The impact of coronary revascularization on long-term outcomes after surgical repair of abdominal aortic aneurysm]

BACKGROUND: Complications due to undetectable coronary artery disease are the major causes of morbidity and mortality in the surgical treatment of abdominal aortic aneurysm (AAA). The aim of our study was to evaluate the importance of significant coronary artery disease identification and the impact of coronary revascularization on early and late outcomes after surgical repair of AAA. METHODS: Between January 1994 and July 2004, 210 patients (204 males and 6 females, mean age 68 +/- 12 years) were candidates to elective surgical repair of AAA. Coronary angiography was performed in 122 patients (58%) in presence of angina symptoms, previous myocardial infarction, echocardiographic or scinti-scan evidence of myocardial ischemia. Coronary revascularization was performed in 83 patients (39.5%). The population was divided into two groups: coronary artery bypass graft/coronary angioplasty (CABG/PTCA) + AAA group (83 patients submitted to CABG surgery [n = 61], or PTCA [n = 22], for significant coronary artery disease before surgical repair of AAA), AAA group (127 patients without significant coronary artery disease, operated for AAA). Follow-up (90% complete) had a mean duration of 42 +/- 23 months. RESULTS: CABG/PTCA + AAA group compared to AAA group presented major symptoms of angina (p = 0.001), higher incidence of previous myocardial infarction (67 vs 10%, p < 0.0001), lower mean value of left ventricular ejection fraction (50 vs 54%, p = 0.01). Operative mortality was 0.95%, and was not related to any cardiac morbidity: operative mortality was observed in the AAA group (2 patients died of anossic cerebral damage and respiratory failure) and was absent in the CABG/PTCA + AAA group (p = 0.8). The overall 8-year survival in the AAA group and in the CABG/PTCA + AAA group was 80 +/- 11 vs 95 +/- 2.8%, respectively (p = 0.7). Freedom from cardiac late death and freedom from cardiac events (recurrence of angina, myocardial infarction, congestive heart failure) were high in both groups (93 +/- 6.4 vs 97 +/- 2.3%, p = 0.6; and 91 +/- 6.6 vs 89 +/- 6.7%, p = 0.5, respectively). In the CABG/PTCA + AAA group symptoms for angina (p = 0.0002) and dyspnea (p < 0.0001) significantly improved during the follow-up. CONCLUSIONS: Significant coronary artery disease was not negligible (39.5%) in patients candidates to surgical repair of AAA. Identification and correction of coronary artery disease prior to AAA surgery is the most important strategy to reduce the risk of vascular procedure. The beneficial impact of coronary revascularization on early and late outcomes is evident, in terms of satisfactory survival and freedom from cardiac adverse events. Therefore, coronary angiography is strongly suggested to optimize early and long-term results.     

Initial and long-term results of coronary angioplasty and coronary bypass surgery in patients of 75 or older.

OBJECTIVE--To evaluate clinical outcome after percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients of 75 or older who underwent either procedure between 1980 and 1987. SUBJECTS--93 patients aged 75-89 with angina pectoris class III-IV (Canadian Cardiovascular Society) who underwent PTCA and 81 patients aged 75-84 with angina class III-IV who underwent CABG. Follow up was 8.2 years in the PTCA group and 8.3 years in the CABG group. MAIN OUTCOME MEASURES--In-hospital complications and survival at follow up. RESULTS--Primary success rate for PTCA was 84% (78/93). Two patients died, two had emergency CABG, three had a myocardial infarction, and one had a cerebrovascular accident. PTCA failed in seven patients (five underwent elective CABG and two were treated conservatively). Median hospital stay was 4.3 days. Primary success rate for CABG was 63% (53/81). Six patients died, two had a cerebrovascular accident, eight had a myocardial infarction, 10 had a rethoracotomy, and four the adult respiratory distress syndrome. Median hospital stay was 14.2 days. In the PTCA group during follow up eight patients died, three had a non-fatal myocardial infarction, two had elective CABG, 10 had repeat PTCA, and four had recurrence of angina. Sixty four patients were free of angina (69%). In the CABG group during follow up eight patients died, one had a non-fatal myocardial infarction, six had PTCA, and three had recurrence of angina. Fifty seven patients were free of angina AP (70%). Actuarial survival after 10 years was 92% for PTCA and 91% for CABG. CONCLUSIONS--PTCA is safe in elderly patients. The complication rate is lower and hospital stay significantly shorter compared with CABG (p < 0.05). Long-term follow up showed no significant difference between PTCA and CABG.     

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.     

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.     

Long-term outcome of unsuccessful percutaneous transluminal coronary angioplasty

We analyzed the long-term outcome of 198 patients after unsuccessful percutaneous transluminal coronary angioplasty. Forty-nine percent underwent emergency coronary artery bypass grafting surgery, 17% had elective bypass surgery, and 34% were treated medically. The in-hospital mortality rate was 4%, and myocardial infarction occurred in 36% of patients. Follow-up was completed in 100% of patients with a mean follow-up period of 35 +/- 22 months. Actuarial cardiac survival at 4 years was 97% in the emergency bypass surgery group, 100% in the elective bypass surgery group, and 86% in the medically treated group. Actuarial event-free survival (freedom from myocardial infarction, bypass surgery, coronary angioplasty, and cardiac death) at 4-year follow-up was 81% in 198 patients, 90% in the emergency bypass surgery group, 85% in the elective bypass surgery group, and 65% in the medically treated group. Results of multivariate analysis showed that emergency or elective bypass surgery after failed coronary angioplasty, normal or mildly impaired left ventricular function, and male sex were predictors of better outcome at 4 years.     

Clinical outcome 5 years after attempted percutaneous transluminal coronary angioplasty in 427 patients

This study was performed to define the 5 year clinical status of 427 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) in 1981. Their mean age was 54 +/- 10 years (+/- 1 SD). Sixty-one percent had unstable angina, 23% had prior myocardial infarction, 86% had one-vessel disease, and 92% had normal left ventricular function. Sixty-seven percent of patients had left anterior descending artery stenosis. Angiographic success was achieved in 84% of patients. Coronary bypass surgery was required in 9.6% of patients, in 5.9% as an emergency procedure. There were no in-hospital deaths. Follow-up at 5 years was 100% complete. There were 15 late deaths (96.3 +/- 1.0% survival), including seven of cardiac cause (98.1 +/- 0.7% cardiac survival). Myocardial infarction occurred in 24 patients (94% freedom from myocardial infarction), coronary bypass surgery was required in 63 (84% freedom from bypass surgery), and 365 patients (85%) were asymptomatic at follow-up. At 5 years, 83 patients (20%) had required an additional PTCA. Unstable angina pectoris and proximal left anterior descending coronary artery stenoses were present in 162 patients. The overall survival and cardiac survival in this subset was 94.4 +/- 1.8% and 98.1 +/- 1.1%, respectively. The excellent survival and low event rates over 5 years in this population support the concept that PTCA is safe and effective for patients with symptomatic angina pectoris, single-vessel disease, and normal left ventricular function.     

Emergency percutaneous transluminal coronary angioplasty for acute myocardial infarction in patients 70 years of age and older

Direct percutaneous transluminal coronary angioplasty (PTCA) was performed as the primary means of establishing reperfusion during acute myocardial infarction in 105 elderly patients (mean age +/- standard deviation 75 +/- 4 years) at a mean of 5.5 +/- 4.0 hours from symptom onset. Fifty-two patients (50%) had anterior infarctions, 70 (67%) had significant narrowing in greater than 1 vessel, and 12 (11%) were in cardiogenic shock. Primary success was achieved in 91% of the infarct-related arteries. Four patients with failed PTCA underwent emergency bypass surgery; 10 had early symptomatic reocclusion of the dilated vessel. There was 1 death acutely in the catheterization laboratory. The overall in-hospital mortality was 18%. Three-vessel coronary artery disease and cardiogenic shock on presentation were the strongest predictors of in-hospital death. Global ejection fraction improved from 54 +/- 13 to 61 +/- 15% (p less than 0.001). The 1- and 5-year survival rates, including in-hospital deaths, were 73 and 67%, respectively. It is concluded that direct PTCA is an effective means of salvaging ischemic myocardium during acute myocardial infarction in the elderly patient. It is associated with a high success rate and low complication rate. The short- and long-term survival in this high-risk group of patients are improved compared with survival rates in historical controls.     

Predictors of long-term cardiac survival in patients with multivessel coronary artery disease undergoing percutaneous transluminal coronary angioplasty

The predictors of 5-year cardiac survival in patients with multivessel coronary artery disease (CAD) undergoing percutaneous transluminal coronary angioplasty (PTCA) were analyzed in a series of 637 consecutive patients. The average age was 59 +/- 11 years in 472 men and 165 women. Diabetes mellitus, previous myocardial infarction and unstable angina were present in 119 (19%), 261 (41%) and 305 (47%) patients, respectively. Angiographically, 460 patients had 2-vessel and 177 patients had 3-vessel CAD. The left ventricular contraction score was greater than or equal to 12 in 55 patients. Angiographic success (less than 50% residual stenosis) was achieved in 85% of the 1,343 narrowings and clinical success was obtained in 526 (83%) of the 637 patients. Complete revascularization was obtained in 177 (34%) of 526 successful patients. Procedure-related complications resulted in death in 9 patients (1.4%), in Q-wave myocardial infarction only in 6 patients (0.9%) and in emergency bypass surgery in 44 patients (6.9%) (of whom 10 had Q-wave myocardial infarction). Follow-up for greater than or equal to 1 year and up to 6 years after PTCA was obtained in 608 (95%) of the 637 patients. To determine the predictors of 5-year cardiac survival, 28 clinical, angiographic and procedural variables were analyzed by Cox proportional-hazards regression. The estimated 5-year survival after PTCA was 88 +/- 2% in successful patients and 77 +/- 5% in patients in whom PTCA was unsuccessful (p less than 0.001). When clinical success was forced into the Cox regression, the left ventricular contraction score of greater than or equal to 12, diabetes mellitus and age greater than or equal to 65 years showed additional adverse effects on survival.(ABSTRACT TRUNCATED AT 250 WORDS)     

Efficacy of primary percutaneous transluminal coronary angioplasty for acute myocardial infarction in patients aged > or = 80 years

The therapeutic result of primary percutaneous transluminal coronary angioplasty (PTCA) in the elderly was assessed in 20 of 44 patients > or = 80 years old (range 81-92 years, mean age 84 +/- 3 years) with acute myocardial infarction who underwent primary PTCA and the results compared with 194 younger patients (< 80 years) who underwent primary PTCA during the same period. In-hospital prognosis, and long-term outcomes were investigated. Emergency coronary angiography was performed in 47.7% of the patients with acute myocardial infarction in the elderly group with 45.5% receiving primary PTCA. Primary PTCA was successful in 95.0% of the elderly group, showing no significant difference from the younger group. In-hospital mortality showed no significant difference between the elderly group and the younger group (5.0% vs 4.1%). However, the incidences of pump failure of the heart and bleeding complication requiring blood transfusion were higher in the elderly group during hospitalization. The 2-year survival rate for the elderly group was 82.5 +/- 9.3%, which was better than previous studies. These results suggest that primary PTCA has a good success rate in the elderly patients with acute myocardial infarction, and decreases the in-hospital mortality and improves the long-term outcome. However, this study was conducted retrospectively in a small group of patients. The efficacy of primary PTCA for the elderly remains to be clarified in a larger prospective trial.     

Long-term results of elective percutaneous transluminal coronary angioplasty. A clinico-angiography study of 289 consecutive patients

289 consecutive patients (255 male, 34 female, 50 +/- 6 years) had an elective single-vessel-PTCA between October 1978 and March 1983. A clinical long-term follow-up was obtained after 4.7 (3-10) years. The PTCA success-rate was 73% with a non steerable balloon catheter being used in 95% of the cases. For 271/289 patients with follow-up (94%), the 56-month-survival rate was 96%, the incidence of non-fatal myocardial infarctions 11%, and the need for a second intervention (PTCA and/or bypass surgery) was 39%. The most favorable long-term outcome was observed in patients without need of a second intervention (97% survival, 7% non-fatal myocardial infarction, 83% without cardiac complaints during everyday life), and in patients with elective bypass surgery after an unsuccessful PTCA (100% survival, 5% myocardial infarction). 32/138 (23%) of patients without a second intervention during follow-up underwent an angiographic control after an average of 4.7 years. In comparison with the first follow-up angiogram 6 months after PTCA, the mean residual stenosis at the PTCA-site showed a slight decrease. It is concluded that PTCA offers good clinical and angio-graphic long-term results in single-vessel disease, with an excellent prognosis of patients without need for a second intervention.     

Prognostic value of pharmacologic stress echocardiography in patients with left bundle branch block

PURPOSE: Although coronary artery disease is a frequent cause of left bundle branch block, the prognostic value of myocardial ischemia in patients with this conduction abnormality has not been defined. We investigated the value of pharmacologic stress echocardiography in risk stratification of patients with left bundle branch block. PATIENTS AND METHODS: Three hundred eighty-seven patients [230 men and 157 women, mean (+/- SD) age, 64 +/- 9 years] with complete left bundle branch block on the resting electrocardiogram underwent dobutamine (n = 217) or dipyridamole (n = 170) stress echocardiography to evaluate suspected or known coronary artery disease. A summary wall motion score (on a one to four scale) was calculated. The primary end points were cardiac death and nonfatal myocardial infarction. RESULTS: A positive echocardiographic result (evidence of ischemia) was detected in 109 (28%) patients. During a mean follow-up of 29 +/- 26 months, there were 21 cardiac deaths and 20 myocardial infarctions, 63 patients underwent coronary revascularization, and 1 patient received a heart transplant. In a multivariate analysis, four clinical and echocardiographic variables were associated with increased risk of cardiac death: resting wall motion score index [hazard ratio (HR) = 7.5 per unit; 95% confidence interval (CI), 2.8 to 20; P = 0.001], previous myocardial infarction (HR = 2.9; 95% CI, 1.1 to 7.3; P = 0.02), diabetes (HR = 2.7; 95% CI, 1.1 to 6.6; P = 0.03), and the change in wall motion score index from rest to peak stress (HR = 3.0 per unit; 95% CI, 1.0 to 8.6; P = 0.04). The 5-year survival was 77% in the ischemic group and 92% in the nonischemic group (P = 0.02). Four variables were associated with increased risk of cardiac death or infarction: previous myocardial infarction (HR = 3.4; 95% CI, 1.7 to 6.8; P = 0.0005), diabetes (HR = 2.4; 95% CI, 1.2 to 4.6; P = 0.01), resting wall motion score index (HR = 2.2 per unit; 95% CI, 1.1 to 4.1; P = 0.02), and positive echocardiographic result (HR = 2.2; 95% CI, 1.1 to 4.5; P = 0.03). The 5-year infarction-free survival was 60% in the ischemic group and 87% in the nonischemic group (P < 0.0001). Stress echocardiography significantly improved risk stratification in patients without previous myocardial infarction (P = 0.0001), but not in those with previous myocardial infarction (P = 0.08). In particular, it provided additional value over clinical and resting echocardiographic findings in predicting cardiac events among patients without previous infarction. CONCLUSIONS: Myocardial ischemia during pharmacologic stress echocardiography is a strong prognostic predictor in patients with left bundle branch block, particularly in those without previous myocardial infarction.     

Comparison of percutaneous transluminal coronary angioplasty versus coronary artery bypass grafting for multivessel coronary artery disease.

Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) are both widely performed in the treatment of multivessel coronary artery disease. Little data directly compare the outcomes of patients treated with these 2 techniques. We examined the characteristics and outcomes of 152 patients who underwent multivessel PTCA and 134 patients who had multivessel CABG. Patients who had prior PTCA or CABG were excluded. Baseline characteristics such as age, sex, and prior myocardial infarction were similar in the 2 groups. Ejection fraction was significantly lower in the CABG group (48 +/- 14%) versus the PTCA patients (53 +/- 15%) (p = 0.002). Narrowing distribution when analyzed by major vascular beds (left anterior descending, circumflex and right coronary arteries) as well as by individual arteries was not significantly different between the groups when left main stenosis was excluded. The surgical group received a larger number of bypasses per patient (3.9) when compared with narrowings dilated in the angioplasty group (3.7) (p less than 0.001). The left internal mammary artery was used in 75% of patients as one of the grafts. Angioplasty success was 95% by standard criteria. Over a mean follow-up of 110 weeks for PTCA patients and 134 weeks for CABG patients the occurrence of death was similar (10 and 14%, respectively) as was myocardial infarction (4 and 2%, respectively). However, all other cardiac events including subsequent cardiac catheterization (49 vs 10%), PTCA (30 vs 2%) and CABG (23 vs 2%) occurred significantly more often in the PTCA group (all p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term follow-up of patients treated with coronary angioplasty for acute myocardial infarction

Long-term follow-up data for patients treated with coronary angioplasty (PTCA) for acute myocardial infarction are limited. Therefore the long-term outcome of 336 consecutive patients treated with PTCA at a median of 4.5 hours (range 0.5 to 48 hours) from symptom onset was evaluated. The in-hospital mortality was 11.1% (37 patients). Follow-up is complete for 293 of 299 (98%) hospital survivors at a median of 24 months. Of patients discharged, the mean age was 55 +/- 11 years, 49% received intravenous thrombolytic therapy, 53% had multivessel coronary artery disease, and the mean ejection fraction was 48 +/- 10%. Post-discharge survival was 96.1% at 1 year and 93.6% at 2 years by life table analysis. Post-discharge survival was independently predicted by no prior myocardial infarction (96.9% versus 87.3% 2-year survival, p less than 0.001 by log rank analysis) and infarct artery patency at hospital discharge (which had its major impact on survival early after hospital discharge: [97.4% versus 93.4% 1-year survival but 94.2% versus 93.4% 2-year survival; overall p = 0.02]). For patients with analyzable ventriculograms at hospital discharge, ejection fraction greater than or equal to 40% was also a significant independent predictor of survival (98.1% versus 85.8% 2-year survival, p = 0.01). For patients with a successful PTCA, time from symptom onset to catheterization and angioplasty less than or equal to 4 hours versus greater than 4 hours was also an independent predictor of outcome (97.1% versus 91.4% 2-year survival; p = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)     

Usefulness of a postoperative exercise test for predicting cardiac events after coronary artery bypass grafting.

The predictive value of a postoperative exercise test in terms of cardiac events after coronary artery bypass grafting (CABG) was prospectively studied in 231 consecutive patients. During a 5-year follow-up there were 28 cardiac events (12%), of which 15 were cardiac deaths (13 sudden), and 13 were nonfatal myocardial infarctions. There was no difference in the rate of graft patency between groups with and without cardiac events, but ejection fraction was lower in patients with than without events (51 +/- 16% vs 58 +/- 10%; p less than 0.05). Duration of the exercise test was shorter, and maximal work load was lower in patients with cardiac events (p less than 0.05 for both). The prevalence of greater than or equal to 1 mm ST-segment depression was 22% (symptomatic in 25%, and silent in 75%) and did not differ between groups with and without cardiac events. After adjustment for prognostic variables using the proportional hazards method, diuretic treatment (p = 0.007) and a low postoperative ejection fraction (p = 0.04) remained significant for predicting the risk of cardiac events within 5 years of CABG, but exercise duration and work load did not have any significant predictive value. Thus, the predictive value of a postoperative exercise test is limited, and signs of impaired left ventricular function are of greater significance for the 5-year prognosis after CABG than are those of myocardial ischemia.     

经皮冠状动脉腔内成形术及置入支架的长期预后分析

目的探讨经皮冠状动脉腔内成形术（PTCA）和PTCA＋支架治疗对我国冠心病患者的远期疗效。方法对1986年12月～1998年6月期间在我院接受PTCA和PTCA＋支架治疗的938例冠心病患者中的790例进行了随访,随访率84.2%。随访方式包括门诊随访和信访。随访时间为0.9－12.7(3.5±2.4)年。结果随访期中死亡4例(0.5%),非致命性急性心肌梗死22例(2.8%),重复PTCA98例(12.4%),行冠状动脉旁路移植术10例(1.3%)。以Kaplan-Meier法计算术后12年的生存率为99.5%,无心脏事件生存率1年为88.2%,12年为80.6%。Cox回归分析显示,陈旧性心肌梗死病史和是否放置支架与心脏事件呈负相关,而病变支数与心脏事件正相关。与单纯PTCA组比较,PTCA＋支架组急性心肌梗死发生率和再次PTCA率均显著降低。结论PTCA、特别是PTCA＋支架治疗对我国冠心病患者有良好的疗效,可作为血管重建治疗的首选方法。     

Stenting of the Infarct-Related Artery During Complicated Angioplasty in Acute Myocardial Infarction

The aim of this study was to assess safety and efficacy of coronary stenting as a strategy for improving PTCA suboptimal angiographic result. From March 1993 to December 1995, 104 patients underwent PTCA during acute myocardial infarction. Unplanned coronary stenting was required in 66 pts (63.5%). Procedural success was obtained in 64 pts (97%). Two patients had an unsuccessful stenting procedure: one patient for a suboptimal stent deployment and another for LAD reocclusion requiring emergency CABG (1.5%). Palmaz-Schatz stents were used in 60 pts (91%) and AVE micro-stent in 6 pts (9%). During the hospital course, subacute reocclusion of the vessel occurred in 3 pts (4.6%); one patient underwent a successful rePTCA while the other two underwent CABG. Two patients had vascular groin complications requiring surgical repair of the femoral artery. During hospitalization, one patient underwent elective CABG for early residual myocardial ischemia. At seventy-two hours from PTCA, one patient (1.5%) died as a result of intestinal infarct. Six months survival rate was 98.3% for 59 pts discharged alive from our department. Ten pts were symptomatic during the follow-up: One patient underwent PTCA on another vessel and the other underwent CABG for a multivessel disease. CABG was used in one patient who presented residual silent ischemia in multivessel coronary artery disease. At six months, the first group of patients (18 pts) underwent planned coronary angiography: Vessel patency was present in 17 patients. One patient had an asymptomatic reocclusion of the treated vessel. This study shows a good angiographic result obtained with intracoronary stenting during primary or rescue PTCA of the infarct-related artery. It does not appear to increase major in-hospital adverse events and may reduce the need for surgical revascularization, reducing in-hospital mortality rate and favorably affecting LVEF.     

Ten-year outcome after coronary angioplasty in patients with single-vessel coronary artery disease and comparison with the results of the Coronary Artery Surgery Study (CASS)

The 10-year results of randomized trials comparing percutaneous transluminal coronary angioplasty (PTCA) in patients with single-vessel coronary artery disease (CAD) with coronary artery bypass grafting (CABG) and medical treatment are not available yet. The aim of this evaluation was to compare our 10-year follow-up results after PTCA in patients with single-vessel CAD with the 10-year follow-up results after CABG and medical treatment in the Coronary Artery Surgery Study (CASS) trial. We evaluated the clinical outcome of 509 patients with single-vessel CAD 10 years after coronary angioplasty. The data were compared with the results of 214 patients with single-vessel CAD after CABG or medical treatment from the CASS trial. End points were defined as death and myocardial infarction. Statistical evaluation was performed by life-table analysis and 2-sided Fisher's exact test. The rate of survival was 86% 10 years after PTCA compared with 85% after CABG and 82% after medical treatment in patients from the CASS trial (p = NS). Survival free from myocardial infarction was 77% after coronary angioplasty, 70% after CABG, and 72% after medical treatment (p = NS). Thus, in patients with single-vessel CAD, infarct-free survival 10 years after coronary angioplasty compared favorably with the results after bypass surgery or medical treatment from the CASS trial.     

Percutaneous transluminal coronary angioplasty in patients with two or more previous coronary artery bypass grafting operations

Between 1979 and 1986, 65 of 76 patients (86%) (82% men, with a mean age of 58 +/- 8 years) with greater than or equal to 2 previous coronary artery bypass grafting (CABG) operations and symptomatic myocardial ischemia underwent successful percutaneous transluminal coronary angioplasty (PTCA). Sixty-two patients had 2 prior CABG operations, 10 had 3 and 4 had 4. Clinical characteristics included prior myocardial infarctions in 49 (65%), severe angina (class III or IV) in 47 (62%) and left ventricular ejection fraction less than or equal to 35% in 13 (17%). There were 139 lesions dilated: 1 lesion in 39 (51%), 2 in 22 (29%) and greater than or equal to 3 in 15 (20%) patients. Arterial lesions were successfully dilated in 71 of 81 cases (88%), vein grafts in 44 of 53 (83%) and mammary artery grafts in 3 of 5 (60%). In 12 patients, PTCA was used to dilate significant lesions less than 15 days after CABG in vessels which were unable to be bypassed. Significant complications were encountered in 4 patients (5%). These included 3 of 53 vein graft dilatations with embolization (6%), with 1 resulting in infarction and death, and 1 patient dying after emergency CABG. At hospital discharge, 65 patients were clinically improved. An apparent symptom-related lesion recurrence occurred in 23 of 65 patients (35%), with 5 patients dying of cardiac causes, 4 having CABG without previous angiography and 12 of 14 patients undergoing repeat successful PTCA (mean time and standard deviation 9 +/- 6 months).(ABSTRACT TRUNCATED AT 250 WORDS)     

A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes

OBJECTIVES: We performed a meta-analysis of randomized trials comparing coronary artery bypass graft surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) for the treatment of coronary artery disease, incorporating new trials and examining long-term outcomes. BACKGROUND: Previous meta-analyses of trials comparing CABG with PTCA have reported short- and intermediate-term outcomes, but since then longer term follow-up and newer trials have been published. METHODS: We performed a meta-analysis of 13 randomized trials on 7,964 patients comparing PTCA with CABG. RESULTS: We found a 1.9% absolute survival advantage favoring CABG over PTCA for all trials at five years (p < 0.02), but no significant advantage at one, three, or eight years. In subgroup analysis of multivessel disease, CABG provided significant survival advantage at both five and eight years. Patients randomized to PTCA had more repeat revascularizations at all time points (risk difference [RD] 24% to 38%, p < 0.001); with stents, this RD was reduced to 15% at one and three years. Stents also resulted in a significant decrease in nonfatal myocardial infarction at three years when compared with CABG. For diabetic patients, CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years. CONCLUSIONS: Our results suggest that, when compared with PTCA, CABG is associated with a lower five-year mortality, less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat revascularization by about half.     

Coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. Twenty-year clinical outcome.

AIMS: The purpose of this study is to compare the long-term outcome (up to 20 years) of coronary artery bypass surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) in a consecutive patient series at a single centre. Survival is similar after CABG and PTCA up to 8 years follow-up in patients with multivessel disease, with a reduced need for repeat revascularization after CABG. As coronary artery disease is a lifetime disease, longer-term follow-up of these revascularization therapies is necessary to help clinical decision-making. METHODS AND RESULTS: The CABG study population consisted of the first 1041 consecutive patients who underwent a first elective coronary bypass surgery between 1970 and 1980. The PTCA study population consisted of 702 consecutive patients who underwent a first elective coronary angioplasty procedure between 1980 and 1985. Mortality and subsequent revascularization up to 20 years were captured. Survival rates were adjusted using proportional hazards methods to account for baseline differences. RESULTS: The unadjusted survival rates were 92%, 77%, 57% and 49% after CABG at respectively, 5-, 10-, 15- and 17 years and 91%, 80%, 64% and 59% after PTCA. In the multivessel disease subgroup, survival was similar with a benefit apparent after CABG in the first 8 years of follow-up. The therapy chosen, CABG or PTCA, was a univariate predictor of mortality in favour of PTCA (RR: 1.28; 95% CI: 1.10-1.49), but after correction for baseline characteristics, the relative risk of mortality for CABG vs PTCA was comparable (RR: 1.03; 95% CI: 0.87-1.24). The adjusted survival curves in the subgroup of diabetic elderly patients with multivessel disease were similar after the tenth year with only a slightly better survival in the CABG population in the first 10 years. Repeat intervention was more frequently required after PTCA during the first 8 years, but after this time more frequently in the CABG group. CONCLUSION: When comparing CABG and PTCA it can be concluded that both strategies are equally effective in terms of 20-year survival. In particular, after more than 10 years all differences tend to disappear. While repeat intervention was significantly higher in the first year after PTCA, after 7-8 years, reintervention was greater in patients who had initial CABG.