High frequency rotational ablation: an alternative in treating coronary artery stenoses and occlusions.

OBJECTIVE--To prove the safety and effectiveness of high frequency rotational ablation of coronary artery stenoses and occlusion in humans. SUBJECTS--106 patients with symptoms (91 men, 15 women) who had 67 significant stenoses, mainly types B and C, and 46-chronic occlusions. MAIN OUTCOME MEASURES--Mean change in diameter stenosis after rotational angioplasty alone and in combination with percutaneous transluminal coronary angioplasty immediately after treatment and 24 hours and six months later; restenosis rates at six months; complication of treatment. RESULTS--Rotational ablation could not be used in five stenoses and 16 chronic occlusions because of inability to reach or cross the lesion with the Rotablator guide wire. In four cases rotational ablation failed. Initial angiographic and clinical success by rotational ablation was achieved in 40 of the 67 stenoses (60%) and in 18 of the 46 chronic occlusions (39%). Additional balloon angioplasty was performed in 45 patients, increasing the success rates to 79% and 54%, respectively. In the 62 stenoses treated by rotational ablation the angiographic diameter stenoses were reduced from 76% (SD 14%) to 32% (14%) after Rotablator treatment alone and from 75% (11%) to 33% (17%) with additional balloon angioplasty. In the 30 chronic occlusions treated by rotational ablation the angiographic diameter stenoses were reduced to 38% (18%). At six months angiographic restenosis was evident in nine of the 25 (36%) stenoses treated with rotational ablation alone, in seven of the 22 (32%) stenoses treated with rotational and balloon angioplasty, and in 14 of the 24 (58%) chronic occlusions. There were no procedural deaths and two patients (2%) underwent emergency coronary artery bypass grafting. Although no transmural infarction occurred, there were five (6%) non-Q wave infarctions (two embolic side branch occlusions, two subacute occlusions, and one acute occlusion). Clinically insignificant slight increases in creatine kinase activity were seen in five patients (6%). Severe coronary artery spasm unresponsive to medical treatment was provoked in seven cases (8%). CONCLUSIONS--High frequency rotational ablation is a safe and effective method for treating type B and C coronary artery lesions with results comparable to percutaneous transluminal coronary balloon angioplasty. The combined use of rotational ablation and balloon angioplasty is feasible and is necessary in about half of all procedures, in most cases because the lumen created by the biggest burr is too small.     

Percutaneous excimer laser coronary angioplasty of lesions not ideal for balloon angioplasty

BACKGROUND. Excimer laser coronary angioplasty is a new, investigational technique for treating coronary artery stenoses. Initial reports have demonstrated acute efficacy and relative safety of this procedure, but have not addressed the effect of lesion type on acute success and complication rates. METHODS AND RESULTS. In the first 100 patients undergoing percutaneous excimer laser coronary angioplasty at our institution, acute laser success was obtained in 84% and procedural success was obtained in 94%. There were six acute closures during laser angioplasty and one myocardial infarction. Two patients required emergency coronary bypass surgery. Sixty-five percent of patients had lesions not ideal for balloon angioplasty because of lesion morphology (tubular, diffuse, or chronic total occlusion) or ostial location. There were 10 tubular stenoses, 29 diffuse lesions, 18 chronic total occlusions, and eight ostial lesions, including five aorto-ostial lesions. In this nonideal subgroup, the acute success rate with laser was 86% (72% of chronic total occlusions and 91% of non-totally occluded lesions), and the procedural success rate was 94%. There were three acute occlusions during laser angioplasty but no myocardial infarctions, emergency bypass surgeries, or deaths. One coronary artery perforation occurred without clinical sequelae. Laser angioplasty was successful in four of six lesions (67%) in which balloon angioplasty had failed. Laser success was obtained in 10 of 11 (91%) moderately or heavily calcified stenoses. Eight eccentric lesions and two lesions on bends were successfully treated without dissection or perforation. No side branch occlusions occurred in the 15 patients in whom one or more major branches originated within the lesion treated. Adjunctive balloon angioplasty was performed in 47% of cases, usually to obtain a larger final luminal diameter. Need for adjunctive balloon angioplasty decreased to 36% after a larger (2.0 mm) laser catheter became available. Twenty-eight percent of the 105 lesions treated were American College of Cardiology/American Heart Association classification type A, 47% were type B, and 25% were type C. Laser and procedural successes were obtained in 83% and 97% of type A, 88% and 96% of type B, and 85% and 88% of type C lesions, respectively. CONCLUSIONS. In our initial experience, excimer laser angioplasty was found to be acutely effective and safe therapy for lesions identified as not ideal for balloon angioplasty. This technique may provide a useful adjunct or alternative to balloon angioplasty in selected patients.     

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)     

Catheter therapy in patients with stable angina pectoris. Results of 662 coronary angioplasties

Coronary angioplasty supplemented by implantation of a stent has become a standard therapeutic method in patients with stable angina pectoris. The authors analyzed the spectrum of patients indicated for this treatment, its successfulness and complications of catheterizations. In the course of a two-year period the authors implemented 662 catheterizations in 602 patients with stable angina. 58% patients indicated for coronary angioplasty on account of stable angina had a history of myocardial Q infarction, 93% had angina grade II or III according to CCS. Affection of one artery was diagnosed in 56% patients, complete revascularization was achieved in 59% of the operations. The clinical rate of success of catheterization was 97% in stenoses of the coronary arteries and 61% in coronary occlusions. In 57% of the treated lesions a coronary stent was implanted. Serious clinical complications developed in 1% of the interventions, none of the patients died. Catheterization treatment of stable angina is very successful and safe.     

Same-day angioplasty and diagnostic catheterization: safe and effective but riskier in unstable angina

Percutaneous transluminal coronary angioplasty was performed at the time of the diagnostic catheterization in 188 patients (215 lesions) at a University Hospital in order to assess the efficacy of this approach and the potential role it should play in the evaluation and treatment of patients. Patients either presented for diagnostic catheterization for evaluation of stable coronary disease (79 patients) or for unstable or new onset anginal symptoms (109 patients). Lesions were graded as to whether they were simple or complex; and post angioplasty films were reviewed for success rate, and degree of revascularization. Patients who were referred for stable anginal symptoms had a slightly higher success rate (91%) compared to those who were referred for new onset or more unstable symptomatology (85%, p = ns). Additionally, lesions morphology was judged to be more complex in unstable patients, as 67% had complex lesions with the presence of thrombus or ulcerated plaque in 56% of these stenoses. Angioplasty success was high for simple lesions in all patients, but was most unfavorable for complex stenoses in patients who presented with unstable symptoms (81% success rate). In patients who presented with new onset or unstable symptoms multivessel disease was present in 69% and angioplasty was more often geared at dilating a culprit stenosis leaving only 49% of these patients with complete revascularization. On the other hand, in 76% of those patients who presented with stable angina complete revascularization was a common outcome. Length of hospital stay was considerably shorter at 2.9 +/- 0.8 days in those patients who presented with stable symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary angioplasty of multivessel coronary diseases. Apropos of 1664 procedures. Immediate results and results following 6 months]

Between 1980 and 1990, 1,664 coronary angioplasty procedures were performed in 1,307 patients (86.6% male) with multivessel disease. The average age was 57 +/- 3 years (range 29 to 83 years). There was a previous history of infarction in 40.1% of patients and 22.4% of the procedures were performed for unstable angina. Catheter and 58.2%, 1,220 double vessel and 444 triple vessel diseases. A total of 2,509 lesions were dilated (1.5 stenoses/patient). The primary success rate was 81.9% with 3.2% of infarcts and 3.5% emergency bypass procedures and a global mortality of 2%. The factors responsible for death in the acute and hospital phases were unstable angina, age > 70 years, and ejection fraction < 35%. Complete revascularisation was achieved in 14.3% of cases: the only predictive factor for complete revascularisation on multivariate analysis was double vessel disease. A 6 months clinical and angiographic control was obtained for 83.8% of controllable procedures (965 dilatations). The restenosis rate was 47.9%. Univariate analysis of the factors of restenosis identified clinical parameters (age > 58 years, triple vessel disease, diabetes and unstable angina), parameters related to the lesion (length of stenosis > 1 cm, percentage stenosis > 80%) and to the procedure (residual stenosis > 20%): 68.4% of patients with restenosis underwent repeat angioplasty with a significantly superior primary success rate 88.7% vs 81.9% of global successes (p < 0.001). With a 82% primary success rate with few major complications, coronary angioplasty is a safe and effective therapeutic alternative. The extent of the lesions and the presence of chronic occlusion are the main limitating factors of revascularisation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary angioplasty in unstable angina and stable angina: a comparison of success and complications

One hundred and five patients with unstable angina and 175 with chronic stable angina were treated by primary percutaneous transluminal coronary angioplasty. Patients with unstable angina had had symptoms for a shorter time and were more likely to have angiographically complex lesions and lesions less than 10 mm in length than patients with chronic stable angina. Other baseline variables were not significantly different in the two groups. The overall primary success rate was similar in both groups (87% v 86%). Nine of the 14 unsuccessful procedures in those with unstable angina and nine of the 24 unsuccessful procedures in those with stable angina were the result of acute occlusion. These results led to a 9% frequency of procedure related myocardial infarction in patients with unstable angina and a 5% rate in those with stable angina (NS). The procedure related infarct rate tended to be higher in patients with unstable angina who had coronary angioplasty soon after an episode of unstable angina (mean 10 days) than in those in whom it was delayed (mean 35 days) (12% v 3%) (NS). In patients with unstable angina who had had a previous myocardial infarction procedure related infarction was significantly more common (18%) than in patients with no previous myocardial infarction (3%). The difference between those with and without previous infarction was also significant in patients with stable angina (10% v 3%).     

Coronary angioplasty in unstable angina and stable angina: a comparison of success and complications.

One hundred and five patients with unstable angina and 175 with chronic stable angina were treated by primary percutaneous transluminal coronary angioplasty. Patients with unstable angina had had symptoms for a shorter time and were more likely to have angiographically complex lesions and lesions less than 10 mm in length than patients with chronic stable angina. Other baseline variables were not significantly different in the two groups. The overall primary success rate was similar in both groups (87% v 86%). Nine of the 14 unsuccessful procedures in those with unstable angina and nine of the 24 unsuccessful procedures in those with stable angina were the result of acute occlusion. These results led to a 9% frequency of procedure related myocardial infarction in patients with unstable angina and a 5% rate in those with stable angina (NS). The procedure related infarct rate tended to be higher in patients with unstable angina who had coronary angioplasty soon after an episode of unstable angina (mean 10 days) than in those in whom it was delayed (mean 35 days) (12% v 3%) (NS). In patients with unstable angina who had had a previous myocardial infarction procedure related infarction was significantly more common (18%) than in patients with no previous myocardial infarction (3%). The difference between those with and without previous infarction was also significant in patients with stable angina (10% v 3%).     

Percutaneous transluminal coronary angioplasty of the "culprit lesion" for management of unstable angina pectoris in patients with multivessel coronary artery disease

The efficacy of 1-vessel percutaneous transluminal coronary angioplasty (PTCA) directed at the presumed angina-producing stenosis, or "culprit lesion," in the treatment of unstable angina pectoris and multivessel coronary artery disease (CAD) was assessed in 27 patients with unstable angina refractory to optimal medical therapy. Eighteen patients had 2-vessel and 9 had 3-vessel CAD. The culprit lesion was identified in all patients by analysis of the qualitative appearance of the coronary lesions and detection of angiographic evidence of plaque fissuring or coronary thrombosis. Intracoronary filling defects were evident in 26% and eccentric stenoses with irregular edges were noted in 41% of patients. Subtotal obstructions were seen in 33%. Confirmation of the identity of the culprit lesion was also available in 78% of patients by analysis of the pattern and distribution of spontaneous electrocardiographic changes. The PTCA primary success rate was 89%, with no procedure-related complications. All patients in whom PTCA was successful had immediate resolution of their unstable angina. Follow-up of the successfully treated patients after a mean of 16 months (range 12 to 20) showed maintenance of long-term clinical improvement, with only 17% of patients having recurrent angina. These data suggest that 1-vessel PTCA of the culprit lesion may serve as a feasible therapeutic option in the treatment of selected patients with multivessel CAD and unstable angina.     

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)     

Rapid angiographic progression of “target” and “nontarget” stenoses in patients awaiting coronary angioplasty

Objectives. Our aim was to compare the short-term evolution of “target” versus “nontarget” stenoses in patients awaiting coronary angioplasty.Background. Coronary angioplasty is effective therapy for angina pectoris, but coronary events occur after successful angioplasty that are caused by both restenosis and progression of mild preexisting nontarget stenoses.Methods. We prospectively studied 161 consecutive patients with stable angina (124 men and 37 women). After diagnostic angiography, target stenoses for angioplasty and nontarget lesions were identified. Patients were put on a routine waiting list and followed up regularly until repeat coronary arteriography was performed (mean ± SD 7 ± 3 months), either immediately before angioplasty (138 patients) or soon after an acute coronary event (23 patients), if one occurred. Stenosis diameter was measured by using computerized arteriography. Progression of disease was defined as ≥20% lesion diameter reduction, new total occlusion or development of a “new” stenosis ≥30%.Results. At study entry, the mean diameter of target (n = 207) and nontarget (n = 184) lesions was 68 ± 9% and 38 ± 9%, respectively (p < 0.001). Disease progression occurred in 33 patients (20%). Seven new lesions (one total occlusion) developed. Eighteen target (9%) and 15 nontarget (8%) stenoses progressed. The power of the study to detect a difference of 1% between the risks of progression of target and nontarget stenoses with a 90% probability was <0.1. Total occlusion developed in 15 (83%) of the 18 target and 6 (40%) of the 15 nontarget stenoses (p = 0.03). During follow-up, a myocardial infarction developed in 3 patients (2%) and unstable angina in 20 (12%). These coronary events were associated with progression of target stenoses in 10 patients and nontarget stenoses in 7 and with the development of new lesions in 1. In five patients coronary events were not associated with stenosis progression.Conclusions. Despite differences in baseline severity, a similar proportion of target and nontarget lesions progressed rapidly. However, target stenoses were more likely than nontarget lesions to progress to total occlusion. Progression of nontarget stenoses may contribute to recurrence of angina and new coronary events after successful angioplasty and should be considered when developing strategies aimed at improving outcome after angioplasty.     

Experience with low-dose intracoronary recombinant tissue-type plasminogen activator for nonacute total occlusions before percutaneous transluminal coronary angioplasty

The primary success rate for angioplasty of total occlusions is significantly worse than for subtotal lesions. Pharmacologic recanalization of total occlusions before angioplasty has the potential to improve the primary success rate. To determine the ability of recombinant tissue-type plasminogen activator (rt-PA) to recanalize occlusive thrombi before elective percutaneous transluminal coronary angioplasty, 12 patients with total occlusions, 100% obstruction and Thrombolysis in Myocardial Infarction (TIMI) grade 0 flow, and 5 with functional total occlusions, severe stenoses and TIMI grade 1 flow received an intracoronary infusion of rt-PA. The first 10 patients received 0.2 mg/min for 90 minutes, and the next 7 patients received 0.4 mg/min for 60 minutes. Flow improved by ≥ 1 TIMI grade in 11 patients. Mean TIMI flow improved from 0.3 ± 0.5 to 1.5 ± 1.2 (p < 0.0001). There was a significant improvement in severity of stenosis after rt-PA infusion by both digital caliper (99 ± 2 vs 84 ± 16%; p < 0.0001) and quantitative videodensitometric area assessment (99 ± 3 vs 94 ± 6%; p < 0.004). Angioplasty was successful in 16 of 17 patients (94%). There were 2 out-of-laboratory abrupt closures at 4 days; both were medically treated and 1 had a small myocardial infarction. Only 1 patient had a bleeding complication significant enough to need a transfusion. It is concluded that tow-dose intracoronary rt-PA is effective at lysing thrombi < 3 weeks old. This approach warrants further investigation since it may significantly improve the primary success rate of percutaneous transluminal coronary angioplasty in patients with occlusive thrombus.     

Percutaneous transluminal coronary angioplasty for chronic total coronary arterial occlusion

Experience is reported with 100 consecutive patients in whom percutaneous transluminal coronary angioplasty (PTCA) was attempted on chronically occluded coronary arteries that had no visible anterograde flow. Ninety-eight patients had angina and all had collateral vessels to the occluded artery on angiography. A movable guidewire/dilatation system was used in all cases. Overall initial PTCA success rate was 56% and was related to duration of occlusion (69% success rate for occlusions of 1 month or less, 50% for 1 to 6 months and 11% after 6 months). Complications were minor; no patient died or required emergency bypass operation. Of the 44 patients in whom PTCA failed, 20 underwent elective bypass surgery for relief of angina and 24 were treated medically. Follow-up at a mean of 8 months (range 1 to 48) was available for 49 of the 56 patients in whom PTCA was successful: 40 had subjective improvement, 6 no change and 3 felt worse. Control angiography was carried out in 40 of the 56 patients with primary success and showed long-term success in 18 and reocclusion or significant stenosis in 22. Of these 22, 11 were successfully treated by a second PTCA, 2 underwent operation and 9 were treated medically. Recanalization of totally occluded coronary arteries with no forward flow has a lower initial success rate (56%) than PTCA for stenoses and the recurrence rate is higher (55%), but effective relief of angina is achieved in successful cases. The risk of serious complications appears to be low.     

Angioplasty in ulcerative coronary artery disease: acute results and early follow-up.

The safety and efficacy of percutaneous transluminal coronary angioplasty (PTCA) for stenoses involving ulcerative lesions were retrospectively studied. Seventy-seven patients (62 men and 15 women, mean age 62 +/- 10 years) representing 3.4% of 2,250 patients treated with PTCA during the period January 1, 1988 and June 30, 1990, had pre-PTCA stenoses defined as ulcerated. Twenty-eight (36%) of the stenoses were localized in the left anterior descending coronary artery, 9 (12%) in the left circumflex and 40 (52%) in the right coronary artery. During angioplasty, percent diameter stenosis was reduced from 73 +/- 14% to 22 +/- 13% and transstenotic gradient decreased from 48 +/- 18 to 12 +/- 6 mm Hg. Clinical success (freedom from angina at discharge without coronary bypass surgery, infarction or death) was achieved in 70 patients (90.9%). There were seven unsuccessful cases: three underwent elective coronary bypass surgery, one was managed medically, and three developed a major flow interrupting dissection during the procedure requiring emergency coronary bypass surgery. There were no deaths. At mean follow-up of 7.6 months, 45 of 61 patients (73.7%) remained asymptomatic. One patient needed an elective coronary bypass surgery and five patients had a successful repeat PTCA. In conclusion, PTCA for an ulcerated stenosis can be performed safely with a high primary success rate and a favorable early clinical course.     

Coronary angioplasty via saphenous vein grafts

Percutaneous transluminal angioplasty of coronary stenoses distal to anastomosis of a venous graft was attempted through the graft 22 times in 19 patients. Ten patients had stable angina, seven unstable angina and two patients acute myocardial infarction. The mean interval between bypass surgery and angioplasty was 6.5 years (range 1-15). Fifteen lesions were dilated in the left anterior descending artery, five in the right coronary artery, and two in the circumflex artery. Three procedures were for double lesions. In two cases, a stenosed vein graft was also dilated. All grafts were cannulated with an El Gamal guiding catheter. The procedure failed in two cases. The remaining 20 lesions were successfully dilated. Early and late occlusion of the graft occurred in one patient, and coronary arterial stenosis recurred in two patients. All three patients underwent successful redilatation. The 17 patients undergoing successful dilatation were asymptomatic, with a normal exercise test and/or maintained angiographic result at follow-up of 14 months mean duration (range 2-48). Angioplasty of coronary stenosis through a vein graft is feasible, safe and effective. This therapeutic approach avoids the need for repeat bypass surgery and, as judged by long-term follow-up, has a favourable clinical outcome.     

Coronary angioplasty of multiple vessels and lesions in unstable functional class-IV angina

A select group of 26, class IV unstable angina patients that had multiple lesions or multivessel disease were treated with percutaneous transluminal coronary angioplasty (PTCA). Complete revascularization was the endpoint in all patients. Seventy lesions were dilated (mean = 2.6 lesions per patient). In the tandem multi-lesion group (13 patients) 2.23 lesions per patient were approached (Range 2-3) and in the multivessel disease group (13 patients) a mean of 3.15 lesions per patient were attempted (Range 2-6). An overall success rate of 96% per patient (25/26 patients) and 95.7% primary success per lesion were achieved with no mortality. We report the results of a select group of unstable angina patients with multi-lesion or multivessel disease who underwent PTCA. A careful performance was associated with high primary success in the high risk group achieving clinical and angiographic improvement.     

Preangioplasty complicated coronary stenosis morphology as a predictor of restenosis.

To assess whether complicated preangioplasty coronary stenosis morphology is associated with restenosis, 41 patients (47 stenoses) who underwent repeat angiography 6 to 8 months after percutaneous transluminal coronary angioplasty (PTCA) were studied. Stenosis diameter and morphology were assessed by computerized quantitative coronary angiography before and immediately after PTCA and at follow-up angiography. Before PTCA 18 stenoses were concentric (symmetric narrowings with smooth borders), 12 were eccentric (asymmetric narrowings with smooth borders), and 17 were complicated (asymmetric with rough borders and overhanging edges). Restenosis occurred in 18 lesions: two (11%) concentric, four (33%) eccentric, and 12 (70%) complicated (p less than 0.05), whereas 29 lesions remained unchanged. Stenosis diameter before and immediately after PTCA was not significantly different in the 18 patients with and the 23 patients without restenosis. Follow-up angiograms showed that 11 (61%) stenoses in the group with restenosis and 18 (63%) in the group without restenosis had morphology similar to that before PTCA. Restenosis occurred in seven (30%) patients who initially had chronic stable angina and in 11 (61%) who were first seen with unstable angina (p less than 0.05). In patients with stable angina 1 of 13 concentric stenoses, two of eight eccentric stenoses, and four of five complicated lesions restenosed. In patients with unstable angina one of five concentric, two of four eccentric, and 8 of 12 complicated lesions had restenosis. Stenoses that were complicated before PTCA tended to adopt an irregular morphology if they recurred, whereas concentric stenoses rarely occurred.(ABSTRACT TRUNCATED AT 250 WORDS)     

Angioplasty in ulcerative coronary artery disease: Acute results and early follow-up

The safety and efficacy of percutaneous transluminal coronary angioplasty (PTCA) for stenoses involving ulcerative lesions were retrospectively studied. Seventy-seven patients (62 men and 15 women, mean age 62 ± 10 years) representing 3.4% of 2,250 patients treated with PTCA during the period January 1, 1988 and June 30, 1990, had pre-PTCA stenoses defined as ulcerated. Twenty-eight (36%) of the stenoses were localized in the left anterior descending coronary artery, 9 (12%) in the left circumflex and 40 (52%) in the right coronary artery. During angioplasty, percent diameter stenosis was reduced from 73 ± 14% to 22 ± 13% and transstenotic gradient decreased from 48 ± 18 to 12 ± 6 mm Hg. Clinical success (freedom from angina at discharge without coronary bypass surgery, infarction or death) was achieved in 70 patients (90.9%). There were seven unsuccessful cases: three underwent elective coronary bypass surgery, one was managed medically, and three developed a major flow interrupting dissection during the procedure requiring emergency coronary bypass surgery. There were no deaths. At mean follow-up of 7.6 months, 45 of 61 patients (73.7%) remained asymptomatic. One patient needed an elective coronary bypass surgery and five patients had a successful repeat PTCA. In conclusion, PTCA for an ulcerated stenosis can be performed safely with a high primary success rate and a favorable early clinical course.     

Initial experience with the Europass™: A new ultra-low profile monorail balloon catheter

One of the causes for percutaneous transluminal coronary angioplasty (PTCA) failure is the inability to cross the lesion with the balloon catheter after guidewire positioning. The Europass? coronary angioplasty catheter is a monorail Duralyn? balloon catheter developed to enhance lesion crossability and to overcome this limitation. This system was evaluated in 50 patients in which target lesions were chronic total coronary occlusions (12 cases) or stenoses that could not be reached or crossed by other new monorail balloon catheters. Overall procedural success was obtained in 49/50 patients (98%), using a single Europass? balloon catheter in 46/50 patients (92%), with no in-hospital complications. Its low profile, small distal shaft, and excellent trackability allowed successful angioplasty in cases where other catheters failed. This balloon catheter represents a significant advance in angioplasty technology and can be considered as a first-choice device for a safe and expeditious single-operator procedure. © Wiley-Liss, Inc.     

Short term results of percutaneous transluminal coronary angioplasty with the monorail technique: experience in the first 1000 patients

The monorail technique allows monitoring of all steps of the coronary angioplasty procedure by high quality coronary angiography; easy, rapid, and safe recrossing and redilatation of the lesion if necessary; and stepwise dilatation of a stenosis with sequential increase of size of balloons. Transstenotic pressure differences cannot, however, be measured through the narrow shaft of the standard monorail balloon catheter. The monorail technique was used in 1014 patients (820 men, 194 women; mean age 57.8 years (range 24 to 84]. The indication for coronary angioplasty was stable angina in 52%, unstable angina in 40%, and acute myocardial infarction in 8%. Single vessel coronary angioplasty was attempted in 78%, multilesion coronary angioplasty in 11%, and multivessel coronary angioplasty in 11%. Angiographic success (reduction of stenosis to less than 50% of the luminal diameter) of all attempted lesions was achieved in 93%. The technique was clinically successful--that is, angiographic success of all attempted lesions, no occurrence of a major complication (death, myocardial infarction, acute bypass surgery), and improvement of symptoms--in 92% and partially successful in 1.3%. The clinical success rates were similar for stable angina (91%) and unstable angina (94%), but were somewhat lower for acute myocardial infarction (88%). Failure without major complication occurred in 3.4% of the patients. Failure with a major complication occurred in 3.3% (death 0.3%, myocardial infarction 2.4%, and acute bypass surgery 2.3%). The total major complication rate was higher in unstable angina (4.2%) than in stable angina (3.0%). These results indicate that the monorail technique can be applied safely and effectively for coronary angioplasty of patients with stable angina, unstable angina, and acute myocardial infarction.