Emergency coronary bypass surgery after coronary angioplasty: the national heart, lung, and blood institute''s percutaneous transluminal coronary angioplasty registry experience

The frequency and outcome of emergency CABG for complications of PTCA in the NHLBI PTCA Registry were analyzed. Emergency surgery was performed in 202 patients (6.6%). The most frequent indications for emergency operation were coronary dissection in 46%, coronary occlusion in 20%, prolonged angina in 14% and coronary spasm in 11%. Emergency surgery was most often necessary in patients in whom lesions could not be reached or traversed, but more than 25% of patients who required emergency surgery had initially successful dilatation followed by abrupt reclosure of the vessel. The mortality rate with emergency CABG was 6.4%, and nonfatal Ml occurred in 41% of patients, with Q waves developing in approximately 60% of patients with MI. However, 53% of patients managed with emergency CABG for severe ischemic events with PTCA did not have evidence of MI or die and had an uncomplicated postoperative course. No baseline clinical predictors of emergency surgery were identified. Lesion eccentricity was associated with a significant increase in frequency of emergency operation, and the incidence of emergency surgery declined with increasing experience with PTCA.     

Percutaneous transluminal coronary angioplasty: report of complications from the National Heart, Lung, and Blood Institute PTCA Registry

The complications reported in the first 1500 patients enrolled in the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry are analyzed. Data were contributed from 73 centers between September 1977 and April 1981. PTCA was successful in 63% of attempts. Five hundred forty-three in-hospital complications occurred in 314 patients (21%). The most frequent complications were prolonged angina in 121, myocardial infarction (MI) in 72, and coronary occlusion in 70. One hundred thirty-eight patients (9.2%) had major complications (MI, emergency surgery or in-hospital death). One hundred two patients (6.8%) required emergency surgery, usually for coronary dissection or coronary occlusion. Sixteen patients (1.1%) died in-hospital; the mortality rate was 0.85% in patients with one-vessel disease and 1.9% in those with multivessel disease. The mortality rate was significantly higher in patients who had had bypass surgery (p less than 0.001). Nonfatal complications were significantly influenced by the presence of unstable angina (p less than 0.001) and initial lesion severity greater than 90% diameter stenosis (p less than 0.001). This report delineates and assesses the complications encountered with PTCA during its initial 3 1/2-year clinical experience. These results support the relative safety of PTCA as a method of nonsurgical myocardial revascularization in carefully selected patients.     

Efficacy of percutaneous transluminal coronary angioplasty: Technique,patient selection,salutary results,limitations and complications

Percutaneous transluminal coronary anglopiasty (PTCA) was performed in 25 patients and 29 vessels during a 12-month period. In six additional patients scheduled for PTCA, the procedure was cancelled when repeat angiography identified progression to occlusion, coronary spasm, or other adverse factors not previously apparent. PTCA was successful in 14 of 25 patients (56%) and in 18 of 29 vessels (62%); success was associated with clinical improvement in all patients by symptomatology, exercise testing and/or myocardial radionuclide imaging. Beneficial results were particularly achieved with left anterior descending artery lesions and with stenoses showing less than 90% narrowing. One peripheral arterial complication occurred and no patients required emergency surgery. While coronary dissection was detected angiographically in four patients and evidence of coronary spasm was present in three patients post-PTCA, neither was accompanied by untoward early clinical events. Multivessel dilatation in three patients was initially successful but symptoms returned in two during follow-up. Restenosis developed in 3 of 14 patients (21%) after 3 months. Our experience indicates (1) that the specific vessel attempted and lesion severity particularly influence the liklihood of success, (2) the not infrequently induced coronary dissection or spasm does not necessarily represent a serious complication, and (3) angiography repeated in preparation for PTCA identifies a significant minority of patients who are no longer candidates.     

Coronary vasospastic activity at sites of percutaneous transluminal coronary angioplasty: evaluation using intracoronary acetylcholine administration]

To investigate coronary vasospastic activity after percutaneous transluminal coronary angioplasty (PTCA), we performed intracoronary injection of acetylcholine in 55 patients, mean 3.3 months after successful PTCA. Coronary spasm was defined as transient total or subtotal occlusion of the PTCA sites. Sixty-nine lesions of the 55 patients were examined to determine whether spasm was provoked by incremental doses of acetylcholine. Restenosis was defined as coronary luminal narrowing of > or = 50% after nitroglycerin or isosorbide dinitrate. Twenty of the 55 patients (36%) and 23 of the 69 lesions (33%) had coronary spasm. There was no correlation between the incidence of coronary spasm and the interval from PTCA to the acetylcholine test. The spasm was provoked in 17 lesions of the 50 non-restenotic lesions (34%) and was also provoked in 6 of the 19 restenotic lesions (32%). On the other hand, restenoses occurred in 6 of the 23 spastic lesions (26%) and in 13 of the 43 non-spastic lesions (28%). There was no correlation between the incidence of coronary spasm and the occurrence of restenoses. Twenty-four patients had undergone acetylcholine provocative test before PTCA. Among these 24 patients, 11 had coronary spasm before PTCA, and 7 had coronary spasticity after PTCA. Four patients who had positive evidence of coronary spasm before PTCA did not show negative spasm after PTCA. On the other hand, 3 patients who did not show evidence of coronary spasm showed positive evidence of coronary spasm after PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Acute closure during coronary excimer laser angioplasty and conventional balloon dilatation: a comparison of management outcome and prediction

Of 523 consecutive patients undergoing elective percutaneoustransluminal coronary angioplasty (PTCA) and 83 patients treatedwith coronary excimer laser angioplasty (ELCA), 17 (3.3%) hadin-laboratory occlusion following PTCA and 25 (30%)followingELCA; they were enrolled into a prospective study. Successfulmanagement (reopened vessel, patency at repeat angiography within24 h, no death, no myocardial infarction (MI), no emergencybypass surgery) including repeat lasing, subsequent PTCA, useof intracoronary nitroglycerin or streptokinase was achievedin 24 (96%) of the 25 patients with acute occlusion during ELCA.An anterior MI occurred in one patient of the laser group. Repeatballoon dilatation was successfully performed in seven of the17 patients (41%) with acute closure during PTCA. Among the10 patients with persistent occlusion after PTCA, five developeda limited myocardial infarction (35%). One patient requiredemergency CABG, and died peri-operatively. Severe spasm priorto occlusion defined by a new coronary flow depression withoutevidence of dissection or thrombus showed a significant positiveassociation with acute occlusion during ELCA (P =0.0008). Thus, in contrast to occlusion during PTCA, subsequent balloondilatation was successfully performed in the majority of patientswith acute occlusion during ELCA, implying that different underlyingmechanisms are responsible for this complication. In this limitedpatient group, occlusion after excimer laser angioplasty wasmuch more frequent than closure during PTCA, but was infrequentlyassociated with major events such as myocardial infarction ordeath.     

Percutaneous transluminal coronary angioplasty (PTCA) in patients with relative contraindications: Results of the national heart, lung, and blood institute PTCA registry

The effects of relative contraindications on the immediate results of PTCA were investigated in 1,939 patients, and on long-term results in 998 patients with isolated stenosis of 1 coronary artery. Immediate results subjected to analysis were: success rate, major complications (coronary occlusion, MI and death) and emergency CABG. The analysis of long-term results included: status of angina pectoris, occurrence of MI, restenosis, repeat PTCA, CABG and death. Unstable angina and previous MI had no negative effects on immediate results, whereas a significantly lower success rate was noted in patients with angina for more than 1 year compared to patients with angina of shorter duration (p < 0.05) and patients older than 60 years compared with younger patients (p < 0.01). During follow-up, patients with unstable angina had higher CABG rate (p < 0.01); the other relative clinical contraindications to PTCA did not exert adverse effects. Angiographically, there was a lower immediate success rate in patients with nonproximal stenosis (p < 0.001) and in patients with calcium in the affected artery (p < 0.01) and at the site of stenosis (p < 0.001). Patients with tubular or diffuse stenoses had similar success rates but higher rates of complications, excluding death, than those with discrete stenoses (p < 0.01). Patients with eccentric stenoses had a lower success rate and a higher rate of complications and emergency CABG than patients with concentric stenoses (p < 0.001 for all 3 variables). Coronary spasm during diagnostic angiography did not adversely affect the immediate results. Finally, patients with an ejection fraction of less than 50 % had a similar success rate but higher rate of complications, including death, than patients with a higher ejection fraction (p < 0.01), and underwent repeat PTCA more often (p < 0.05) during follow-up. None of the other angiographic relative contraindications had unfavorable effects on long-term results of PTCA.

The study suggests that the present guidelines for PTCA eligibility are somewhat restrictive. However, the individual cardiologist should relax the guidelines cautiously and gradually, and only after reaching the plateau of his learning curve.     

Cardiac tamponade following percutaneous transluminal coronary angioplasty: four case reports

Percutaneous transluminal coronary angioplasty (PTCA) has had complications related to dilating catheters and guide wires such as coronary artery dissection, spasm, rupture, and perforation. This report describes four patients who developed cardiac tamponade following PTCA, presumably from right ventricular (RV) perforation. All four received large doses of heparin during PTCA and three received antiplatelet therapy. In three cases, cardiac tamponade occurred several hours after PTCA. All patients did well following operative intervention and no patient required repair of a cardiac perforation. We postulate that impaired hemostasis in the presence of an otherwise inconsequential RV perforation causes tamponade. Three alternatives to provide standby pacing are proposed.     

Intracoronary stenting for acute and threatened closure complicating percutaneous transluminal coronary angioplasty.

BACKGROUND. Acute closure remains a significant limitation of percutaneous transluminal coronary angioplasty (PTCA) and underlies the majority of ischemic complications. This study details the clinical and angiographic characteristics of a series of patients receiving an intracoronary stent device to manage acute and threatened closure and presents the early clinical results. METHODS AND RESULTS. From October 1989 through June 1991, 115 patients undergoing PTCA received intracoronary stents to treat acute or threatened closure in 119 vessels. Sixty-three percent had multivessel coronary disease, 33 (29%) had undergone prior coronary artery bypass grafting (CABG), and 52 (45%) had had previous PTCA. Using the American College of Cardiology/American Heart Association (ACC/AHA) classification, 15% of lesions were class A, 55% were class B, and 30% were class C. Eight patients were referred with severe coronary dissection and unstable angina after PTCA at other institutions. Acute closure was defined as occlusion of the vessel with TIMI (Thrombolysis in Myocardial Infarction) 0 or 1 flow immediately before stent placement. Threatened closure required two or more of the following criteria: 1) a residual stenosis greater than 50%, 2) TIMI grade 2 flow, 3) angiographic dissection comprising extraluminal dye extravasation and/or a length of greater than 15 mm, 4) evidence of clinical ischemia (either typical angina or ECG changes). Twelve vessels (10%) met the criteria for acute closure, and 87 vessels (73%) satisfied the criteria for threatened closure. Twenty vessels (17%) failed to meet two criteria. Stenting produced optimal angiographic results in 111 vessels (93%), with mean diameter stenosis (+/- 1 SD) reduced from 83 +/- 12% before to 18 +/- 29% after stenting. Overall, in-hospital mortality was 1.7% and CABG was required in 4.2%; Q wave myocardial infarction (MI) occurred in 7% and non-Q wave MI in 9%. Stent thrombosis occurred in nine patients (7.6%). For the 108 patients who presented to the catheterization laboratory without evolving MI, Q wave MI occurred in 4% and non-Q wave MI occurred in 7%. Angiographic follow-up has been performed in 81 eligible patients (76%), and 34 patients (41%) had a lesion of greater than or equal to 50%. CONCLUSIONS. This stent may be a useful adjunct to balloon dilatation in acute or threatened closure. Randomized studies comparing this stent with alternative technologies are required.     

Pathophysiology of early coronary angioplasty with stenting on non-Q-wave vs Q-wave myocardial infarction

This study was undertaken to evaluate the pathophysiologic and clinical effects of the early application of percutaneous transluminal coronary angioplasty (PTCA) supported by stenting on non-Q-wave myocardial infarction (MI). Ninety-four patients with non-Q-wave MI and 316 patients with Q-wave MI were studied. Early PTCA with provisional stenting (40%) was performed in all of them. A history of MI (22% vs 12%, p=0.018), preinfarction angina < or = 24 hours before the onset of MI (60% vs 33%, p<0.001), and patent infarct-related vessels (83% vs 21%, p<0.001) were significantly more common in non-Q-wave MI than in Q-wave MI. As predictors of the occurrence of non-Q-wave MI, preinfarction angina (p=0.001) and previous MI (p=0.021) were significant variables. Clinical outcomes showed more improvement in in-hospital death (0.0% vs 5.0%, p=0.036) and long-term event-free curves for death and/or MI (p=0.035) in non-Q-wave MI than Q-wave MI when patients with previous MI were excluded. There was no significant difference in clinical outcome between the two groups when patients with previous MI were included. The high incidence of patent infarct-related vessels and preinfarction angina as well as the improved outcome obtained by early PTCA/stenting suggest instability of coronary occlusion and culprit coronary lesions in non-Q-wave MI. In conclusion, non-Q-wave MI constitutes a characteristic feature of MI induced by unstable coronary lesions, and early interventional therapies are presumed to result in improved outcomes by stabilizing the unstable culprit lesions.     

Frequency of provoked coronary vasospasm in patients undergoing coronary arteriography with spasm provocation test of acetylcholine

This study examines the incidence of spasm by intracoronary injection of acetylcholine in Japanese patients who underwent coronary angiography. The subjects were 685 consecutive patients (477 men, mean age 63.2 +/- 7.5 years) who were studied with an acetylcholine test. Acetylcholine was injected in incremental doses of 20, 50, and 80 microg into the right coronary artery and 20, 50, and 100 microg into the left coronary artery. Spasm was defined as total or subtotal occlusion. Coronary vasospasm was determined in 221 patients (32.3%). Spasm occurred often during effort and rest in patients with angina (25 of 51, 49.0%), exertional angina (25 of 74, 33.8%), recent myocardial infarction (30 of 80, 37.5%), healed myocardial infarction (14 of 37, 37.8%), and especially in patients with rest angina (83 of 124, 66.9%), whereas spasm was relatively uncommon in patients with nonischemic heart disease (23 of 252, 9.1%). Spasm was superimposed on significant atherosclerotic lesions in 35.9% of patients as well as on nonfixed atherosclerotic lesions in 30.8% of patients. We conclude that >9% of Japanese patients may have coronary vasospasm with intracoronary injection of acetylcholine and recommend the provocation test for evaluating coronary vasospasm if coronary angiography is undertaken.     

Directional coronary atherectomy for the treatment of coronary lesions with abnormal contour

Directional coronary atherectomy is a newly developed percutaneous transluminal procedure which excises and removes obstructive tissue from coronary arteries or saphenous vein grafts. This procedure was performed on 47 lesions with abnormal contour; 24 ulcerative lesions, 10 lesions with dissection, 7 flap-like lesions and 6 lesions with aneurysm dilatation. Overall success rate was 89%; 96% in ulcerative lesions, 70% in lesions with dissection, 86% in flap-like lesions and 100% in lesions with aneurysmal dilatation. Complications with this procedure were as follows: Vessel occlusion in 2 patients (4.5%), perforation in 1 patient (2.3%), and guiding catheter induced dissection in 1 patient (2.3%). Coronary artery bypass surgery was required in 4 patients (9.4%) for these complications. Of these, 3 patients had lesions with dissections prior to the atherectomy procedure. The success rate for lesions with abnormal contour was similar to those of 270 lesions with normal contour. In conclusion, directional coronary atherectomy is a safe and effective procedure for lesions with abnormal contour, however, outcome of a lesion with dissection is suboptimal and it needs to be approached cautiously.     

Frequency and importance of unprovoked coronary spasm in patients with angina pectoris undergoing percutaneous transluminal coronary angioplasty

Coronary spasm superimposed on fixed coronary artery stenosis was discovered in 14 of 74 candidates for percutaneous transluminal coronary angioplasty (PTCA). In 3 of the 14, spasm developed during PTCA and was presumably catheter-induced. Eleven of the 14, with unprovoked spasm, are the subject of this study. Three of the 11, in whom the fixed component of the mixed stenosis was subcritical were treated medically, with good results in 2 but with persistent angina pectoris and eventual myocardial infarct in 1. Nitroglycerin administered by the intracoronary route relieved spasm resistant to sublingual nitroglycerin in 1 of the 3. In 8 of the 11 with critical fixed stenosis, spasm was discovered either before PTCA (7 patients) or on follow-up (1 patient). Six of the 8 had successful PTCA, with no or mild symptoms on follow-up. Of the 2 failures, 1, uncomplicated, was followed by successful elective coronary artery bypass surgery while the other, complicated, led to successful emergency coronary artery bypass surgery, with disappearance of symptoms in both. The rate of success was similar in patients with documented unprovoked spasm (6 of 8) and patients without (39 of 63, 62%). It is concluded that (1) coronary spasm, if properly sought for, is probably not uncommon in single-vessel candidates for PTCA; (2) patients considered candidates for PTCA should have intracoronary nitroglycerin administered before PTCA; (3) in patients with critical, fixed coronary artery disease, associated spasm does not reduce the chances of successful PTCA; (4) coronary spasm may outlast the relief by PTCA of the fixed component of the mixed stenosis and requires long-term vasodilator therapy; and (5) the lack of adverse effects when PTCA is performed in patients with spasm superimposed on critical fixed single-vessel stenosis appears to justify its use for the time being.     

Two years experience with the Palmaz-Schatz coronary stent in a heterogeneous patient population

Between January 1991 and December 1992, 136 Palmaz-Schatz coronary stents were implanted in 113 native coronary arteries in 106 patients. Forty-seven patients presented with stable angina, 50 with unstable angina, 7 with congestive cardiac failure and unstable angina and 2 were asymptomatic. Stenting was carried out in 15 patients for restenosis after coronary angioplasty (PTCA), 32 for significant dissection during PTCA (with 19 acute and 13 threatened closure), 10 for suboptimal PTCA results and 56 for de novo lesions, 52 (92.9%) of which were either ACC/AHA type B or C. Successful delivery was achieved in 97.2% (103/106) of patients or 97.3% (110/113) of vessels. Percent diameter stenosis was reduced from 78 +/- 13% to 4 +/- 11%. There were two subacute stent thromboses (1.9%), resulting in Q-Wave myocardial infarction. Three deaths (2.9%) occurred, all from the group with congestive cardiac failure and unstable angina. Major bleeding/vascular complications occurred in 4 patients (3.9%). All patients were followed up for a mean of 18 months (6 months to 30 months). Eighty-five patients were asymptomatic. Three patients were angina-free but continued to have, albeit improved, congestive cardiac failure. Ten patients had recurrence of angina, all within 6 months of the stenting procedure. Four were treated medically and 4 had PTCA of whom one eventually had coronary bypass surgery. Two patients had new lesions, successfully treated by PTCA or stenting. In conclusion, a high rate of successful delivery of the Palmaz-Schatz coronary stent can be achieved in a wide spectrum of patients with few complications which are mostly related to anticoagulation. It offers very effective bailout for acute closure during PTCA. Despite the presence of unfavorable pre-procedure patient and lesion characteristics, the acute and long term clinical results are encouraging.     

Comparative results of coronary intervention in patients with variant angina versus those with non-variant angina

Coronary angioplasty is reported to be feasible and safe in patients with coronary spasm and fixed stenosis. However, the long-term results are not positive. We compared the results of coronary angioplasty in 20 patients with variant angina versus 17 patients with non-variant angina among 231 consecutive patients with vasospastic angina. Coronary angioplasty was performed successfully in all 37 patients without any complications. Stenting for coronary dissection or recoil was performed in 8 patients, directional coronary atherectomy was selected for ostial lesion of left anterior descending coronary artery stenosis in 2 patients, and standard balloon angioplasty was performed in 27 patients. There were no clinical differences between the two groups. The restensois rate in patients with variant angina was similar to that in patients with non-variant angina (30% vs 29%, ns). There was no relationship between the provoked spasm and restenosis. During the follow-up period, no major complications were observed in patients with variant angina or those with non-variant angina. In conclusion, full medication with calcium channel antagonists and isosorbide dinitrate, and treatment by coronary angioplasty including the use of new devices, were useful treatments for patients with coronary vasospasm and significant organic stenosis. There was no difference concerning the results of coronary intervention between the patients with variant angina and those with non-variant angina.     

Outcome after prolonged balloon inflations of greater than 20 minutes for initially unsuccessful percutaneous transluminal coronary angioplasty.

Prolonged balloon inflation with or without autoperfusion techniques is a common initial approach to major dissection or abrupt occlusion after percutaneous transluminal coronary angioplasty (PTCA). To assess such a strategy in the setting of unsuccessful angioplasty, 40 patients who underwent prolonged balloon inflations of greater than 20 minutes between January and July of 1991 after initially unsuccessful angioplasty were studied. These patients (median age 59 years) underwent PTCA for progressive or unstable angina (16[40%]), symptomatic or asymptomatic residual stenosis after myocardial infarction (10[25%]), acute myocardial infarction (3[8%]), stable angina (3[8%]), reinfarction (2[5%]), and other indications (6[15%]). The significant stenoses were primarily in the proximal and midportions of the right coronary (53%), left anterior descending (30%) and left circumflex (17%) coronary arteries. Before prolonged balloon inflation, the longest single inflation was 11 +/- 6 minutes and the total time of all inflations was 17 +/- 8 minutes (mean +/- standard deviation). Stenosis was reduced from 91 +/- 9 to 68 +/- 16% before prolonged inflation. After prolonged balloon inflation of 30 +/- 9 minutes, the residual stenosis was 47 +/- 21% (p = 0.0001 vs value before prolonged inflation). Furthermore, improvements in the appearance of filling defects or dissections, or both, occurred in 19 patients (48%). Procedural success was obtained in 32 of 40 patients (80%). Coronary bypass grafting was performed in 8 patients (20%): 4 after unsuccessful PTCA (3 emergently) and 4 electively after initially successful PTCA. Although 5 patients had creatine kinase-MB elevations greater than 20 IU/liter after the procedure, only 1 sustained a Q-wave myocardial infarction. There were no deaths in the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Frequency of provoked coronary spasms in patients undergoing coronary arteriography using a spasm provocation test via intracoronary administration of ergonovine

There are no data concerning the incidence of provoked coronary arterial spasms via intracoronary administration of ergonovine (ER). This study sought to establish the incidence of spasms due to intracoronary injection of ER in Japanese patients who underwent coronary angiography. The subjects were 596 consecutive patients (369 men, mean age 64.2 +/- 10.3 years) who were studied with a selective ER test. ER was administered in total doses of 40 microg into the right coronary artery and 64 microg into the left coronary artery. A positive spasm was defined as a total or subtotal occlusion. Coronary vasospasms were determined in 173 patients (29.0%). Spasms occurred often in patients with ischemic heart disease (43.3%); during effort and rest in patients with angina (46.3%), exertional angina (27.7%), recent myocardial infarction (36.7%), healed myocardial infarction (34.1%), and especially in patients with rest angina (55.5%), but were relatively uncommon in patients with nonischemic heart disease (3.7%). The incidence of provoked coronary spasms in this study was 2.2-2.6 times higher than in previous reports with intravenous ER administration. More spasms were superimposed on significant atherosclerotic lesions than on nonfixed atherosclerotic lesions (42.8% vs 24.0%, p < 0.01). No serious or irreversible complications were observed in this study. In conclusion, intracoronary administration of ER was a safe and reliable test. Compared with Caucasian patients, in Japanese patients, coronary arterial spasms occurred 2-3 times more frequently with various cardiac disorders.     

Clinical experience of percutaneous transluminal coronary angioplasty

PTCA (percutaneous transluminal coronary angioplasty) was performed on 44 patients with angina pectoris during the 18-month period from April 10, 1981 to September 30, 1982. It was successful in 36 of the 44 patients (82%), resulting in a subsidence of the symptoms and a considerable increase in exercise tolerance. Successful dilatations were achieved in 30 of 35 left anterior descending arteries (86%) and 7 of 11 right coronary arteries (64%). Five patients had complications: myocardial infarction in 2, unstable angina pectoris in 1, and dissection of the coronary artery in 2. One of these patients underwent an urgent A-C bypass operation. The patients were followed up for 0.5 to 18 months (average: 7.4 +/- 0.9 months). Stenosis recurred in 6 patients (16.7%), but repeat PTCA disclosed successful dilatations of stenotic lesions in 3 patients. No deaths occurred throughout the study period including the follow-up period. Our experience suggests that PTCA is of use in the treatment of certain groups of angina pectoris patients if case selection is appropriate.     

In-hospital morbidity and mortality in patients undergoing elective coronary angioplasty

We prospectively recorded all in-hospital complications of the first 3500 consecutive patients to undergo elective coronary angioplasty (PTCA) at Emory University Hospitals from July 14, 1980, to August 28, 1984, by three operators. PTCA was attempted in a total of 3933 lesions, with a primary success rate of 91%. Multiple-lesion PTCA was performed in 401 patients, and PTCA of saphenous vein grafts was attempted in 172. No complications were recorded in 3116 (89%) cases, isolated minor complications occurred in 241 (6.9%), and major complications (emergency surgery, myocardial infarction, death) were observed in 145 (4.1%). Emergency coronary artery bypass graft surgery (CABG) was performed in 96 patients (2.7%), with a myocardial infarction rate of 49% (47/96), a Q wave infarction rate of 23% (22/96), and an emergency surgery mortality rate of 2% (2/96). Hospital discharge occurred within 2 weeks of attempted PTCA in 91% (87/96) of patients undergoing emergency CABG. The overall myocardial infarction rate was 2.6% (94/3500). There were two nonsurgical deaths, giving a total mortality rate of 0.1% (4/3500). Univariate and multivariate analysis of 3099 patients undergoing single-lesion PTCA identified five preprocedure predictors of a major complication: multivessel coronary disease, lesion eccentricity, presence of calcium in the lesion, female gender, and lesion length. Unstable angina, duration of angina, lesion severity, previous CABG, and vein graft dilatation were not associated with an increased incidence of major complications. The strongest predictor of a major complication was the procedural appearance of an intimal dissection. Intimal dissection was evident in 894/3099 (29%) patients.(ABSTRACT TRUNCATED AT 250 WORDS)