Predictability and prognosis of PTCA-induced coronary artery aneurysms

The natural history of coronary aneurysms, defined as local dilatations exceeding the diameter of the normal adjacent vessel segments by at least 1.5 times, is not significantly different from the natural history of nonaneurysmal coronary disease. However, little is known about the prognosis of percutaneous transluminal coronary angioplasty (PCTA)-induced coronary aneurysms. Therefore, we investigated the occurrence and the medium long-term prognosis of such aneurysms in 728 patients who, after successful PTCA, underwent repeat coronary angiography at mean 4.5 months post-PTCA. A coronary aneurysm at the site of PTCA ws noted in 3.9% of patients (n = 28). Of the potentially predictive factors analyzed, only a coronary dissection at the time of PTCA had statistically significant influence. The long-term prognosis of PTCA-induced coronary aneurysms was excellent. One patient underwent (unrelated) cardiac surgery, all other 27 patients remained eventfree. We conclude that the same benign nature of coronary aneurysmal disease holds true for those aneurysms that develop after PTCA.     

Coronary aneurysm after transluminal angioplasty. Report of 13 cases

The aim of this study was to determine the incidence, angiographic characteristics, clinical consequences, therapeutic implications and evolution of coronary arterial aneurysms after percutaneous transluminal coronary angioplasty (PTCA) based on a series of 13 cases out of a total population of 752 patients undergoing balloon dilatation. Before BTCA, 10 patients had unstable angina and 3 had stable angina. The stenoses were of type A in 6 cases and, more complex, type B, in 7 cases. The results of PTCA were good except in 1 case in which the procedure was complicated by a rudimentary infarct due to an extensive intra mural rupture. The frequency of coronary aneurysms evaluated in a series of 150 patients dilated and controlled systematically was 4 p. 100. This complication was observed relatively late, 2 to 13 months after PTCA. The length of aneurysm ranged from 2 to 13 mm (3.9 +/- 2.9 mm). Nine aneurysms were sacciform and 4 were fusiform. They were isolated in 6 cases and associated with restenosis in 7 cases. The predisposing role of an oversized angioplasty balloon was a probable etiological factor; the balloon/artery ratio was over 1.1 in 4 cases and over 1.2 in 3 cases. Intramural rupture observed at the time of PTCA (8/13 cases) did not seem to be a predisposing factor as the incidence of coronary aneurysm was not significantly different in patients without this complication in the group of 150 patients dilated and controlled systematically by angiography (5.8% vs 3%; NS). In the 6 cases of isolated coronary aneurysm the patients were asymptomatic and were followed up with medical treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

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

Certain clinical and morphologic observations are described in 4 men who had PTCA of the left anterior descending coronary artery early (4 hours) or late (80, 90 and 150 days) before sudden death. Histologically, each of the 4 patients had the site of PTCA narrowed 76 to 95% in cross-sectional area by atherosclerotic plaque. The early PTCA patient had coronary artery dissection at the site of PTCA. Each of the 3 late PTCA patients had a decrease in the mean transstenotic coronary gradient (17, 38 and 43 mm Hg) and an angiographic increase in the left anterior descending coronary artery luminal diameter (55, 60 and 65%) 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 to 95% in cross-sectional area by plaques. No cracks in plaques or other lesions that may have resulted from PTCA were identified histologically in the left anterior descending coronary artery in any late PTCA patient.     

Fate of coronary aneurysms in Kawasaki disease: Serial coronary angiography and long-term follow-up study

Between January 1973 and December 1979, 290 patients with Kawasaki disease were evaluated with coronary angiography after the acute stage of illness. Of these patients, 43 (15 percent) were diagnosed as having coronary aneurysms. Forty-two patients have been followed up for an average of 4 years (range 15 months to 8 years). One 8 month old girl died of myocardial infarction after 4 months of illness. Follow-up coronary angiography was performed in 42 patients 5 to 18 months after the acute illness. Four groups can be distinguished. Group I: In 21 (50 percent) of 42 patients angiography showed that the coronary aneurysms had regressed, so that no observable lesions were seen. During convalescence, none of these patients experienced cardiac symptoms, and results of electrocardiography, exercise stress testing and thallium scintigraphy were within normal limits. In the other 21 patients abnormal findings persisted on follow-up angiography. Group II: Ten patients showed persistent coronary aneurysms, although reduced in size. Group III: In seven patients the aneurysms had disappeared, but complete obstruction or marked stenosis of coronary arteries was found. Group IV: In four patients, irregularities of the coronary arterial wall without stenosis were seen. Among patients with abnormal angiographic findings myocardial infarction and mitral regurgitation were also seen. Early initiation of aspirin therapy remains the mainstay in the prevention of thrombus formation. Coronary aneurysms show regression on angiography in 1 or 2 years in about half of patients. The remaining patients are at risk for ischemic heart disease. Thus, Kawasaki disease should be considered an important cause of ischemic heart disease in children and a possible risk factor of premature coronary atherosclerosis.     

Percutaneous transluminal coronary angioplasty: Application for acute myocardial infarction

Seventy-eight of 1,000 consecutive PTCA procedures were performed in the setting of acute MI. Twenty-four of 26 patients with subtotal coronary occlusions underwent successful PTCA, including 9 patients with and 15 patients without previous intracoronary streptokinase infusions. Of 52 patients with total occlusions, PTCA was performed after reperfusion by streptokinase in 24 patients, after unsuccessful intracoronary streptokinase infusion in 6 patients and without previous thrombolytic therapy in 14 patients (27%). Six patients (7.7%) died. The immediate post-PTCA course was stable in 59 of 63 successfully dilated patients and 4 had coronary reocclusion. Late catheterization (mean 10 days) in 41 patients showed improved left ventricular function in most. At 6.5 months of follow-up, there were 9 restenoses that required PTCA, 1 reocclusion, 1 elective CABG and no deaths.     

Percutaneous transluminal coronary angioplasty in evolving acute myocardial infarction

In 29 patients with evolving acute myocardial infarction, acute reperfusion of the infarct-related coronary artery was attempted using percutaneous transluminal coronary angioplasty (PTCA). Before PTCA, angiography showed 23 totally occluded and 6 severely stenotic infarct-related coronary arteries. PTCA was initially successful in 25 of 29 patients (86%). Reocclusion occurred in 4 patients within 12 hours after successful PTCA and was associated with new electrocardiographic changes or recurrence of symptoms. In 17 patients the infarct-related coronary artery remained patent at early follow-up; late stenosis occurred in 4 patients. Recurrence of stenosis was accompanied by development of angina. No clinical or angiographic features distinguished those with ultimate vessel patency, occlusion or recurrence of stenosis. On follow-up, ventricular function appeared better preserved or improved in those with a patent infarct-related coronary artery than in those with an occluded infarct-related coronary artery. Further studies are warranted to compare PTCA and streptokinase as primary reperfusion modalities in evolving acute myocardial infarction.     

Relation to restenosis after percutaneous transluminal coronary angioplasty to vasomotion of the dilated coronary arterial segment

Among 868 patients with successful percutaneous transluminal coronary angioplasty (PTCA), 437 were restudied angiographically and had a provocative test with ergonovine during coronary angiography performed before and 6 months after the procedure. The relation between provoked coronary artery spasm and restenosis was studied and 4 groups of patients were analyzed. Those in group 1 (n = 63) had spasm before and after PTCA and their rate of restenosis was high (55%), especially when spasm after PTCA was observed on the dilated coronary segment (restenosis rate 58%). Patients in group 2 (n = 78) had spasm before PTCA but without abnormal vasoconstriction at 6 months and their incidence of restenosis was 19%. Sixty-one patients in group 3 had no spasm before PTCA but developed spasm at restudy. The rate of restenosis was high (38%) in this group, especially when the spasm after PTCA was located on the dilated segment (43%). In group 4 (n = 235), patients had no spasm before or after PTCA and the restenosis rate was 20%. Thus, the presence of coronary artery spasm on the dilated coronary segment, 6 months after a successful PTCA, is frequently accompanied (43% in group 3 and 58% in group 1) by restenosis.     

Natural history of patients with single-vessel disease suitable for percutaneous transluminal coronary angioplasty

To permit comparison of percutaneous transluminal coronary angioplasty (PTCA) with conventional therapy, the clinical outcome was established in patients who would have been suitable candidates for PTCA but who presented before the technique was available. Coronary angiograms were reviewed of patients who met the following criteria: single-vessel disease with proximal subtotal coronary stenosis, chest pain of at least class II, and cardiac catheterization before 1981. Angiograms were evaluated according to established criteria for PTCA by an experienced angiographer. One hundred ten patients (2.1% of the patient population) were judged suitable for PTCA. Clinical and catheterization findings closely resembled those of patients in the national PTCA registry. Five years after catheterization, 97% of PTCA candidates treated medically were alive and 85% had not had myocardial infarction. Forty-six patients had coronary artery bypass surgery within 6 months of catheterization and 10 other patients had subsequent surgery. Five years after surgery, 91% were alive and 87% had not had myocardial infarction. At 6 months of follow-up, 78% of all patients had improved at least 1 functional class, and 86% of all patients working before catheterization were still employed. Functional capacity was well maintained during long-term follow-up (median 6.5 years, range 1.4 to 12.2). These data indicate that PTCA candidates have an excellent prognosis for survival, a low risk of infarction, and well-maintained functional capacity when revascularization is reserved for those with inadequate control of symptoms by medical therapy.     

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.     

Acute coronary syndrome in adult patients with coronary artery lesions caused by Kawasaki disease: review of case reports

Information about acute coronary syndrome caused by Kawasaki disease-related coronary artery lesions in adults is sketchy. We reviewed the clinical features of 50 adult patients who had an acute coronary syndrome caused by coronary artery lesions due to Kawasaki disease or probable Kawasaki disease from 1980 to 2008. Of the 50 patients, 43 (90%) were male and seven were female (10%). Their ages at the onset of acute coronary syndrome ranged from 18 to 69 years, with a median of 28 years. The culprit lesion in 43 patients was thrombotic occlusion of an aneurysm, and 40 patients had giant aneurysms. In the three patients in whom no aneurysms were seen in coronary angiograms performed at the time of acute myocardial infarction, either giant aneurysms or aneurysms had been visualised in childhood. The initial treatment of acute coronary syndrome was as follows: intracoronary thrombolysis, 11; primary percutaneous coronary intervention, 9; emergency coronary artery bypass grafting, 3; and medication, 26. Elective coronary artery bypass grafting was performed in 15 patients. Three patients (6%) died. Of the 27 patients with additional coronary risk factors, 20 were smokers. Giant aneurysms due to Kawasaki disease continued to cause acute coronary syndrome in adult life with onset at a younger age than typifies that due to atherosclerosis in the general population, especially in male population rather than female population. Even when giant aneurysms regressed after the acute phase, a few patients still developed acute coronary syndrome in adult life. Smoking appears to be the most prominent additional risk factor.     

Acute coronary occlusion occurring after successful percutaneous transluminal coronary angioplasty: temporal relationship to discontinuation of anticoagulation

The incidence and prognosis of acute coronary reocclusion occurring after patients had left the catheterization laboratory following a successful percutaneous transluminal coronary angioplasty (PTCA) procedure and the temporal relation of this event to the discontinuation of systemic heparin administration were analyzed in a series of 1238 consecutive patients. Acute reocclusion, 1 to 96 hours after successful PTCA, occurred in 22 of 1238 patients (1.8%). Patients undergoing PTCA in the setting of acute myocardial infarction were excluded. Out of 22 patients, 15 had a nonocclusive dissection and four had evidence of small intracoronary thrombus immediately post-PTCA, with no evidence of flow disturbance. Acute reocclusion occurred within 5 hours of heparin discontinuation in 12 patients or while they were receiving inadequate anticoagulation (four patients). In 16 of 22 (73%) patients, acute reocclusion was temporally related to a time of diminished anticoagulation. Redilation was attempted in 14 patients and was ultimately successful in five patients (36%). Ten patients required coronary artery bypass surgery and three patients died. Our findings suggest that acute reocclusion after an initially successful PTCA has a poor outcome and seems to be temporally related to the loss of effective anticoagulation in most of these patients. It is advisable to discontinue heparin infusion at a time when facilities for urgent revascularization are available.     

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)     

Initial management and long-term clinical outcome of restenosis after initially successful percutaneous transluminal coronary angioplasty.

Restenosis remains a critical limitation after percutaneous transluminal coronary angioplasty (PTCA). The clinical experience with restenosis was reviewed in 1,490 patients who had restenosis of at least 1 site within 1 year of their PTCA. The source of data was the clinical database at Emory University. Patients who had previous coronary bypass surgery or PTCA and patients who underwent PTCA in the setting of acute myocardial infarction were excluded. When restenosis was angiographically documented, 363 were treated medically, 1,051 with repeat PTCA, and 76 with coronary bypass surgery. In the repeat PTCA group there were 778 patients who originally had 1-vessel disease and 273 with multiple vessel disease. Re-dilatation of restenotic sites was performed in 95%. Angiographic success of all lesions dilated was achieved in 99%. Coronary bypass surgery was required in 2.5% of patients with restenosis first treated with repeat PTCA. One patient with multiple vessel disease died. Coronary bypass surgery was performed in fewer patients aged greater than or equal to 65 years, but more patients with multiple vessel disease. Two (2.6%) of the coronary bypass surgery patients had Q-wave myocardial infarction and there were no deaths. In the PTCA group, 5-year actuarial survival was 95%, and cardiac survival 96%. Freedom from cardiac events or further revascularization procedures was 51% at 5 years. Patients treated with PTCA and medically treated patients had similar cardiac survival rates. The most important correlates of cardiac survival were age and the presence of diabetes mellitus. At 5 years, cardiac survival without diabetes was 97 and 83% with diabetes (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Direct percutaneous transluminal coronary angioplasty (PTCA) for treatment of acute myocardial infarction: comparison with PTCA immediately after thrombolysis

We studied 73 patients with acute myocardial infarction (AMI) treated by percutaneous transluminal coronary angioplasty (PTCA) without thrombolysis (direct PTCA) and 52 patients with AMI treated by PTCA immediately after thrombolysis (PTCR + PTCA). The initial results, angiographic findings and preservation of ventricular functions of the direct PTCA group were compared with those of the PTCR + PTCA group. 1. The success rate of coronary recanalization was higher in the direct PTCA group than in the PTCR + PTCA group, but there was no statistical significance (89% vs 77%; p = NS). 2. Major complications occurred in 4.1% of the direct PTCA group and in 5.8% of the PTCR + PTCA group (p = NS). 3. The incidence of acute coronary reocclusion was higher in the PTCR + PTCA group than in the direct PTCA group (7.4% vs 22%; p less than 0.05). 4. Angiographic haziness at the dilated site following PTCA was seen more frequently in patients in the PTCR + PTCA group than in those of the direct PTCA group (43% vs 23%; p less than 0.05). 5. Patients with haziness at the dilated site had a significantly higher incidence of acute coronary reocclusion than did the patients without such haziness (28% vs 6.3%; p less than 0.05). 6. Left ventricular ejection fraction and regional wall motion were better preserved in the direct PTCA group than in the PTCR + PTCA group, but there was not statistical significance. It was suggested that direct PTCA is safe and can be performed with good success rates. It is superior to PTCR + PTCA in avoiding acute coronary reocclusion, and thus we supposed that the response of lesions to angioplasty may be altered by the administration of thrombolytic agents.     

Percutaneous transluminal coronary angioplasty in acute myocardial infarction

Percutaneous transluminal coronary angioplasty (PTCA) has, in general, been restricted to therapy for patients with angina pectoris. Thrombolytic therapy and guide wire recanalization have been used to recanalize coronary arteries in patients with evolving myocardial infarction. Recently we and others have examined the use of PTCA to recanalize the acutely occluded artery associated with the early evolving phase of myocardial infarction. PTCA was performed as definitive therapy in eight patients with acute myocardial infarction. Seven of these had totally occluded arteries to the region of infarct. The infarct-related artery was open within 20 minutes in each of these cases. PTCA recanalization resulted in evidence for reperfusion in each case. Residual stenoses either were not present or were minimal. The procedure was well tolerated. These preliminary results suggest that PTCA may be a reasonable alternative to intracoronary thrombolytic therapy in certain patients with acute evolving myocardial infarction.     

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.     

Combined intracoronary streptokinase infusion and coronary angioplasty during acute myocardial infarction

PTCA was performed in 28 patients with acute MI immediately after intracoronary streptokinase administration. Indications were failure to obtain reflow in 16 patients and high-grade residual stenosis in 12. PTCA was successful in 11 of 16 cases of streptokinase failure, increasing the overall reflow rate from 66% to 77%. PTCA reduced residual coronary stenosis by more than 20% in 9 of 12 cases in which streptokinase infusion was successful, with 1 acute reocclusion. The frequency of recurrent ischemic events in hospital was 76% in patients with a stenosis of 90% or greater after streptokinase infusion (no PTCA), 14% when residual stenosis was less than 90%, and 6% after successful PTCA. Late restenosis or reocclusion was documented in 5 of 11 PTCA cases (45%). Immediate PTCA after streptokinase administration produces increased clinical stability in hospital, but late restenosis is frequent.     

Long-term efficacy of percutaneous transluminal coronary angioplasty (PTCA): Report from the national heart, lung, and blood institute PTCA registry

The NHLBI PTCA Registry has collected data from 3,079 patients who underwent PTCA at 105 centers from September 1977 through September 1981 that document the initial risks and benefits of PTCA. A subgroup of 2,272 patients at 65 centers was chosen to examine the long-term effects of PTCA (97% follow-up). All patients were followed for 1 year, 191 for 3 years and 57 for 4 years. Initial success occurred in 1,397 (61%), and 72% remained improved at 1 year with no further procedures; during the first year of follow-up, 14% had repeat PTCA, 12% had CABG, 3% had MI and 1.6% died. After 1 year, 67% were asymptomatic; of these, 52% had no other procedure, 7% had a second PTCA and 8% had CABG. Follow-up at 2 to 4 years was similar except that there were few repeat PTCA or CABG procedures after 1 year. The annual mortality rate after PTCA in patients with 1-vessel diseases was less than 1% per year and with multivessel CAD, 3% per year. Thus, successful PTCA alone results in sustained improvement in 84% of patients; 59% were asymptomatic (12% had repeat PTCA). PTCA offers extended effective therapy in selected patients with CAD.     

Percutaneous transluminal coronary angioplasty after intracoronary streptokinase in evolving acute myocardial infarction

To achieve optimal myocardial revascularization and prevent rethrombosis of the infarct-related coronary artery, percutaneous transluminal coronary angioplasty (PTCA) was attempted in 18 patients with evolving acute myocardial infarction (9 anterior and 9 inferior) after administration of intracoronary streptokinase. PTCA was attempted 338 +/- 151 minutes after the onset of symptoms. After thrombolytic therapy, 11 patients had a severe residual stenosis and 7 a persistent total occlusion of the infarct-related coronary artery. PTCA was successful in 13 of 18 patients: in 9 of 11 with coronary stenoses and in 4 of 7 with total coronary occlusions. PTCA reduced the severity of the coronary lesion from 91 +/- 2% to 27 +/- 7% (p less than 0.001), and the transstenotic pressure gradient from 38 +/- 5 to 6 +/- 2 mm Hg (p less than 0.01). One patient in cardiogenic shock died during urgent coronary surgery after unsuccessful PTCA. After PTCA, all patients received heparin and antiplatelet agents. One patient had reinfarction with reocclusion of the infarct-related artery 5 days after PTCA. The other 12 patients had an uneventful hospital course, and cardiac catheterization before hospital discharge (8 to 17 days) revealed reocclusion of the infarct-related coronary artery in 3 and persistent patency in 9. Persistent patency of the infarct-related artery was associated with preservation of left ventricular end-diastolic volume (initial 86 +/- 6 ml/m2, follow-up 91 +/- 6 ml/m2), and improvement in left ventricular ejection fraction in some patients.     

Recurrent ischemia more than 1 year after successful percutaneous transluminal coronary angioplasty. An analysis of the extent and anatomic pattern of coronary disease

Of 1,181 consecutive patients who underwent successful percutaneous transluminal coronary angioplasty (PTCA) as an initial revascularization procedure and who had at least 1 year of asymptomatic follow-up, 66 (6%) underwent repeat angiography because of recurrent symptoms or evidence of exercise-induced ischemia. Patients who had revascularization procedures within 1 year of PTCA were not included in the analysis. Mean time to recurrent ischemia was 30.8 +/- 17.4 months (range 12-89 months). At follow-up, 47 patients had angina, 13 had atypical chest pain, two had acute myocardial infarction, and four had positive exercise tests without symptoms. No patient showed spontaneous regression in the extent of coronary artery disease (CAD). As compared with the extent of CAD immediately after PTCA, the extent of CAD at follow-up did not change in 26 patients (39%); it increased by one vessel in 30 (45%), by two vessels in seven (11%), and by three vessels in three (5%). The pattern of CAD seen at follow-up compared with that seen after PTCA was as follows: 18 patients (27%), no change; seven (11%), restenosis only; 30 (45%), progression of CAD at other sites only; and 11 (17%), a combination of restenosis and progression of CAD at other sites. The time to recurrence of ischemia was significantly different between those with restenosis only versus those with progression only (20.1 +/- 9.2 vs. 38.3 +/- 18.5 months) (p less than 0.009). Progression of CAD was equally distributed between dilated and nondilated vessels; however, when progression occurred in the PTCA vessel, it was significantly more likely to be distal to the PTCA site (p less than 0.008).