Coronary stenting for failed angioplasty in acute myocardial infarction

Intracoronary stents were implanted in 15 patients after unsuccessful PTCA in the setting of acute myocardial infarction (AMI). The stented vessel was the left anterior descending (LAD) in 11 patients, the right coronary artery (RCA) in 3 patients, and a venous bypass graft to the LAD in a single patient. A total of 16 stents were implanted (15 Palmaz-Schatz, Johnson and Johnson; and 1 Wiktor, Medtronic). Follow-up: 1 patient died 10 days after stent implantation as a result of renal failure and cardiogenic shock. Subacute thrombosis occurred in 2 patients, 5 and 15 days after stent implantation; both underwent successful emergency coronary artery bypass grafting (CABG). The remaining 12 patients were free from major ischemic events (death, AMI, and further revascularization) after a mean follow-up of 18.7 ± 4.1 months. We conclude that the long-term results of intracoronary stenting in AMI after failed PTCA are favourable. © 1996 Wiley-Liss, Inc.     

溶栓禁忌证的老年急性心肌梗死患者直接介入治疗的探讨

目的　探讨不能溶栓的老年急性心肌梗死 (AMI)患者直接介入治疗的安全性与有效性。方法　对 31例 70岁以上的患者 ,3例 6 0～ 6 9岁有溶栓禁忌证的老年心肌梗死的患者进行了直接经皮冠状动脉腔内成形术 (PTCA)与冠状动脉内支架术。结果　有 34例梗死相关动脉 (IRA)心肌梗死溶栓试验 (TIMI)血流 0级 2 7例 ,1级 7例。 31例直接行PTCA成功 ,其中 4例患者直接PTCA后其残余狭窄 <10 %且无明显的内膜撕裂和夹层。 2 7例IRA具有支架置入的适应证 ,即刻造影IRATIMI血流达 3级。 2例行冠状动脉旁路移植术 (CABG)。有 1例因IRA完全闭塞 ,PT CA未能成功。直接介入成功率 97%。 31例患者经过平均 (11.4± 3.7)个月随访 ,无再梗死及急诊再次血运重建 ,但 4例有心绞痛 ,造影证实为冠状动脉支架再狭窄再次行PTCA成功。结论　对溶栓有禁忌证的老年AMI患者行直接介入治疗 ,具有较高的成功率及安全性。     

Comparative results of coronary angioplasty performed at the time of coronarography and at a later time

Between January 1986 and December 1988, 558 patients underwent percutaneous transluminal coronary angioplasty (PTCA) of whom 40 per cent were dilated at the time of diagnostic coronary arteriography. In order to assess the value of this therapeutic strategy we compared the results of 221 patients dilated at the time of diagnostic coronary arteriography (Group 1) with those of 337 patients who underwent deferred PTCA. In Group 1, the incidence of stable angina was lower (26.7% vs 46.3%, p less than 10-5), that of thrombolysed myocardial infarction was higher (24% vs 2.7%, p less than 10-9) and a higher proportion of patients had previously undergone PTCA (29.4% vs 3.2%, p less than 10-9). The proportion of patients with single vessel disease was higher in Group 1 (84.6% vs 74.7%, p less than 0.01) as was that of angioplasty of a single lesion (97.7% vs 88.1%, p less than 10-4). There were fewer dilations of the left circumflex artery in Group 1 (17.2% vs 27.3%, p less than 0.05) which was compensated by a higher number involving the right coronary artery (26.1% vs 15.5%, p less than 0.01). The immediate results were comparable in the two groups with 87.8 per cent primary successes, 3.6 per cent of myocardial infarcts and 1.3 per cent of coronary bypass operations with no fatalities in Group 1. These favorable results encourage the development of PTCA at the time of diagnostic coronary arteriography in the following indications: unstable angina, thrombolysed myocardial infarction and restenosis irrespective of the patient's symptomatology.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prognosis of culprit lesion PTCA in acute myocardial infarction for multi versus single vessel disease.

We studied 417 patients undergoing single vessel culprit lesion percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction to determine the impact of disease in other vessels. Group A (189 patients, 45%) had coronary artery disease (greater than or equal to 70% stenosis) in at least 1 additional vessel while Group B (228 patients, 55%) did not. The groups were similar in sex distribution (A = 75% male, B = 76%), number of lesions in the single culprit vessel dilated (1 lesion in 83% A, 80% B), and PTCA success (A = 92%, B-94%) (all p = NS). Group A patients were older (63 +/- 10 vs. 56 +/- 11 years) and had more prior myocardial infarctions (27% vs. 7%), and more prior coronary artery bypass grafting (15% vs. 0.4%) (all p less than .01). Group A patients were more likely to have repeat catheterization (48% vs. 32%, p less than .005) although restenosis of the infarct-related vessel was similar (A = 24%, B = 16%) (p = NS). Group A was more likely to need angioplasty in a 2nd vessel (23% vs. 8%) and to need coronary artery bypass grafting (20% vs. 8%) (both p less than .001). Cumulative mortality was higher in Group A at 1 month (10% vs. 5%), 1 year (11% vs. 6%), and long-term (13% vs. 7%). This difference appeared to be due to the impact of lower mean ejection fraction in Group A. Conclusion: Treatment of acute myocardial infarction by direct PTCA of the culprit lesion can be performed with a high likelihood of success in patients with or without multivessel coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)     

Beating heart versus conventional reoperative coronary artery bypass surgery

BACKGROUND: The incidence of reoperative coronary artery bypass grafting is increasing with an increase in the number of patients undergoing coronary artery bypass surgery. The clinical outcome of redo coronary artery bypass grafting without cardiopulmonary bypass and conventional coronary artery bypass grafting using cardiopulmonary bypass are different. METHODS AND RESULTS: We compared clinical parameters in patients who underwent off-pump (n=156) versus on-pump (n=194) redo coronary artery bypass grafting performed between January 1995 and December 2001 in our institute, to determine if off-pump surgery has improved the surgical outcome of redo coronary artery bypass grafting and emerged as an ideal technique. Patients who underwent on-pump redo surgery required more postoperative blood transfusion (86.53% on-pump v. 12.82% off-pump. p=0.001), prolonged ventilatory support (>24 hours) (16.49% on-pump v. 7.7% off-pump, p=0.021) and higher inotropic support (23.71% on-pump v. 10.89% off-pump, p=0.003). On-pump redo coronary artery bypass grafting was also associated with a prolonged stay in the intensive care unit (40+/-6.2 hours on-pump v. 20+/-4.1 hours off-pump, p=0.001) and longer hospital stay (9+/-4.2 days on-pump v. 5+/-3.4 days off-pump, p=0.001). In-hospital mortality was higher in on-pump patients than in off-pump ones (7.7% v. 3.2%); however, this was not statistically significant (p=0.114). CONCLUSIONS: Off-pump redo coronary artery bypass grafting is a safe method of myocardial revascularization with lower operative morbidity and mortality, less requirement of blood products and early hospital discharge, compared with conventional on-pump redo coronary artery bypass grafting.     

Results of 232 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures in single- and double-vessel coronary artery disease

Over a 3-year period, we performed 232 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures in 171 patients, 132 (77%) of whom were men and 39 (23%) of whom were women. The patients' ages ranged from 26 to 85 years (average, 56.5 years). All of the patients had symptoms of coronary insufficiency, manifested by stable angina in 106 cases, unstable angina in 44 cases, post myocardial infarction angina in 19 cases, arrhythmia in 1 case, and syncope in 1 case. All PTCA dilatations were done by the same operators, using the same technique. The procedures were categorized as follows: Group 1 included 157 single-vessel PTCA procedures, which had a success rate of 87.3%; these included 52 dilatations of the right coronary artery (success rate, 84%), 94 dilatations of the left anterior descending artery (success rate, 86%), and 11 dilatations of the left circumflex system (success rate, 90%). Group 2 included 29 double-vessel PTCA procedures (58 total procedures), which had an 88% success rate, and group 3 comprised 17 vein-graft PTCAs, with an 86.9% success rate. Complications included coronary artery occlusion in 15 cases (9.0%), myocardial infarction in four cases (2.3%), and cardiac arrhythmia in one case (0.6%). There were no deaths. Fifteen patients (8.8%) underwent coronary artery bypass surgery during the same hospitalization (3.8% of these operations were performed on an emergency basis). Thirty-six patients (15.5%) had a second PTCA procedure owing to restenosis, which occurred either before the patient was discharged from the hospital (eight cases) or 3 to 30 months after the original procedure. We conclude that, when performed by experienced operators with optimal technical resources, PTCA results in an acceptable success rate; therefore, this procedure should be a satisfactory method of myocardial revascularization in well-selected patients with either single- or double-vessel coronary artery disease.     

Off-pump bypass surgery: the early experience, 1969-1985

This is a review of 733 patients who underwent off-pump bypass surgery of the right coronary artery and left anterior descending coronary artery between 1969 and 1985. Two hundred sixty-four patients underwent single bypass of the left anterior descending coronary artery, and 79 patients underwent single bypass of the right coronary artery. Both the left anterior descending and right coronary arteries were bypassed in 390 patients. In contrast to the present-day use of mechanical devices to stabilize the target vessel, a 4-suture surgical technique was used for this purpose. This technique, which we illustrate, proved less cumbersome and made the graft anastomosis easy to perform. Our early experience (1969 through 1972) in operating on 199 patients resulted in an operative mortality rate of 4.5% (9/199). From 1973 through 1985, improved patient selection and use of the left internal thoracic artery as the conduit of choice for bypass of the left anterior descending coronary artery reduced the operative mortality rate for 534 patients to 1.3% (7/534). Routine postoperative angiograms were not performed; therefore, the graft patency rate is not available. However, an ongoing 34-year follow-up study of the 264 patients who underwent a single left anterior descending bypass showed the saphenous vein graft to be open in 64.3% (18/28) patients and the left internal thoracic graft in 92.2% (59/64) of patients studied. Seventy-four of the 264 patients in this study were still alive in 2003.     

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

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

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

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

Early neurological and electroencephalographic changes after coronary artery surgery in low-risk patients younger than 70 years

Between September 1986 and January 1988 neurological examination and electroencephalography (EEG) was performed before and one week after coronary artery bypass grafting in 66 patients younger than 70 years. Twenty patients were randomized to a bubble oxygenator without an arterial line filter (Group I), 22 patients to a bubble oxygenator with a depth adsorption filter (Group II), and 24 patients to a membrane oxygenator without a filter (Group III). No patient suffered a major stroke but early central nervous system dysfunction occurred after the operation in four patients (20%) in Group I, in four patients (18%) in group II and in two patients (8%) in group III. The difference between group I and III was not statistically significant but a larger number of patients in the groups might alter this. Our prospective study demonstrated a significant incidence of neurologic dysfunction in a low risk patient population undergoing standard coronary artery bypass surgery.     

Surgical treatment of acute myocardial infarction

In 1989 the following indications for surgical treatment of acute myocardial infarction are: (1) acute evolving myocardial infarction less than 6 h from onset, in patients in whom percutaneous transluminal coronary angioplasty (PTCA) or streptokinase (SK), depending on the coronary anatomy, has been unsuccessful; if single vessel disease, coronary artery bypass grafting (CABG) is unlikely; if multiple vessel disease, CABG is preferable to SK/PTCA unless a very major 'culprit' lesion can be identified with certainty; (2) postinfarction angina hours to days after a transmural myocardial infarction unyielding to maximal medical therapy and in patients with a coronary artery obstruction not amenable to PTCA; (3) occlusion of a coronary artery during cardiac catheterization that cannot be fixed by PTCA and/or SK; (4) occlusion of a coronary artery during PTCA causing hemodynamic obstruction and a threatened myocardium subtended by the obstructed coronary artery; (5) balloon-dependent patients in cardiogenic shock without mechanical defects who have adequate residual left ventricular function as determined by regional wall motion studies; (6) ventricular septal defect secondary to myocardial infarction unless there is terminal organ damage; (7) mitral valve replacement with coronary bypass for acute papillary muscle rupture; (8) semi-emergency cardiac transplantation, either with or without a mechanical bridge to transplant in young individuals (less than 50 years) who have suffered massive destruction of left ventricular myocardium by an acute coronary occlusion with or without recurring ventricular tachyarrhythmias. Ejection fraction in this clinical category is always under 0.20 and usually under 0.15.     

Evaluation of coronary lesions in biventricular inferoposterior infarction

Fifty-two patients with primary transmural infero-posterior infarcts underwent right heart catheterisation on admission to hospital and coronary angiography between the 7th day and 4th month after onset of symptoms. The patients were divided into two groups A (N = 34) with signs of right ventricular dysfunction on admission indicating biventricular infarction, and B (N = 18) without right ventricular dysfunction classified as isolated LV infarction. No significant differences were observed between the two groups with respect to: global and regional LV function; the incidence of single, double and triple vessel disease; the incidence and location of right coronary artery thrombosis; the incidence and location of lesions of the left coronary tree (LCA, LAD, Cx); the extent of coronary disease (Gensini score); the dominant artery (right coronary/circumflex), the frequency and quality of revascularisation of distal vessels. The only significant differences were the higher incidence of severe lesions (90 p. 100) of the right coronary and circumflex arteries and of stenosis of the first large septal branch of the LAD artery in Group A (p less than 0.05). These results show that the indications for coronary angiography in biventricular inferior infarction are no greater than those in mono LV inferior infarction. This supports experimental data on the physiopathology of RV infarction which demonstrates that except in cases of proximal thrombosis of the right coronary artery, the possibilities of revascularisation from the left coronary tree are limited.     

左主干病变导致急性ST段抬高型心肌梗死的诊治体会

目的:总结左主干狭窄或闭塞导致急性ST段抬高型心肌梗死(AMI)患者的临床特点,并提出其早期诊断和治疗体会.方法:复习我院2年内246例AMI急诊经皮冠状动脉介入治疗(PCI)的临床资料,其中7例梗死相关血管为左主干,均为男性,年龄36～83岁,所有患者无论是否存在心源性休克,均立即行主动脉内球囊反搏术,并在其支持下尽早接受急诊造影检查.结果:7例患者心电图均存在aVR导联ST段抬高(≥0.05 mV),5例患者同时存在V1 -V6导联ST段抬高及新出现完全右束支传导阻滞,其中4例入院时即存在严重心源性休克,6例急诊置入支架,另1例仅行球囊扩张,并接受急诊冠状动脉旁路移植术,住院期间死亡3例(42.9％),存活患者4例均完成1年随访.其中2例于1月随访时对其LAD进行PCI,1例于3月随访时进行了LAD和LCX的冠状动脉旁路移植术.结论:左主干急性闭塞或严重狭窄所致的AM I患者急性期病死率高;根据心电图和临床特点早期识别梗死部位,早期评估,并且无论是否出现低血压或心源性休克早期行主动脉内球囊反搏术,并在其支持下尽早再灌注治疗,加强术后监护,提高随访质量,可以挽救部分患者的生命和改善预后.     

Early and late morphologic changes in human coronary arteries after percutaneous transluminal coronary angioplasty

Certain clinical and morphologic observations are described in 6 men who had percutaneous transluminal coronary angioplasty (PTCA) of the left anterior descending (LAD) or right (R) coronary artery early (4 hours to 7 days) or late (80, 90, and 150 days) before coronary endarterectomy and aortocoronary bypass grafting or death. Histologically, each of the 3 early patients had the site of PTCA narrowed 76–95% in cross-sectional area by atherosclerotic plaque, and each had either coronary dissection or plaque hematoma or both at the site of PTCA. Each of the 3 late patients had a decrease in the mean trans-stenotic coronary gradient (17, 38, and 43 mmHg, respectively) and an angiographic increase in the LAD luminal diameter (55, 60, and 65%, respectively) at the time of PTCA. At necropsy, 80, 90, and 150 days later, the LAD coronary artery in the area of the PTCA in each patient was narrowed 76–95% in cross-sectional area by plaques. No cracks in plaques or other lesions which may have resulted from the PTCA procedure were identified histologically in the LAD coronary artery of any late patient.     

数字电影计帧法对冠状动脉狭窄程度的功能性评价

目的:通过对经皮冠状动脉腔内成形术(PTCA)前后病变血管的电影充盈帧数的计测,探讨数字电影计帧法对冠状动脉狭窄程度的功能性评价.方法:选择冠状动脉前降支单支病变择期PTCA患者(PTCA组)68例,同期冠状动脉造影正常者(对照组)38例.用德国西门子Angiostar plus血管造影机,以30帧/秒进行数字电影图像采集.计测PTCA前后冠状动脉左前降支和回旋支的电影帧数,并计算前降支与回旋支电影帧数比值(LAD/LCX).结果:病变血管的电影帧数PTCA后显著低于PTCA前,有极显著性差异(P＜0.01),而回旋支的电影帧数PTCA前后无显著变化.PTCA前PTCA组LAD的电影帧数显著高于对照组,有极显著性差异(P＜0.01),PTCA后两者对比无显著差异.PTCA前的电影帧数LAD/LCX显著高于PTCA后,有极显著性差异(P＜0.01).结论:左前降支的电影帧数及LAD/LCX随病变程度的加重而增加.计帧法能够更准确地反映狭窄局部的功能状况.     

Surgical intervention for failed percutaneous transluminal coronary angioplasty

From July 1978 through April 1983, 125 patients underwent attempted PTCA at the Massachusetts General Hospital. The first 25 patients were considered to be surgical candidates after failure of the PTCA attempt regardless of the presence of acute myocardial ischemia (Group I). The subsequent 100 patients (Group II) were considered to be surgical candidates only if acute myocardial ischemia was caused by a failed PTCA attempt. Four of the Group I patients (16%) required urgent operative intervention and 7 of the Group II patients (7%) required urgent operative intervention yielding, a total of 11 patients (8.8%) of the entire group. There were no hospital deaths and only 1 MI, actually documented before cardiopulmonary bypass. Women required urgent operative intervention more frequently than men (14.7% vs 6.6%). Patients with right coronary artery lesions required urgent operative intervention more often than those with left anterior descending lesions (13.0% vs 8.0%). Factors that lead to low operative mortality and myocardial infarction rates include an available operating room and team during the PTCA attempt, systemic arterial and Swan-Ganz pulmonary artery catheter pressure measurements at the time of angioplasty, intraaortic balloon pumping at the first sign of myocardial injury and expeditious surgery.     

Mid-term results of conventional bypass surgery for complex proximal left anterior descending coronary artery stenoses.

BACKGROUND: The significant involvement of proximal left anterior descending (LAD) coronary artery affects patient prognosis and must be treated. Recently, as alternative methods to conventional coronary bypass (CABG), minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous transluminal coronary angioplasty with stent implantation (PTCA/S) have been proposed to reduce costs and patient discomfort. The aim of this study was to obtain early and medium-term results of CABG in patients with complex LAD disease in whom the expected results with PTCA/S or MIDCAB would have been suboptimal. METHODS: We retrospectively examined one hundred consecutive patients subjected to isolated CABG who received either a single graft to LAD or several grafts to LAD and diagonal branches. The choice of CABG was due to poor expectable results with PTCA/S or MIDCAB because of anatomical characteristics of the lesion, inclusion in ongoing randomized study comparing surgical versus non-surgical revascularization, or preference on the part of the cardiologist or patient. RESULTS: Left internal mammary artery (LIMA) was grafted to LAD in 99 (99%) patients; 65 (65%) patients received at least one saphenous graft to the diagonal branches. No death was observed within 30 days from the operation. One (1%) patient had a perioperative non-Q myocardial infarction (MI). At a mean follow-up time of 38 +/- 16 months (range 2-60), there were no cardiac deaths and no new MI. Six patients complained of recurrent angina: in all cases but one (vein graft failure to a diagonal branch), there were no clinical or diagnostic signs suggesting other graft failures. The probability of freedom from early and late events, including cardiac death, MI and recurrence of angina regardless of site, was 99% at 1 year and 86% at 5 years. CONCLUSIONS: At present, conventional CABG seems to be the "gold standard palliation" of LAD disease in most cases. It can be performed safely with excellent early and medium-term results in terms of freedom from cardiac events. Its comparison with percutaneous transluminal techniques and MIDCAB needs to be addressed in further prospective studies.     

Clinical Outcome in Patients with Intermediate Stenosis of Left Anterior Descending Coronary Artery after Deferral of Revascularization on the Basis of Noninvasive Coronary Flow Reserve Measurement

Background: Several reports suggest that noninvasive measurements of coronary flow reserve (CFR) by use of echocardiography may support decision making in intermediate stenosis of the left anterior descending coronary artery (LAD). The aim of the present study was therefore to analyze the clinical outcome in patients with intermediate stenosis of LAD after deferral of coronary revascularization on the basis of noninvasive CFR measurement. Methods: the study population included 280 patients with intermediate LAD stenosis (50–70% by angiography) (62.2 ± 9.6 years). All the patients underwent transthoracic CFR assessment of LAD (after dipyridamole infusion) within 2 weeks from coronary angiography. If CFR of LAD was ≤ 2, PTCA was recommended; if CFR was > 2, medical treatment was chosen. Primary end points were cardiac death, myocardial infarction, coronary revascularization procedure, and unstable angina. Results: mean follow-up was 43 ± 11 months (range 12–52 months). In 150 patients (53.6%) (CFR ≤ 2), coronary artery revascularization was performed (PTCA group); the remaining 130 patients (46.4%) (CFR > 2) were medically treated (medical group). Survival from cardiac death was 94% in the PTCA group and 92.4% in the medical group (P = 0.56). As for all cardiac events, the Kaplan–Meier percentage survival from cardiac events was 88.3% in the PTCA group and 86.4% in the medical group (P = 0.36). Conclusions: even if CFR as a "stand-alone" diagnostic criterion suffers from several structural limitations, a combined strategy including also other clinical and instrumental measurements before undergoing interventional procedures could improve the cost–benefit practice, in particular, for the management of patients with intermediate LAD stenosis.     

Predictors of adverse outcome 10 years after coronary angioplasty

To determine which factors before percutaneous transluminal coronary angioplasty (PTCA) predict long-term outcome, we evaluated the clinical follow-up data from 535 patients 10 years after single-vessel PTCA. Events were defined as death, myocardial infarction, bypass surgery or repeat PTCA. During the follow-up period 79 patients (15%) died, 59 patients (11%) suffered a myocardial infarction, 107 patients (20%) had coronary artery bypass surgery and 141 patients (26%) underwent a redilatation. To determine the predictors of 10-year follow-up, 12 patient-related and 9 lesion parameters were analyzed by logistic regression analysis. Mortality was independently increased in patients with diabetes, with multi-vessel disease, after a previous myocardial infarction and in smokers. The presence of multi-vessel disease, symptoms of a higher angina class and younger age increased the risk for undergoing bypass surgery. In the statistical model with lesion parameters, the risk of bypass surgery was decreased if the stenosis was located in the distal segment of the coronary vessel and by a higher minimal luminal diameter before PTCA. CONCLUSION: Logistic regression analysis identified multi-vessel disease, diabetes, smoking and a previous myocardial infarction as independent clinical predictors of an adverse outcome 10 years after coronary angioplasty. Lesion parameters before PTCA seem to be less important with regard to the long-term outcome after PTCA.     

Coronary angioplasty at the time of initial diagnostic coronary angiography in patients with unstable angina

Of the last 200 consecutive patients undergoing PTCA procedures at our institution, 29 (15%) had unstable angina; and angioplasty was performed at the time of diagnostic coronary arteriography. There were 26 males and three females with an age range of 31-82 (mean 57) years. Factors favoring PTCA at the time of initial coronary arteriography included clinical indications for revascularization, appropriate anatomy based on high-quality fluoroscopy, and availability of emergency surgery if required. Of 34 coronary lesions in 29 patients, 19 involved the anterior branch of the left anterior descending coronary artery (LAD), eight the circumflex branch (Cx); and seven the right coronary artery (RCA). Five patients had two vessels dilated (one LAD + RCA, two LAD + Cx, and two RCA + Cx). Of the coronary artery lesions, 19 were concentric, seven were eccentric, 20 were single and discrete, six were long or multiple in the same vessel; eight vessels were totally occluded, and in nine patients there was good collateral circulation. Twenty-nine (85%) arteries were successfully dilated. Of the unsuccessful cases, one was from failure to cross a totally occluded lesion, and three residual lesions and/or postdilatation pressure gradients remained significant. One patient required emergency aortocoronary bypass surgery because of total occlusion of the LAD immediately post-PTCA. There were no postprocedural myocardial infarcts or deaths. It is concluded that, in selected patients with unstable angina, PTCA can be performed successfully and with low risk at the time of initial diagnostic coronary arteriography. This approach offers certain clinical financial advantages.