Long-tip guiding catheter: successful and safe for left coronary artery angioplasty.

A long-tip guiding catheter was designed for angioplasty of the left coronary artery. Principal factors of guiding catheter function were identified, and the catheter's shape was designed to utilize them efficiently. Emphasis was placed on an overbent secondary curve (150-180 degrees) for more precise catheter control. The distal tip of the catheter is 2 cm long in the 4.0 size and the primary bend is shallow, approximately 20%. A 1.5 cm long segment between the secondary and tertiary curves enhances stability and support. Catheter performance was studied during procedures on 90 patients; 89 patients underwent coronary artery angioplasty and one patient underwent diagnostic angiography. The success rate for angioplasty was 95% with no major complications. Mild pressure damping occurred in 18 patients, and mild catheter displacement from the left main coronary artery occurred in 24 patients. Catheter support was judged as excellent to very good in 82 patients. Judkins or Amplatz catheters were not required during this study. The observed disadvantages of the long-tip catheter were the risk of catheter buckling up during advancement into the left main coronary artery and, perhaps, a higher risk of pressure damping. Superselective engagement of the catheter in the left anterior descending or circumflex arteries may be a problem when the left main coronary artery is very short. This study showed the long-tip catheter to be safe and highly successful for angioplasty of the left coronary artery.     

Improved success rate of percutaneous transluminal graft and coronary angioplasty with the El Gamal guiding catheter

In the period between October 1980 and December 1982 we evaluated the outcome of percutaneous transluminal graft and coronary angioplasty when a Judkins type guiding catheter (J gc) was initially used, but the lesion could not be passed and a subsequent attempt was made with the El Gamal guiding catheter (EG gc). Seven of twelve attempts to dilate stenotic coronary artery bypass grafts failed. The EC gc was tried in six, five were successfully dilated; one failed. Our initial attempts to dilate a stenosed right coronary artery failed in 16 of 68 attempts. The EG gc was attempted in 14. We successfully dilated ten, two dissections required emergency coronary artery bypass grafting (CABG); two failed. Our initial attempts to dilate a left anterior descending artery stenosis failed in 14 of 109 attempts. Six lesions were passed when the EG gc was tried. Five were successfully dilated, and one acute dissection required emergency CABG; eight failed. The EG gc is useful for transluminal angioplasty of stenosed aortocoronary bypass grafts. It increased the success rate of right coronary artery dilatation from 76-91%, but was of limited use in dilatation of left anterior descending lesions.     

Long-tip guiding catheter: Successful and safe for left coronary artery angioplasty

A long-tip guiding catheter was designed for angioplasty of the left coronary artery. Principal factors of guiding catheter function were identified, and the catheter's shape was designed to utilize them efficiently. Emphasis was placed on an overbent secondary curve (150–180°) for more precise catheter control. The distal tip of the catheter is 2 cm long in the 4.0 size and the primary bend is shallow, ～20%. A 1.5 cm long segment between the secondary and tertiary curves enhances stability and support. Catheter performance was studied during procedures on 90 patients; 89 patients underwent coronary artery angioplasty and one patient underwent diagnostic angiography. The success rate for angioplasty was 95% with no major complications. Mild pressure damping occurred in 18 patients, and mild catheter displacement from the left main coronary artery occurred in 24 patients. Catheter support was judged as excellent to very good in 82 patients. Judkins or Amplatz catheters were not required during this study. The observed disadvantages of the long-tip catheter were the risk of catheter buckling up during advancement into the left main coronary artery and, perhaps, a higher risk of pressure damping. Superselective engagement of the catheter in the left anterior descending or circumflex arteries may be a problem when the left main coronary artery is very short. This study showed the long-tip catheter to be safe and highly successful for angioplasty of the left coronary artery.     

Angioplasty of an occluded left anterior descending coronary artery: usefulness of retrograde opacification of the distal part of the occluded vessel via the contralateral coronary artery in positioning the balloon catheter.

A 59 year old man was admitted to hospital with a non-transmural anterior myocardial infarction. Recurrent angina pectoris eight days after the initial infarction was investigated by cardiac catheterisation, which showed moderate anterior hypokinesis and proximal occlusion of the left anterior descending coronary artery. The distal part of this vessel was opacified via collaterals from the right coronary artery. Percutaneous transluminal coronary angioplasty was attempted during the same catheterisation; good positioning of the balloon catheter was confirmed by the use of retrograde opacification of the distal part of the left anterior descending coronary artery via the collateral vessels and dilatation was safely achieved. Opacification of the contralateral coronary artery may be a useful and safe positioning of guide wire system or balloon dilatation catheter when dilatation of a totally occluded coronary artery is attempted.     

Randomized evaluation of six French Voda-type guiding catheters for left coronary artery balloon angioplasty

In order to evaluate 6 French (6F) Voda-type guiding catheters for left coronary artery balloon angioplasty, we randomized the choice of the guiding catheter in 100 consecutive patients between a Voda (group 1, n = 50) and a Judkins or Amplatz curve (group 2) guiding catheter. Angioplasty success rate (98% for both), need for guiding catheter crossover exchange (2 in group 1 vs. 1 in group 2), fluoroscopy time, and volume of injected contrast were similar in both groups, but the operator's appreciation of good back-up support was better with the Voda-type guiding catheter (90% vs. 74%, P < 0.05). No complications attributed to the guiding catheter were noted in either group. Efficiency of the Voda-type guiding catheter appeared similar for both left anterior descending (n = 35, success rate 100%) and circumflex (n = 18, success rate 94%) coronary artery angioplasty. Voda-type guiding catheters are an efficient and safe approach to routine left coronary angioplasty. They appear to be as effective as a choice bewtween a Judkins or an Amplatz configuration and could be of particular use when a double angioplasty of the left anterior descending and circumflex arteries is attempted during the same procedure. © 1995 Wiley-Liss, Inc.     

Performance characteristics of a new shape of guiding catheter for ptca of the left coronary artery

The inability to successfully perform angioplasty commonly involves inadequate guiding catheter performance. We evaluated the use of a new left coronary guiding catheter for angioplasty (PTCA) of lesions in both the left anterior descending and left circumflex arteries. The Nesto? guide in two different sizes was used in 100 consecutive PTCA cases as a primary catheter. The catheter successfully cannulated the left main coronary artery in 93 patients and PTCA was successfully performed in 85 patients for target lesions at various locations in either or both vessels. Positive features of this new guiding catheter include superior back-up support and ease of disengagement.     

Performance characteristics of a new shape of guiding catheter for PTCA of the left coronary artery.

The inability to successfully perform angioplasty commonly involves inadequate guiding catheter performance. We evaluated the use of a new left coronary guiding catheter for angioplasty (PTCA) of lesions in both the left anterior descending and left circumflex arteries. The Nesto guide in two different sizes was used in 100 consecutive PTCA cases as a primary catheter. The catheter successfully cannulated the left main coronary artery in 93 patients and PTCA was successfully performed in 85 patients for target lesions at various locations in either or both vessels. Positive features of this new guiding catheter include superior back-up support and ease of disengagement.     

Coronary occlusion immediately following a successful coronary angioplasty. Treatment by repeat angioplasty

The authors report the case of a 52 year old patient with a significant stenosis of the medial portion of the left anterior descending artery (LAD) with excellent left ventricular function. Transluminal coronary angioplasty (TCA) was indicated following a positive exercise stress test. This was initially performed successfully. Fifteen minutes after the end of the procedure, a total obstruction occurred at the site of dilatation immediately eliciting significant precordial chest pain and massive elevation of the ST segment. Isosorbide dinitrate (ISDN) at a dose of 2 mg was injected into the artery 3 times without success as was an attempt to pass through the obstruction with a guide wire. Another TCA was then attempted without administration of the thrombolytic agent. The dilating catheter passed easily by the obstruction permitting several dilatations which restored rapid coronary artery flow, relieved completely the chest pain, and normalized electrocardiographic abnormalities. This procedure represents a new therapeutic approach to obstruction, an often unpredictable and serious complication of coronary angioplasty in the absence of collateral circulation, thereby preventing the development of a myocardial infarction and an emergency aortocoronary bypass operation.     

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

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

Successful repeat percutaneous transluminal coronary angioplasty after failed coronary artery surgery for left main coronary artery dissection.

A 57 year old man required emergency coronary artery bypass surgery after dissection of the left main coronary artery during percutaneous transluminal coronary angioplasty. His symptoms recurred when the vein grafts became occluded. A dilatation device with the lowest profile was used to reduce the need for firm support from the guiding catheter during repeat percutaneous transluminal coronary angioplasty. The repeat procedure was successful in opening up the left circumflex coronary artery.     

Prospective analysis of electrocardiographic variables as markers for extent and location of acute wall motion abnormalities observed during coronary angioplasty in human subjects

To assess the usefulness of different electrocardiographic variables as markers for the presence, extent and location of new wall motion abnormalities seen after sudden controlled coronary occlusion, 23 patients with isolated left anterior descending (n = 12), or right (n = 11) coronary artery disease and a normal baseline left ventriculogram were prospectively studied during transluminal coronary angioplasty. A simultaneous 12 lead electrocardiogram was recorded before passing the balloon catheter and again at 30 seconds into the fourth inflation cycle. Using a second arterial catheter, a left ventriculogram was obtained at 40 seconds into the fourth inflation cycle. The extent of wall motion abnormalities was described as the percent of left ventricular perimeter showing hypocontractility. During balloon inflation, 19 of the 23 patients developed new hypocontractility ranging from 3 to 40%. ST segment elevation in lead V2 was the most sensitive marker for anterior wall hypocontractility and ST segment elevation in lead III was the most sensitive marker for inferior wall hypocontractility. Highly significant correlations were observed between the extent of the hypocontractile perimeter and 1) the sum of ST segment elevation in all 12 leads; 2) the magnitude of ST segment elevation in either lead V2 or lead III; and 3) the total number of leads with ST elevation greater than or equal to 0.5 mV. No significant changes were seen in the sum of R wave amplitudes, but a significant prolongation of the QT interval was seen during ischemia. In conclusion, acute ST segment elevation parallels the development of new asynergy during transluminal coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)     

Successful repeat percutaneous transluminal coronary angioplasty after failed coronary artery surgery for left main coronary artery dissection

A 57 year old man required emergency coronary artery bypass surgery after dissection of the left main coronary artery during percutaneous transluminal coronary angioplasty. His symptoms recurred when the vein grafts became occluded. A dilatation device with the lowest profile was used to reduce the need for firm support from the guiding catheter during repeat percutaneous transluminal coronary angioplasty. The repeat procedure was successful in opening up the left circumflex coronary artery.     

"Kissing balloon" of the protected common trunk of the left coronary artery: description of a successfully treated case]

The authors describe a case of coronary angioplasty on a distal Left Main coronary lesion. The left coronary tree was protected by the left internal mammary connected to left anterior descending artery. The procedure was performed using the "kissing balloon" technique, with a single guiding catheter. Immediate angiographic result and one-year follow-up have been excellent.     

Morphologic evidence of accelerated left main coronary artery stenosis: a late complication of percutaneous transluminal balloon angioplasty of the proximal left anterior descending coronary artery

Histologic evidence of restenosis after percutaneous transluminal coronary angioplasty has been confined to the site of previous dilation. In this study, attention is focused on the accelerated development of coronary stenosis proximal to the site of previous angioplasty in a necropsy patient who developed severe left main stenosis 4 months after successful dilation of the proximal left anterior descending coronary artery. The unique fibrocellular tissue proliferation at the site of previous angioplasty and involvement of the adjacent distal segment of the left main coronary artery make possible the histologic diagnosis of accelerated left main coronary artery narrowing. Mechanisms for development of coronary stenoses proximal to the angioplasty site include: intimal injury by guiding catheters, guide wires, dilating balloons or combinations; or retrograde extension of the fibrocellular response to an adjacent proximal coronary segment. Histologic analysis of left main coronary arteries from 11 patients who died within 72 hours of angioplasty of the left coronary system disclosed focal loss of luminal endothelium in 9. This finding suggests that intimal injury from catheters or balloons, or both, proximal to the angioplasty site probably initiates a fibrocellular reaction. The amount of underlying atherosclerotic plaque in the injured proximal coronary segment determines the clinical significance of a subsequent fibrocellular response.     

Transluminal coronary angioplasty and early restenosis. Fibrocellular occlusion after wall laceration.

Transluminal coronary angioplasty was performed in a 51 year old man with a localised narrowing of the proximal segment of the left anterior descending coronary artery. Initial inflations with a small size balloon catheter were unsuccessful. A second attempt, during the same procedure, using a larger calibre catheter relieved the obstruction but produced a dissection. Angina pectoris reappeared approximately three months later. Another attempt to relieve the obstruction by angioplasty, five months after the initial procedure, induced ST segment elevation before angioplasty, followed by ventricular fibrillation and death. The necropsy showed a split in the pre-existent sclerotic plaque and a dissecting aneurysm of the media. A proliferation of fibrocellular tissue filled the false channel and almost totally occluded the pre-existent arterial lumen. The observation suggests that wall laceration with exposure of smooth muscle cells to blood may have initiated the excessive fibrocellular tissue response. This event may be the underlying pathogenetic mechanism for the occurrence of early restenosis after transluminal coronary angioplasty.     

The brachial artery method to transluminal coronary angioplasty

The development of a brachial artery guiding catheter for (percutaneous) trans-luminal coronary angioplasty is described. Three-hundred angioplasty procedures were attempted with 196 (65%) via the branchial and 104 (35%) via the femoral artery. The coronary stenosis was crossed in 202 attempts (67%); in 138 via the brachial (70%) and 64 via the femoral artery (62%). A successful angioplasty occurred in 117 via the brachial (85%) and in 50 via the femoral artery (78%). Successful angioplasty of the left anterior descending artery was equally effective with either technique. Successful angioplasty of the right coronary artery was more difficult (P < 0.05) using the femoral artery. An unsuccessful angioplasty with one technique was occasionally overcome by use of the other technique. No brachial artery complications were encountered. The brachial method to transluminal coronary angioplasty is an acceptable and complementary alternative to the femoral technique. Those laboratories contemplating percutaneous transluminal coronary angioplasty may desire to utilize both approaches.     

Multiple complex coronary plaques in a patient with acute myocardial infarction

 This report describes the case of a patient who developed acute myocardial infarction with ST segment elevation in anterior and inferior leads, simultaneously. After treatment with systemic thrombolysis, and after an initial short-lasting symptomatic improvement, chest pain and ST segment elevation recurred. Coronary angiography revealed severe complex stenotic lesions at both the right coronary artery and the left anterior descending (LAD) coronary artery. Percutaneous coronary angioplasty and stent implantation were successfully performed at both lesions. This case supports the concept that, at least in some patients, acute coronary artery disease reflects a diffuse pathophysiologic process that may lead to multifocal plaque instability associated with clinical instability at multiple sites. Received: November 12, 2001 / Accepted: February 16, 2002     

Effects of successful percutaneous transluminal coronary angioplasty on global and regional left ventricular function in unstable angina pectoris

Sixty-eight patients (58 men, 10 women, mean age 56.3 years, range 31 to 72) with unstable angina pectoris, either initially stabilized with or refractory to optimal pharmacologic treatment, were studied to determine whether regional dysfunction due to stunning of the myocardium caused by attacks of chest pain at rest could be improved with percutaneous transluminal coronary angioplasty (PTCA). Patients were included in the study if they had successful 1-vessel PTCA, no angiographic restenosis, no reocclusion or late myocardial infarction and 2 serial left ventriculograms of sufficient quality to allow automated contour analysis before and after PTCA. Global ejection fraction increased significantly (from 56% to 60%, p < 0.05) only after successful dilatation of a stenosis of the left anterior descending coronary artery. Analysis of regional wall displacement showed significant improvement of regional wall motion in the areas supplied by the dilated vessel of either the left anterior descending, the left circumflex or the right coronary artery. Thus, regional myocardial dysfunction due to stunning of the myocardium in patients with unstable angina improves after successful PTCA.     

Early experience of transluminal coronary angioplasty (TCA) by the brachial artery (the sones technique in transluminal angioplasty)

Sixteen translumlnal coronary angioplasty procedures (TCA), eight right coronary artery (RCA) and eight left anterior descending coronary artery (LAD), by the brachial artery cut-down approach, were attempted with 9/16 (56%) immediate successes and 2/16 (12%) early recurrences. The procedure success rate for RCA obstructive lesions, 6/8 (75%) was greater than for LCA obstructions, 3/8 (38%). In six unsuccessful procedures the balloon catheter could not be advanced into the lesion, and in one unsuccessful procedure dissection of the coronary artery proximal to the lesion occurred. The brachial (Sones) technique for transluminal coronary angioplasty permits the use of softer guiding catheters for selective probing and approach to the coronary lesion but may be more likely to induce coronary spasm. Complete and high-resolution pre TCA anglograms with multiple views to disclose the exact anatomy of the coronary artery and Its lesion Is essential to ensure successful dilatation.     

Differential effects on right ventricular function of transient right, left anterior descending and left circumflex coronary occlusions during percutaneous transluminal coronary angioplasty

Right ventricular function was studied by means of a thermodilution catheter before, during and after percutaneous transluminal angioplasty of the proximal right (group 1, n = 8), left anterior descending (group 2, n = 8) or left circumflex (group 3, n = 8) coronary artery. All patients had evidence of myocardial ischemia, with single-vessel disease affecting the proximal segment of one of the three major coronary arteries; no patient had had a previous myocardial infarction and all had normal cardiac function at baseline study. Cardiac index decreased during balloon inflation. Mean pulmonary artery pressure was unaffected in group 1 but increased in group 2 (from 19 +/- 5 to 31 +/- 11 mm Hg, p less than 0.01) and in group 3 (from 19 +/- 2 to 22 +/- 5 mm Hg, p less than 0.05). Right ventricular ejection fraction decreased from 62 +/- 9% to 52 +/- 10% (p less than 0.01) in group 1 and from 64 +/- 7% to 44 +/- 10% (p less than 0.005) in group 2, and returned to normal within 2 min after balloon deflation in both groups. In group 3, right ventricular ejection fraction was unchanged during balloon inflation (58 +/- 5% at baseline, 58 +/- 9% at 60 s, p = NS). Therefore, brief occlusion of the proximal segments of the left anterior descending or right coronary artery results in marked alteration of right ventricular performance that is probably caused by right ventricular free wall ischemia in the right coronary group and by the concomitant effects of septal ischemia and increased right ventricular afterload in the left anterior descending artery group.(ABSTRACT TRUNCATED AT 250 WORDS)