom acute thrombotic occlusion of the left anterior descending coronary artery (LAD) occurred immediately after a mildly abnormal exercise T1-201 stress test done 6 weeks after PTCA.     

Acute coronary occlusion during transluminal angioplasty: role of coronary thrombosis

We here report on 2 patients treated by transluminal coronary angioplasty, who presented baseline angiographic aspects of an intracoronary thrombus upon vessel stenosis. In both cases mechanical dilatation was successful in increasing vessel diameter, but was complicated by activation of the thrombotic process with clot proliferation--as shown by multiple coarse filling defects irregularly stained by contrast material--and vessel occlusion. The intracoronary injection of streptokinase achieved partial slowing of the thrombotic process, but did not succeed in inhibiting it completely or in restoring vessel patency. As clinical conditions were stable, the patients were not sent to emergency surgery, but were treated conservatively with anticoagulants and platelet inhibitors: in only one patient the procedure was followed by moderate myocardial enzyme release. In both cases the coronary artery was patent at short term angiographic control. These 2 cases confirm that in the outset of transluminal angioplasty an acute coronary occlusion can be managed conservatively by thrombolytic treatment when thrombus formation can be clearly identified the cause of vessel occlusion: the activation of spontaneous lytic systems can completely restore vessel patency. If coronary occlusion was of short duration or collateral supply was adequate, myocardial infarction may not occur and emergency coronary surgery will not be necessary.     

Acute coronary events associated with percutaneous transluminal coronary angioplasty

Acute coronary events reported in patients enrolled in the NHLBI PTCA Registry were analyzed. Data were collected on 3,079 patients from 105 contributing centers. Coronary vascular events (dissection, occlusion, spasm, embolism, perforation or rupture) or ischemic events (MI or prolonged angina) occurred in 418 patients (13.6%). Major complications (MI), emergency surgery or death) occurred in 280 patients (67%) with acute coronary events. The most frequent events were prolonged angina, which occurred in 211 (6.8%), and MI, in 170 (5.5%). Coronary dissection, occlusion and spasm each occurred in approximately 5% of patients. Coronary embolism, perforation and rupture were rare (< 0.2% for each). Dissection and occlusion each had a high frequency (> 80%) of associated major complications. A substantially lower incidence of major complications occurred in patients with isolated coronary spasm (18%) or prolonged angina (35%). Clinical and angiographic predictors for overall and specific events were identified. Coronary events occurred more frequently in women and patients with unstable angina. Eccentric lesions were associated with a higher rate of coronary events, and event rates were lower with single discrete lesions than with other types of lesions. The frequency of any coronary event, MI, prolonged angina and coronary spasm each decreased with increasing experience with PTCA. The frequency of dissection and occlusion did not change with experience.     

Acute coronary occlusion occurring after successful percutaneous transluminal coronary angioplasty: temporal relationship to discontinuation of anticoagulation

The incidence and prognosis of acute coronary reocclusion occurring after patients had left the catheterization laboratory following a successful percutaneous transluminal coronary angioplasty (PTCA) procedure and the temporal relation of this event to the discontinuation of systemic heparin administration were analyzed in a series of 1238 consecutive patients. Acute reocclusion, 1 to 96 hours after successful PTCA, occurred in 22 of 1238 patients (1.8%). Patients undergoing PTCA in the setting of acute myocardial infarction were excluded. Out of 22 patients, 15 had a nonocclusive dissection and four had evidence of small intracoronary thrombus immediately post-PTCA, with no evidence of flow disturbance. Acute reocclusion occurred within 5 hours of heparin discontinuation in 12 patients or while they were receiving inadequate anticoagulation (four patients). In 16 of 22 (73%) patients, acute reocclusion was temporally related to a time of diminished anticoagulation. Redilation was attempted in 14 patients and was ultimately successful in five patients (36%). Ten patients required coronary artery bypass surgery and three patients died. Our findings suggest that acute reocclusion after an initially successful PTCA has a poor outcome and seems to be temporally related to the loss of effective anticoagulation in most of these patients. It is advisable to discontinue heparin infusion at a time when facilities for urgent revascularization are available.     

Clinicopathologic study of acute coronary occlusion in percutaneous transluminal coronary angioplasty

ACO occurred within 40 min (mean 15.7 min) after PTCA in 22 patients and more than 12 hours in 2. The group with ACO had a significantly higher incidence of female (46% vs 23%), acute myocardial infarction (63% vs 35%), eccentric lesions (73% vs 28%), tortuous lesions (30% vs 4%) and coronary dissection or intraluminal haziness (89% vs 34%). Luminal narrowing before and after PTCA was significantly higher in ACO group than in control group (93% and 56% vs 87% and 23%). Repeat PTCA was performed in 17 patients and was successful in 13. Coronary bypass surgery was performed in 4 patients. Intracoronary urokinase was ineffective to ACO. In 3 autopsy cases dying 5, 14 and 17 days after PTCA, large extent of intimal tears and thrombus in the space of tears and the lumens were observed. These results suggest that coronary dissection chiefly contributes to ACO and coronary thrombosis is superimposed for a secondary event in most of cases with ACO.     

Acute coronary thrombotic occlusion following exercise testing 6 weeks after percutaneous transluminal coronary angioplasty.

Exercise stress testing is often performed following percutaneous transluminal coronary angioplasty (PTCA) in order to evaluate the efficacy of the procedure. Together with thallium-201 (Tl-201) scintigraphy, these noninvasive tests provide valuable data for predicting the recurrence of angina and restenosis. However, concerns regarding the safe timing of exercise testing post-PTCA have been raised in 3 previous case reports. Each case documents acute coronary occlusion shortly after stress testing performed within several days of successful angioplasty, leading to the recommendation that such testing be deferred up to 4 weeks following PTCA. This paper reports a patient in whom acute thrombotic occlusion of the left anterior descending coronary artery (LAD) occurred immediately after a mildly abnormal exercise Tl-201 stress test done 6 weeks after PTCA.     

Exercise echocardiography performed early and late after percutaneous transluminal coronary angioplasty for prediction of restenosis

The purpose of this prospective study was to examine the incidenceof exercise-induced ischaemia before and after angioplasty aswell as 4 months later by exercise echocardiography, to evaluatethe prognostic value of exercise echocardiography performedafter angioplasty as regards the development of restenosis andto determine whether serial exercise tests, increase the accuracyof detecting angiographically relevant reslenosis. Fifty patients (39 males; mean age 52 ± 9 years) withoutprior Q wave infarction entered the study protocol. Exerciseechocardiography was performed 2 days prior to angioplasty,13 ± 6 days after successful angioplasty as well as atroutine follow-up angiography 3.8 ± 1.6 months afterangioplasty. Angiographically successful angioplasty was achieved in 94%(47/50) of patients, and early and late follow-up examinationswere performed in all 47 patients. A verage luminal diameterstenosis decreased from 65 ± 5% to 26 ± 9% immediatelyafter angioplasty. Control angiography showed significant restenosisin 30% (14/47) of patients. Exercise echocardiography beforeangioplasty was positive in 90%, continued to be positive in30% of patients after angioplasty and was positive in 43% atcontrol angiography. The exercise echocardiogram performed earlyafter angioplasty had an overall accuracy for prediction ofrestenosis of 70%, with a positive predictive value of 50% anda negative predictive value of 79%. Sensitivity for detectionof restenosis at control angiography was high (86%), but specificity(76%) was moderate. Exercise echocardiograms showing deteriorationfrom 2 weeks to 4 months after angioplasty were taken as a signof restenosis and resulted in an increased specificity of 94%.Sensitivity, however, decreased to 36%, indicating that somepatients with an early positive stress echo had already sufferedrestenosis 13 days after angioplasty. In conclusion, exercise echocardiography documents improvementin regional function after angioplasty. However, a significantproportion of patients continue to have a positive exerciseechocardiogram even though angioplasty was angiographicallysuccessful, probably due to persistent ischaemic regions orearly restenosis. While exercise echocardiography performedearly after angioplasty is of insufficient value for the predictionof restenosis, if performed at late follow-up it has a gooddiagnostic accuracy for detecting restenosis.     

Exercise echocardiography performed early and late after percutaneous transluminal coronary angioplasty for prediction of restenosis

The purpose of this prospective study was to examine the incidenceof exercise-induced ischaemia before and after angioplasty aswell as 4 months later by exercise echocardiography, to evaluatethe prognostic value of exercise echocardiography performedafter angioplasty as regards the development of restenosis andto determine whether serial exercise tests, increase the accuracyof detecting angiographically relevant reslenosis. Fifty patients (39 males; mean age 52 ± 9 years) withoutprior Q wave infarction entered the study protocol. Exerciseechocardiography was performed 2 days prior to angioplasty,13 ± 6 days after successful angioplasty as well as atroutine follow-up angiography 3·8 ± 1·6months after angioplasty. Angiographically successful angioplasty was achieved in 94%(47/50) of patients, and early and late follow-up examinationswere performed in all 47 patients. A verage luminal diameterstenosis decreased from 65 ± 5% to 26 ± 9% immediatelyafter angioplasty. Control angiography showed significant restenosisin 30% (14/47) of patients. Exercise echocardiography beforeangioplasty was positive in 90%, continued to be positive in30% of patients after angioplasty and was positive in 43% atcontrol angiography. The exercise echocardiogram performed earlyafter angioplasty had an overall accuracy for prediction ofrestenosis of 70%, with a positive predictive value of 50% anda negative predictive value of 79%. Sensitivity for detectionof restenosis at control angiography was high (86%), but specificity(76%) was moderate. Exercise echocardiograms showing deteriorationfrom 2 weeks to 4 months after angioplasty were taken as a signof restenosis and resulted in an increased specificity of 94%.Sensitivity, however, decreased to 36%, indicating that somepatients with an early positive stress echo had already sufferedrestenosis 13 days after angioplasty. In conclusion, exercise echocardiography documents improvementin regional function after angioplasty. However, a significantproportion of patients continue to have a positive exerciseechocardiogram even though angioplasty was angiographicallysuccessful, probably due to persistent ischaemic regions orearly restenosis. While exercise echocardiography performedearly after angioplasty is of insufficient value for the predictionof restenosis, if performed at late follow-up it has a gooddiagnostic accuracy for detecting restenosis.     

Acute occlusion after percutaneous transluminal coronary angioplasty--a new approach

Between July 1980 and November 1982, there were 935 coronary angioplasties attempted at Emory University Hospital. Of these patients, 20 developed acute occlusion. Of these 20, 19 presented within 3 hr of surgery or within 3 hr after stopping a continuous heparin infusion. Five patients required emergency surgery, but in 15 nitrates, nifedipine, and/or repeat angioplasty reopened the artery and the patient could be stabilized on continuous infusions of heparin and nitroglycerin. In only one case was an occluding thrombus evident on angiographic examination. The mechanism of acute occlusion is unknown, but coronary artery spasm may play a role.