Results of percutaneous transluminal coronary angioplasty for angina pectoris early after acute myocardial infarction

Between May 1980 and July 1985, 70 patients underwent percutaneous transluminal coronary angioplasty (PTCA) for angina occurring 24 hours after and within 30 days of acute myocardial infarction (32 with Q-wave infarction and 38 with non-Q-wave infarction). One-vessel disease was present in 42 (60%) and multivessel in 28 (40%); the mean ejection fraction was 0.56 (greater than or equal to 0.50 in 77% of patients). PTCA was successful in 56 patients (80%) and after introduction of steerable dilating systems in February 1983 this rate became 86%. The success rate for complete occlusions was 76%. The interval from myocardial infarction to PTCA was similar in patients with successful dilation (12.7 +/- 8.1 days) and those without (13.4 +/- 8.0 days). PTCA failed in 14 patients (20%); 8 underwent emergency coronary artery bypass for acute occlusion and 4 of 6 patients whose lesions could not be crossed had elective bypass surgery. There was 1 operative death. No patient sustained a Q-wave infarction. Three patients had non-Q-wave infarctions after technically successful PTCAs. Mean follow-up was 27 months (6 to 67 months). Of the 56 patients successfully dilated, 14 (25%) had 15 cardiac events during follow-up: death (1), non-Q-wave infarction (2), repeat PTCA (7), coronary bypass (4) and recurrence of severe angina (1). The cumulative mortality was 3% and the reinfarction rate was 7% (no Q-wave reinfarctions). Forty-two (60%) of the 70 patients were free of complicating events acutely and during follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)     

Angioplasty in total coronary artery occlusion

Percutaneous transluminal coronary angioplasty was attempted without streptokinase in 24 patients with total coronary artery occlusion but without acute transmural myocardial infarction. The maximal duration of occlusion was estimated to be 1 week or less in 10 patients, more than 1 to 4 weeks in 6, more than 4 to 12 weeks in 3 and more than 12 weeks in 5. Dilation of the occluded artery was attempted in the left anterior descending coronary artery in 17 patients, in the right coronary artery in 4 and in the circumflex coronary artery in 3. Angioplasty was successful in 13 patients (54%): left anterior descending coronary artery in 59%, right coronary artery in 50% and circumflex coronary artery in 33%. In patients with successful dilation, there was a mean decrease in coronary artery stenosis from 100 to 23%. In the 19 patients whose occlusion was estimated to be of 12 weeks' duration or less, angioplasty was successful in 68%. In the five patients whose occlusion was estimated to be of more than 12 weeks' duration, dilation was not successful in any (p = 0.006). It is concluded that in selected patients with symptomatic coronary artery disease and recent coronary artery occlusion without associated acute myocardial infarction, percutaneous transluminal coronary angioplasty alone may be effective in restoring patency.     

Primary angiographic success rates of percutaneous transluminal coronary angioplasty

Three distinct periods in catheter design have been identified since the advent of percutaneous transluminal coronary angioplasty (PTCA) in 1977. In the first period PTCA was performed using a double-lumen balloon catheter that had a fixed, flexible guidewire at the tip. In the second period, an independent, steerable guidewire and the steerable catheter system were used. In the third period, low-profile catheters were introduced. A total of 2,969 patients who had single-vessel PTCA of a native coronary artery was separated into groups according to the period during which PTCA was performed. Introduction of the steerable catheter system was accompanied by improvement in primary success rate in PTCA attempts on the right coronary artery (78% vs 88%, p less than 0.005). Introduction of the low-profile catheter was accompanied by improved primary success in PTCA attempts on the left anterior descending coronary artery (LAD) (90% vs 94%, p less than 0.005). The percentage of PTCA attempts on the LAD decreased over the 3 periods (70% to 60% to 56%), while the percentage of attempts on the left circumflex artery increased (7% to 12% to 16%). Before steerable and low-profile catheters were used, there were significant differences in ability to reach and cross stenoses among the 3 major coronary arteries. These differences no longer exist. These results indicate that technical improvements and operator experience have made stenoses in all 3 major coronary arteries equally accessible to dilatation catheters and that primary success rates and reasons for failure in these arteries are now similar.     

Acute reocclusion during percutaneous transluminal coronary angioplasty: immediate and long-term outcome

Acute total occlusion of a coronary artery during percutaneous transluminal coronary angioplasty (PTCA) has previously resulted in emergency surgical intervention (CABG). We retrospectively surveyed 211 elective procedures and 65 procedures for acute myocardial infarction (AMI). There were 42 patients (pts) [29 elective (14%) and 13 AMI (20%)] in whom total occlusion occurred after initial dilation had been achieved. In 30 of 42 pts reangioplasty successfully reperfused the vessel. Ten patients (24%) required CABG and two (5%) were treated medically for AMI. Death occurred in 2 pts due to irreversible cardiogenic shock despite successful angioplasty. After 6 months follow-up 22 pts remained asymptomatic. It is concluded that aggressive redilation of total occlusions which develop during PTCA will frequently result in a successful angioplasty with a long-term restenosis rate comparable to uncomplicated angioplasty.     

Complications of emergency coronary angioplasty for acute myocardial infarction]

To assess the incidence and consequences of complications occurring during emergency percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI), we studied 347 patients who underwent PTCA within 24 hours after the onset of AMI. Acute occlusion occurred in 29 patients (8.4%), of whom 16 patients underwent successful repeat PTCA. All of them survived until hospital discharge. The in-hospital reocclusion rates of these 16 patients were comparable to those of patients who had not experienced acute occlusion (18.8 vs 12.8%, ns). In the remaining 13 patients, reperfusion were not successful after acute occlusion, and 6 died. Side branch occlusion occurred in 21 patients (6.1%). Left circumflex artery occlusion occurring during PTCA for the proximal left anterior descending artery was fatal in 3 patients. Right ventricular branch occlusion during PTCA for the middle of the right coronary artery resulted in intractable right ventricular infarction in one patient, and he died. Among 14 patients who underwent repeat angiography, 13 had a patent side branch which had been occluded during PTCA. One patient had coronary rupture and died. During PTCA of the proximal left anterior descending artery, acute occlusion of the artery without reperfusion or occlusion of the left circumflex artery was often fatal. However, the prognosis of acute occlusion was relatively good, if repeat PTCA was successful and most of the occluded side branches remained patent in the chronic state.     

慢性冠状动脉闭塞置入支架术与球囊扩张术的比较

目的为了解冠状动脉内支架及经皮冠状动脉腔内成形术（ＰＴＣＡ）治疗完全闭塞性冠状动脉血管的临床及冠状动脉造影效果。方法９５例完全冠状动脉闭塞的病人随机分成为：置入支架组（Ａ组４８例）;单纯ＰＴＣＡ组（Ｂ组４７例）,观察二组病人发生临床事件及６个月后的冠状动脉造影效果。结果６个月后两组病人完成临床及冠状动脉造影随访的共８５例,随访率为８９％,Ａ组４２例,Ｂ组４３例。Ａ组：１例于术后１０天内出现心肌梗塞,无１例死亡,其再狭窄率为２８．５％,血管再闭塞率为１１９％,最终重复血管重建术为１９％。Ｂ组：１例死亡,２例发生急性心肌梗塞,再狭窄率为５８％,血管再闭塞率为２２％,最终重复血管重建术达４５％。两组之间临床疗效差异均有显著性（Ｐ＜０．００１）。结论冠状动脉慢性闭塞的病人ＰＴＣＡ成功后选择性置入支架比单纯ＰＴＣＡ的近期及远期临床疗效预后要好（发生临床事件及重复血管重建术明显下降）。     

闭塞性冠状动脉病变PTCA成功率及影响因素

目的探讨完全闭塞性和几乎完全闭塞性病变ＰＴＣＡ成功率及其影响因素。方法对３５例发生过心肌梗塞和２１例未发生心肌梗塞的完全或几乎完全闭塞性病变施行了ＰＴＣＡ。结果完全闭塞性病变心梗发生后１周内ＰＴＣＡ成功率为１００％,２周～３个月为６６．７％,３个月以后为４２．９％;无桥侧支的几乎完全闭塞性病变ＰＴＣＡ成功率为１００％,桥侧支丰富的几乎完全闭塞性病变ＰＴＣＡ成功率为６２．５％。结论心肌梗塞早期ＰＴＣＡ成功率明显高于心肌梗塞晚期ＰＴＣＡ成功率（Ｐ＜０．０５）,无桥侧支的几乎完全闭塞性病变ＰＴＣＡ成功率明显高于桥侧支丰富的几乎完全闭塞性病变的成功率（Ｐ＜０．０５）     

Elective PTCA of totally occluded coronary arteries not associated with acute myocardial infarction; short-term and long-term results

Of 652 consecutive patients referred for coronary angioplastybetween September 1980 and March 1984, 49 patients presentedwith total or functional ‘occlusion’ of the involvedvessel. Total vessel occlusion was defined as absent anterogradefilling beyond the lesion. Functional occlusion was definedas faint, late anterograde opacification of the distal segmentin the absence of a discernible luminal continuity. In 39 patients,the total or functional occlusion represented a progression,without acute myocardial infarction, of a previously diagnosedstenotic lesion. The maximal potential duration of occlusion was estimated tobe 4 weeks or less in 21 patients, more than 4 to 8 weeks in12, and more than 8 weeks in 16. Dilation of the occluded arterywas attempted in the left anterior descending coronary arteryin 30 patients, in the right coronary artery in 8, in the circumflexcoronary in 7 and in 4 jumpgrafts. For the whole group, angioplastywas successful in 28 patients (57%). The primary success ratewith the functionally occluded vessel (81%) was significantlyhigher than with the total occlusion (45%). In 33 patients withan occlusion estimated to be of 8 weeks or less, angioplastywas successful in 65%. In the 16 patients with an occlusionestimated to be of more than 8 weeks duration, dilation wassuccessful in 44%. Of the 21 patients in whom angioplasty wasunsuccessful, 11 required surgery (1 urgent with persistentpain and ST elevation and 10 elective). Ten patients were maintainedon medical treatment. Of the 28 patients in whom angioplastywas successful, 10 patients had recurrence of symptoms duringfollow-up (1–42 months). Four were kept on medical therapy,three required bypass surgery and three underwent repeat percutaneoustransluminal coronary angioplasty (PTCA). After primary success, late angiographic studies obtained in20 out of 28 patients showed reocclusion in 8. In conclusion,elective PTCA of totally occluded coronary arteries is feasiblebut the primary success rate is lower (57%) than that associatedwith conventional lesions. the long-term clinical results followingsuccessful angioplasty are satisfactory (64%), but the incidenceof reocclusion is higher (40%).     

Characteristics and outcome of patients in whom reperfusion with intravenous tissue-type plasminogen activator fails: results of the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) I trial

To examine the outcome of patients with persistent coronary artery occlusion despite treatment with intravenous tissue-type plasminogen activator (t-PA), the clinical course of 96 patients with persistent occlusion after 90 min of therapy was evaluated. All patients underwent cardiac catheterization 90 min after initiation of intravenous t-PA. Immediate coronary angioplasty (PTCA) was attempted when the infarct-related artery failed to reperfuse unless the vessel was technically unsuitable or the infarct was thought to be small. No baseline differences could be found between these 96 patients and 288 patients who achieved perfusion with the same protocol. Although patients with and without successful perfusion after t-PA had similar clinical courses before cardiac catheterization, those without perfusion had more complications (ventricular fibrillation, severe bradycardia, hypotension) during catheterization. PTCA achieved reperfusion with less than 50% residual stenosis in 73% of the 86 patients in whom it was attempted, while 16% were left with a high-grade (greater than 50%) residual stenosis and PTCA failed in 11%. Mortality was highest in the nine patients with complete PTCA failure (44%), compared with a 6% mortality in the 63 patients with an insignificant residual stenosis after PTCA and a 14% mortality in the 14 patients with reperfusion, but a greater than 50% residual stenosis after PTCA. In 10 patients with small infarcts (six), unsuitable anatomy (two), or "spontaneous" drug induced (but later) opening before contemplated PTCA (two), PTCA was not attempted and no mortality occurred. The in-hospital reocclusion rate after successful PTCA was 29%, despite the use of heparin and antiplatelet agents.(ABSTRACT TRUNCATED AT 250 WORDS)     

Usefulness of percutaneous transluminal coronary angioplasty for unstable angina pectoris after non-Q-wave acute myocardial infarction

Without revascularization, patients with non-Q-wave acute myocardial infarction (AMI) are predisposed to angina, recurrent AMI and cardiac death. Percutaneous transluminal coronary angioplasty (PTCA) was performed in 68 patients with angina an average of 2.3 months after non-Q-wave AMI (41 anterior, 27 inferior). Mean diameter stenosis was 95%, with collateralized total occlusion of the infarct-related artery in 23 patients. PTCA was successful in 87% (59 of 68), with a mean residual stenosis of 30%. One patient had emergency bypass surgery. Long-term follow-up (average 17 +/- 10 months) was available for 58 of the 59 patients in whom PTCA was successful. Recurrent angina developed in 41% (24 of 58), but was relieved by repeat PTCA in 14, by late coronary artery bypass surgery in 4 and by medical therapy in 6. There was 1 nonfatal AMI, due to progressive disease in a nondilated vessel, and 1 noncardiac death At last follow-up, 46 of 58 patients (79%) were asymptomatic and fully active or employed. Thus, patients undergoing PTCA for angina after non-Q-wave AMI appear to have a relatively high clinical restenosis rate, but with repeat PTCA have a low incidence of subsequent angina, AMI and cardiac death.     

Asymptomatic myocardial ischemia during percutaneous transluminal coronary angioplasty and importance of prior Q-wave infarction and diabetes mellitus

Eighty-eight patients undergoing percutaneous transluminal coronary angioplasty (PTCA) of 100 stenoses were studied for the presence of factors deemed significant in the etiology of silent myocardial ischemia. Thirty-two patients were asymptomatic during balloon dilations of 36 arteries, and 56 patients had angina during PTCA of 64 arteries. There were no differences in age, sex, prior anginal history, antianginal regimen, extent of coronary artery disease and number or duration of inflations between the 2 study groups. Previous infarction (33 vs 12%, p less than 0.02), Q waves in the target area (31 vs 7%, p less than 0.005) and diabetes mellitus (36 vs 17%, p less than 0.05) were present more often in the asymptomatic group. Sixty-four% of all asymptomatic patients had either diabetes or previous infarction in the target territory. Collateral circulation was more frequent in asymptomatic patients, probably reflecting the ability of collateral arteries to ameliorate ischemia. During 2-vessel PTCA, patients without angina during dilation of only 1 of the 2 treated arteries (discordant responders) had previous infarction in that artery's territory (5 of 5, 100%), whereas patients without previous infarction were either symptomatic or asymptomatic (concordant responders) during PTCA of both arteries. This study shows that asymptomatic ischemia occurs frequently during PTCA in patients with symptomatic coronary disease. Prior Q-wave infarction and diabetes mellitus are important, independent factors associated with painless ischemia. It is suggested that infarction produces a localized dysfunction of afferent cardiac pain fibers, whereas diabetes can cause a global cardiac sensory neuropathy.     

Acute coronary artery occlusion during and after percutaneous transluminal coronary angioplasty. Frequency, prediction, clinical course, management, and follow-up

BACKGROUND. Acute coronary artery occlusion after percutaneous transluminal coronary angioplasty (PTCA) continues to remain a serious complication despite significant improvement in operator performance and technological advancements. This retrospective study was performed to ascertain the frequency, predictive variables, management, and outcome of acute coronary artery occlusion. METHODS AND RESULTS. The study was based on data from 1,423 consecutive patients who underwent an elective coronary angioplasty between January 1986 and December 1988. Acute coronary artery occlusion occurred in 104 patients (7.3%). Acute occlusion developed during the dilatation procedure in 80 patients (5.6%) and within 24 hours after the procedure in 24 patients (1.7%). Four clinical and 14 angiographic variables predictive for acute coronary artery occlusion were analyzed in these 104 patients with a complicated procedure and were compared with those in 104 representative patients with successful attempts. Multivariate analysis found three independent predictive variables: unstable angina, multivessel disease, and complex lesions. The overall clinical outcome after management of acute coronary artery occlusion including immediate repeat dilatation (95 patients), use of intracoronary streptokinase (34 patients), or autoperfusion catheter (12 patients) was successful (reduction of lumen diameter to less than 50%, no death, no myocardial infarction [MI], and no emergency surgery) in 42 patients (40%), was a failure without major complication in four patients (4%), and was a failure with major complication (death, MI, and emergency surgery) in 58 patients (56%). The overall mortality rate was 6% (six patients), the overall MI rate was 36% (37 patients), and emergency bypass surgery was required in 30% of patients (31 patients). At 6 months' follow-up of 42 patients with successful management, recurrent angina pectoris due to restenosis occurred in 10 patients (24%), and a late MI occurred in one patient (3%). At 6 months' follow-up of 56 survivors with unsuccessful management (development of MI or need for emergency bypass surgery), recurrent angina occurred in nine patients (16%), and cardiac death in two patients (4%). However, the majority of patients in both groups were either symptom free or had mild angina pectoris. CONCLUSION. Acute coronary artery occlusion during PTCA is often unpredictable, but its frequency is higher in patients with unstable angina, multivessel disease, and complex lesions. Despite immediate redilatation, use of intracoronary streptokinase, and emergency bypass surgery, PTCA is associated with a high mortality and morbidity.     

Percutaneous transluminal coronary angioplasty--effect of the moveable guide wire on the complication rate

Beginning with the first percutaneous transluminal coronary angioplasty (PTCA) performed at Baystate Medical Center, 152 consecutive procedures were analyzed. Sixty were done using USCI-G (nonsteerable) series catheters. In two patients both a G and S (steerable) catheter were used. In 90 procedures the S system was used exclusively. Among the attempted angioplasties with the G series catheter, the percutaneous transluminal coronary angioplasty was successful in 47 (78%). Eight coronary occlusions were induced and all these patients underwent coronary bypass surgery. There were no deaths, but three patients (5%) had acute myocardial infarctions (MI). The two patients in whom both G and S catheters were used had occlusions. One went to surgery and died postoperatively of uncontrollable ventricular arrhythmias. The other patient had a myocardial infarction and recovered. Of the 90 attempts with the exclusive use of the steerable system, 75 were successful (83%). Three coronary occlusions were induced in the 90 attempts and two of the patients had coronary artery bypass surgery. None of the three sustained a myocardial infarction. In summary, the proportion of patients requiring emergency surgery was significantly reduced from 13.3% (8 of 60) to 2.2% (2 of 90) (p=0.02), the incidence of myocardial infarction was reduced from 5 to 0%, and there was a slight increase in the siccess rate of the procedure after the introduction of the steerable system. It is concluded that the steerable system increases the safety of PTCA.     

Follow-up after coronary arterial reperfusion with intravenous streptokinase in relation to residual myocardial infarct artery narrowings

Short- and long-term changes in residual stenosis of the myocardial infarct-related coronary arteries in patients with successful reperfusion by intravenous streptokinase have not been determined until now. In 15 patients the residual diameter stenosis decreased significantly from 62 +/- 9% after 24 hours to 55 +/- 13% in the fourth week (p less than 0.005). Quantitative angiographic analyses in 61 patients with patent infarct-related coronary arteries in the fourth week revealed a mean diameter stenosis of 61 +/- 13%. The patients were followed up 34 +/- 10 months. Sixteen had elective coronary artery bypass surgery or percutaneous transluminal coronary angioplasty (PTCA). Eighteen without coronary artery bypass surgery or PTCA had undergone repeat angiography after 26 +/- 9 months. Twenty-five (41%) have had a residual diameter stenosis greater than 65% in the fourth week. A stenosis greater than 65% was found in: 4 of 5 patients with late reinfarction; 3 of 7 with 1-vessel coronary artery disease and persistent angina, compared with none of 11 with a stenosis less than 65%; 6 of 7, whose silent reocclusion had been found at long-term follow-up compared with 1 of 9 with a residual stenosis less than 65%. In 8 patients with persistent patency of the infarct artery, the stenosis had decreased significantly from 55 +/- 6% to 36 +/- 12% (p less than 0.005). Correspondingly, there was a significant improvement in the infarct-related left ventricular wall motion disorders.(ABSTRACT TRUNCATED AT 250 WORDS)     

Angiographic follow-up after multivessel percutaneous transluminal coronary angioplasty

In 100 consecutive patients undergoing multivessel percutaneous transluminal coronary angioplasty (PTCA), dilation was attempted in 207 arteries. Primary success was achieved in 85 patients. Complications occurred in 8 patients: acute myocardial infarction in 5 and need for emergency coronary artery bypass surgery in 5. Control angiography was done in 77 of 85 patients (91%) with primary success at a mean of 12 +/- 6 months. Complete revascularization had been achieved in 59 patients and incomplete revascularization in 18. Angiographic restenosis was found in 39 of 77 patients (51%) and in 47 of 143 arteries (33%) at 9 +/- 7 months. The restenosis rate was 57% for chronic total occlusions (8 of 14) and 30% for stenoses (39 of 129). The restenosis rate was significantly higher for the left anterior descending coronary artery (40%) than for the left circumflex coronary artery (21%). However, the significance was lost after exclusion of chronic total occlusions. A higher residual stenosis and a high coronary wedge pressure were predictors for restenosis. Restenosis was clinically silent in 14 patients (18%). Repeat PTCA was done in 19 patients with recurrence and elective surgery in 8. Clinical follow-up was available in all patients at 24 +/- 12 months. Patients with incomplete revascularization had less favorable clinical follow-up results than patients with complete revascularization: 44% (8 of 18) vs 81% (48 of 59) were asymptomatic (p less than 0.005), and 28% (5 of 18) vs 5% (3 of 59) had undergone elective bypass surgery during follow-up (p less than 0.005). Most patients with restenosis after multivessel PTCA had only 1-vessel restenosis and only 7% had restenosis of all lesions.     

Early occlusion following successful coronary angioplasty: clinical and angiographic observations

To assess clinical and angiographic features of early occlusion after percutaneous transluminal coronary angioplasty (PTCA), 25 successful PTCA procedures (3%) with early occlusion were analyzed from a PTCA population of 917. Twenty patients (80%) had unstable angina, while 12 (48%) had a recent (less than 1 mo) myocardial infarction subtended by the PTCA vessel. All patients received a calcium blocker, aspirin, dipyridamole, and heparin prior to PTCA. In 20 of 25 patients (80%), occlusion occurred in the catheterization laboratory, while five occurred out of laboratory, three within 5 hours and 1 each within 24 and 48 hours. Angiographic features before PTCA included complex lesions (hazy, stained, or ulcerated) in 12 (48%) and intracoronary filling defects in eight patients (32%). Post-PTCA intracoronary filling defects were present in 17 dilated stenoses (68%). Compared to a consecutive control population of 100 patients with similar demographics but without acute occlusion, the frequency of unstable angina, acute myocardial infarction, and filling defects was greater in patients with early occlusion (P less than .001 for all). Intracoronary nitroglycerin was utilized in all patients with reopening in only one (4%), while bypass surgery was performed in five (20%). Intravenous streptokinase was administered to two patients with reperfusion in one. Immediate repeat PTCA was successful in 15 of 17 patients (88%). In summary, recent unstable angina, myocardial infarction, complex lesions or intracoronary filling defects before and particularly after PTCA all suggest an association of clot with early occlusion. Immediate repeat PTCA is frequently successful.     

Multilesion coronary angioplasty: clinical and angiographic follow-up

Determination of the restenosis rate after multilesion percutaneous transluminal coronary angioplasty is an important consideration in defining expanded indications for the procedure. Of 209 patients who underwent successful multilesion coronary angioplasty, 55 symptomatic and 74 asymptomatic patients were restudied an average of 7 +/- 4 months after dilation. The restenosis rate was 82% (45 of 55) in the symptomatic patients and 30% (22 of 74) in the asymptomatic patients (p less than 0.001). Only 4% of the asymptomatic patients had restenosis at more than one dilation site. When only patients who developed a restenosis were considered, the restenosis occurred at more than one dilation site in 47% (21 of 45) of the symptomatic group versus 14% (3 of 22) of the asymptomatic group (p less than 0.05). When all recurrent stenoses were examined, the severity of the luminal narrowing was greater than or equal to 70% in 64% (45 of 70) of the stenotic lesions in the symptomatic patients versus 31% (8 of 26) of the stenotic lesions in the asymptomatic patients (p less than 0.05). Proximal left anterior descending coronary artery disease, increased length of the stenotic narrowing, male gender and diabetes were associated with an increased incidence of restenosis by multivariate analysis. Patient-related variables were not predictive of multilesion restenosis. In conclusion, the majority of patients are clinically improved after multilesion coronary angioplasty. Recurrent symptoms after multilesion coronary angioplasty are frequently associated with multilesion restenosis and a more severe degree of restenotic narrowing. Restenosis at more than one dilation site is uncommon in the asymptomatic patient.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous transluminal coronary angioplasty using a steerable guiding catheter: a new technique

A new type of steerable guiding catheter is described for use in percutaneous transluminal coronary angioplasty (PTCA). It is simple to use and externally steerable. The catheter incorporates a steering system by means of which the catheter tip can be made to assume the form of either a right or left Judkins catheter or to be fixed in any intermediate configuration, entirely through external manipulation. We used this new guiding catheter to perform PTCA on 15 patients. Single lesions were found in the left anterior descending branch in seven patients, in the right coronary artery in four, and in the circumflex artery in two, whereas stenosis of a coronary bypass graft was found in two patients. Angioplasty was successful in all cases. There were no complications, during either the procedure or the postoperative hospitalization. The steerable guiding catheter described here may prove useful for PTCA in cases where a conventional catheter cannot be placed accurately or in cases with multi-vessel coronary disease.     

Acute vascular occlusion caused by percutaneous transluminal coronary angioplasty: early and late results of repeat-PTCA

Acute vascular occlusion after percutaneous transluminal coronary angioplasty (PTCA) often necessitates a prompt aortocoronary bypass-operation (CABG). Alternatively, a re-PTCA can be attempted. In 1500 consecutive patients there was acute symptomatic occlusion due to PTCA 5 min to 16 h after the operation in 47 cases (3.1%). An immediate re-PTCA was attempted in all cases. Results: Reopening was successful in 43 of 47 cases (91%): in 15 patients (30%) within 30 min, in 36 patients (68%) within 60 min and in 42 patients (89%) within 90 min. In eight patients there was early re-occlusion 30 min to 20 h after re-PTCA, necessitating acute CABG in four patients. In 35 patients with re-PTCA the vessel remained open. Re-stenosis occurred within 1 to 10 days in 10 patients, and in additional 12 patients after 2-4 months. In most cases an additional PTCA was successful. Complications: Six patients had an emergency CABG (three with an exchange wire as a stent in the dissected coronary artery). Three patients died (one after CABG); 14 patients experienced myocardial infarction (30%) (in three of these 14 the infarct was large). Conclusion: Acute vascular occlusion after PTCA can successfully be treated by re-PTCA in four of five cases. However a rate of re-stenosis of about 60% is to be anticipated. Reperfusion with re-PTCA is fast and in these patients with transmural ischemia there are obviously less complications in comparison to emergency CABG after PTCA. 60% of the patients remain symptom free or markedly improved and without infarction or emergency CABG after 4 months.     

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.