Early postoperative balloon coronary angioplasty for failed coronary artery bypass grafting

In a small number of patients, coronary artery bypass grafting (CABG) fails to relieve anginal symptoms. The usefulness of coronary angioplasty for the treatment of early (less than or equal to 90 days) recurrent ischemia after CABG was examined. Forty-five patients were treated from 2 to 90 days after CABG, including 8 patients studied emergently for prolonged ischemic symptoms. One-, 2- and 3-vessel native disease was found in 4, 10 and 31 patients, respectively. At the time of postoperative angiography, the major anatomic mechanism of recurrent ischemia was complete vein graft occlusion in 12 patients (27%), internal mammary artery occlusion in 3 (7%), vein graft stenoses in 13 (29%), internal mammary artery stenoses in 10 (22%), unbypassed disease in 4 (8%) and disease distal to the graft insertion site in 3 (7%). Angioplasty was successful at 91 of 98 sites (93%), including 95% of 41 lesions in native arteries, 89% of 46 lesions in vein grafts and 100% of 11 internal mammary artery lesions attempted. Complete revascularization was achieved in 84% of patients. There were 2 in-hospital deaths and 2 myocardial infarctions. Two additional patients underwent repeat CABG before discharge after uncomplicated but unsuccessful angioplasty. At late follow-up of the 43 survivors (mean 44 months), there were 4 deaths, 2 of which were noncardiac. Repeat CABG was required in only 3 patients and repeat angioplasty was performed in 10. Angina was absent or minimal in 35 patients; 17 patients were employed full time. Thus, percutaneous transluminal coronary angioplasty can relieve myocardial ischemia after unsuccessful CABG in the majority of patients.     

Coronary angioplasty in patients with prior coronary artery bypass grafting

We studied the clinical and angiographic outcome of patients with prior coronary arterial bypass grafting who underwent percutaneous transluminal coronary angioplasty at the Royal Infirmary of Edinburgh. Over a 4 year period, 47 patients with prior bypass surgery underwent angioplasty of 23 stenotic graft sites and 37 stenotic sites of native vessels. The procedure was performed a mean of 31.3 months after surgery for recurrence of symptoms refractory to maximal medical treatment. Satisfactory angiographic results were achieved in 42 patients (58 stenotic grafts or native vessels). At a median follow up period of 18 months, 20 patients were symptomatically improved, but 22 patients experienced recurrence of symptoms a mean of 4.7 months after angioplasty, despite a good initial angiographic result. Overall, 4 patients had a repeat bypass grafting and 9 patients had a repeat angioplasty. Angioplasty can be used as an alternative to a repeat operation in patients with prior bypass grafting who experience recurrence of symptoms. Initial success rates are high and complication rates low. Restenosis or development of new lesions in the native circulation, and/or in the grafts, remain significant problems. Patients with a long asymptomatic interval (greater than 6 months) between the bypass operation and recurrence of symptoms are more likely to have better long-term results after successful angioplasty, perhaps because of slower progression of atherosclerotic heart disease.     

Outcome of women is impaired in patients undergoing emergency coronary artery bypass grafting for failed PTCA

There is an ongoing debate whether female gender is associated with increased cardiovascular morbidity and mortality, especially after coronary interventions. The impact of gender on the outcome of patients undergoing emergency coronary artery bypass grafting (CABG) for failed PTCA was analyzed. Clinical and procedural data of all patients who underwent PTCA and subsequent emergency CABG at our institution from 1989 to 1998 were assessed. During these 10 years, 6681 PTCA procedures were performed, 1312 in women (19.6%). Subsequently, 110 patients underwent emergency CABG of whom 32 were females (29.1%). Postoperatively, 9 women and 5 men died (mortality 12.7%). Women presented with higher age (61.2 +/- 2.1 vs. 58.3 +/- 1.0 years, n.s.), smaller height (1.61 +/- 0.01 vs. 1.76 +/- 0.01 m, p < 0.0001), lower weight (67.7 +/- 2.4 vs. 82.1 +/- 1.2 kg, p < 0.0001), smaller body surface area (1.70 +/- 0.04 vs. 1.98 +/- 0.02 m2, p < 0.0001), and higher comorbidity as expressed by their Cleveland score (7.9 +/- 0.3 vs. 7.1 +/- 0.2, p = 0.013). The risk for failure of PTCA with subsequent emergency CABG was higher in women than in men (2.4% vs. 1.5%, p = 0.012, odds ratio 1.66) as well as for postoperative death (28.1% vs. 6.4%, p = 0.004, odds ratio 4.39). Women had longer in-hospital stays (19.7 +/- 4.2 vs. 12.9 +/- 1.3 days, p = 0.044). Logistic regression analyses found lower weight (p = 0.003), higher number of diseased coronary vessels (p = 0.024) and higher Cleveland score (p = 0.023) to be independent predictors of operative mortality. A Kaplan-Meier model (follow-up 5.3 +/- 2.5 years) showed an increased in-hospital mortality in women (p = 0.0034, log rang test), but a comparable long-term survival. Women had an increased risk for failure of PTCA and a markedly higher operative mortality after emergency CABG. In multivariate analyses, however, gender was not an independent predictor of postoperative death.     

Outcome of women is impaired in patients undergoing emergency coronary artery bypass grafting for failed PTCA

Zusammenfassung Es wird kontrovers diskutiert, ob Frauen eine erhöhte Letalität bei kardiovaskulären Erkrankungen oder Interventionen haben. Wir untersuchten diesen Aspekt bei weiblichen und männlichen Patienten, bei denen eine Notfallbypass-Operation nach nicht erfolgreicher PTCA durchgeführt wurde. Die klinischen und prozeduralen Parameter aller Patienten, die zwischen 1989 und 1998 eine Notfallbypass-Operation erhielten, wurden retrospektiv aus den Patientenakten erhoben. In diesen 10 Jahren wurden 6681 PTCAs in unserer Klinik durchgeführt, davon 1312 PTCAs bei Frauen (19,6%). Bei 110 dieser Patienten wurde eine Notfall-Bypassoperation durchgeführt, wovon 32 Frauen betroffen waren (29,1%). Postoperativ verstarben 9 Frauen und 5 Männer (Letalität 12,7%). Die weiblichen Patienten waren zum Zeitpunkt der Untersuchung älter (61,2DŽ,1 vs. 58,3ǃ,0 Jahre; n.s.), kleiner (1,61ǂ,01 vs. 1,76ǂ,01 m; p<0,0001), leichter (67,7DŽ,4 vs. 82,1ǃ,2 kg; p<0,0001), und hatten eine kleinere Körperoberfläche (1,70ǂ,04 vs. 1,98ǂ,02 m²; p<>;0,0001) sowie eine höhere Komorbidität ausgedrückt durch den sogenannten Cleveland Risikoscore (7,9ǂ,3 vs. 7,1ǂ,2 Punkte; p=0,013). Das Risiko für eine nicht-erfolgreiche PTCA mit nachfolgender Notfall-Bypassoperation war bei Frauen höher als bei Männern (2,4% vs. 1,5%; p=0,012; Odds Ratio 1,66) ebenso wie das Risiko für ein postoperatives Versterben (28,1% vs. 6,4%; p=0,004; Odds Ratio 4,39). Frauen verblieben postoperativ länger im Krankenhaus als Männer (19,7dž,2 vs. 12,9ǃ,3 Tage; p=0,044). Eine logistische Regressionsanalyse identifizierte niedrigeres Körpergewicht (p=0,003), eine höhere Anzahl erkrankter Koronararterien (p=0,024) und einen höheren Cleveland Score (p=0,023) als unabhängige Prädiktoren für ein postoperatives Versterben. In einem Kaplan-Meier Modell (Nachbeobachtungszeit 5,3DŽ,5 Jahre) zeigte sich eine höhere Krankenhaus-Sterblichkeit bei Frauen (p=0,0034; Log Rank Test), wobei das Langzeitüberleben vergleichbar war. Frauen hatten in dieser Untersuchung eine erhöhtes Risiko für eine nicht-erfolgreiche PTCA mit nachfolgender Notfall-Bypassoperation sowie eine dann deutlich erhöhte postoperative Letalität. In der multivariaten Analyse war weibliches Geschlecht jedoch kein unabhängiger Prädiktor sondern Körpergewicht, Anzahl erkrankter Koronararterien und Komorbidität. Summary There is an ongoing debate whether female gender is associated with increased cardiovascular morbidity and mortality, especially after coronary interventions. The impact of gender on the outcome of patients undergoing emergency coronary artery bypass grafting (CABG) for failed PTCA was analyzed. Clinical and procedural data of all patients who underwent PTCA and subsequent emergency CABG at our institution from 1989 to 1998 were assessed. During these 10years, 6681 PTCA procedures were performed, 1312 in women (19.6%). Subsequently, 110 patients underwent emergency CABG of whom 32 were females (29.1%). Postoperatively, 9 women and 5 men died (mortality 12.7%). Women presented with higher age (61.2DŽ.1 vs. 58.3ǃ.0 years, n.s.), smaller height (1.61ǂ.01 vs. 1.76ǂ.01m, p<0.0001), lower weight (67.7DŽ.4 vs. 82.1ǃ.2 kg, p<0.0001), smaller body surface area (1.70ǂ.04 vs. 1.98ǂ.02m², p<0.0001), and higher comorbidity as expressed by their Cleveland score (7.9ǂ.3 vs. 7.1ǂ.2, p=0.013). The risk for failure of PTCA with subsequent emergency CABG was higher in women than in men (2.4% vs. 1.5%, p=0.012, odds ratio 1.66) as well as for postoperative death (28.1% vs. 6.4%, p=0.004, odds ratio 4.39). Women had longer in-hospital stays (19.7dž.2 vs. 12.9ǃ.3 days, p=0.044). Logistic regression analyses found lower weight (p=0.003), higher number of diseased coronary vessels (p=0.024) and higher Cleveland score (p=0.023) to be independent predictors of operative mortality. A Kaplan-Meier model (follow-up 5.3DŽ.5 years) showed an increased in-hospital mortality in women (p=0.0034, log rang test), but a comparable long-term survival. Women had an increased risk for failure of PTCA and a markedly higher operative mortality after emergency CABG. In multivariate analyses, however, gender was not an independent predictor of postoperative death.     

Will emergency coronary bypass grafting after failed elective percutaneous transluminal coronary angioplasty prevent myocardial infarction?

An emergency aorto-coronary bypass grafting operation was performed within 12 hours after the development of acute myocardial ischemia due to partial or complete vascular occlusion in 34 of 950 (3.6%) patients who had received elective percutaneous transluminal coronary angioplasty (PTCA). Of the 34 patients, three (= 8.8%) died postoperatively in irreversible cardiogenic shock. Half of the surviving patients developed a Q-wave infarction after the operation, whereas the other half remained without transmural infarct. With comparable clinical data and times of operation up to placement of the aorto-coronary bypass vessel, an adequate residual perfusion must still have been present in the cases with non Q-wave infarction. Since in many cases a myocardial necrosis is unavoidable despite relatively early operative revascularization, the decisive role will be played by the remaining perfusion of the vessel concerned and any collaterals. It follows that treatment of an early PTCA complication, occurring in the catheter laboratory, ought to be the earliest possible aorto-coronary bypass operation unless available cardiological methods can reliably assure reperfusion. Treatment of a PTCA complication occurring later, however, e.g. after hours in the intensive-care unit, should be a repeat PTCA attempt: surgery at this stage will not prevent the transmural infarction but will increase risk of lethal complications.     

Heart transplantation after emergency coronary artery bypass for failed angioplasty

We describe the case of a 48-year-old woman who required emergency coronary artery bypass grafting because of extensive dissection, cardiogenic shock, and ventricular fibrillation after failed percutaneous transluminal coronary angioplasty for stenosis of a proximal left anterior descending coronary artery. Despite maximal inotropic support and intra-aortic balloon pumping, the patient could not be weaned from cardiopulmonary bypass, and a left ventricular assist device was placed. After 2 days of postoperative circulatory support, during which her respiratory and renal functions declined and cardiac output remained negligible due to a massive myocardial infarction, she underwent successful orthotopic heart transplantation.     

Percutaneous transluminal coronary angioplasty in patients with prior coronary artery bypass grafting: ten years' experience

We evaluated the acute and long-term results of percutaneous transluminal coronary angioplasty in 140 patients with prior coronary artery bypass grafting treated over a 10-year period (1981–1991). Angioplasty was technically successful in 85% of 122 nonoccluded native vessels and in 86% of 50 saphenous vein grafts. Two patients (1.4%) had a myocardial infarction and there were three procedure-related deaths (2.1%). The cumulative probability of survival was 91.5% and 74.5% at 1 and 5 years, respectively. Survival free from myocardial infarction and repeat bypass grafting at 1 and 5 years was 77.3% and 53.9%, respectively. At census, 31% of the 117 survivors were asymptomatic, and 47% were improved by at least two angina grades. Coronary angioplasty provides an apparently safe and effective alternative method of revascularization in selected patients with prior coronary artery bypass grafting. This treatment strategy potentially avoids reoperation with its attendant risks. © 1994 Wiley-Liss, Inc.     

Results of coronary surgery after failed elective coronary angioplasty in patients with prior coronary surgery

The results of coronary artery bypass surgery after failed elective coronary angioplasty in patients who have undergone prior coronary surgery are unknown. Coronary angioplasty may be performed to relieve angina after surgery either to the native coronary vessels or to grafts. Failure of attempted coronary angioplasty may mandate repeat coronary surgery, often in the setting of acute ischemia. From 1980 to 1989, 1,263 patients with prior coronary bypass surgery underwent angioplasty; of these patients, 46 (3.6%) underwent reoperation for failed angioplasty during the same hospital stay. Of the 46 patients who underwent reoperation, 33 had and 13 did not have acute ischemia. In the group with ischemia, 3 patients (9.1%) died and 14 (42.4%) died or had a Q wave myocardial infarction in the hospital compared with no deaths (p = NS) and no deaths or Q wave myocardial infarction (p = 0.005) in the group without ischemia. At 3 years, the actuarial survival rate was 88 +/- 6% in the group with ischemia, whereas there were no deaths in the group without ischemia (p = NS), and freedom from death or myocardial infarction was 51 +/- 10% in the group with ischemia, versus no events in the group without ischemia (p = 0.006). In most patients with prior coronary bypass surgery, coronary angioplasty was performed without the need for repeat coronary bypass surgery. Should coronary angioplasty fail, reoperation in patients without acute ischemia can be performed with overall patient survival comparable to that of elective reoperative coronary bypass without coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)     

Usefulness of angioplasty during acute myocardial infarction in patients with prior coronary artery bypass grafting

The efficacy and risk of reperfusion strategies for myocardial infarction in patients with prior coronary artery bypass surgery are uncertain. In this study 72 patients with prior bypass grafting underwent direct percutaneous transluminal coronary angioplasty without antecedent thrombolytic therapy. There were 26 anterior and 46 inferior infarctions, including 11 patients (15%) in cardiogenic shock. The baseline ejection fraction was less than 40% in 47 (65%) patients. Angioplasty was successful in 41 of 48 (85%) vein grafts and 24 of 24 (100%) arteries (difference not significant) at 5.1 +/- 4.0 hours from the onset of symptoms (79% treated less than 6 hours). There were no urgent bypass operations, strokes or transfusions. In-hospital survival was 90% (nonshock 95% vs shock 64%, p less than 0.01). Symptomatic acute reclosure occurred in 1 patient. Predischarge coronary arteriography in 34 patients demonstrated continued vessel patency in 32 infarct vessels (94%), although 5 of these vessels were redilated for restenoses. Predischarge paired ventriculography in 26 patients showed an increase in ejection fraction from 44 +/- 16% to 51 +/- 18% (p less than 0.01). One- and 3-year actuarial survival was 89 and 87%. Thus, prior coronary surgery should not preclude reperfusion therapy by direct angioplasty, which can be accomplished with low procedural risk, improvements in ventricular function and excellent in-hospital and late survival.     

Reperfusion through balloon catheter to minimize myocardial infarction during the interval between failed percutaneous transluminal coronary angioplasty and emergency coronary artery bypass grafting

Summary A 65-year-old man was admitted with chest pain. A diagnosis of spastic angina was made because of symptoms of recurrent anginal attacks associated with ST-segment elevations in the electrocardiogram. A selective coronary arteriogram revealed a 90% diameter narrowing of the proximal left anterior descending coronary artery (LAD). No angiographically visible collaterals from the right coronary artery to the LAD were observed. The ventriculogram showed normal contraction of the left ventricle with an ejection fraction of 65%. Percutaneous transluminal coronary angioplasty (PTCA) failed resulting in total occlusion of the stenosis. Repeat PTCA at a higher pressure and of longer duration failed to redilate the artery. Reperfusion with the blood from the femoral artery through the balloon catheter, which was used for the PTCA, was carried out until coronary artery bypass grafting (CABG). Blood flow rate of perfusion was approximately 25 ml/min. Reperfusion through the balloon catheter reduced chest pain and ST-segment elevations in the electrocardiogram. The patient tolerated the operative procedure well and his post-operative course was uncomplicated. The interval between the acute occlusion and revascularization by CABG was approximately 4 1/4 h. The ventriculogram taken 56 days after the CABG demonstrated normal contraction of the anterior wall of the left ventricle with an ejection fraction of 63%. Abnormal Q waves did not appear in precordial leads of the electrocardiogram after the surgery. The thallium scintigram showed no perfusion defects.In conclusion, this case suggested that autologous blood reperfusion through balloon cathether would be worth attempting in some cases for minimization of myocardial infarction during the interval between failed PTCA and emergency CABG.     

Perfusion therapy to reduce myocardial ischemia en route to emergency coronary artery bypass grafting for failed percutaneous transluminal coronary angioplasty

Despite improvements in operator technique, catheter technology, and the development of new devices, emergency coronary artery bypass grafting (CABG) is still required in 1%-4% of attempted catheter based revascularization procedures. Patients who require such emergency CABG after failed percutaneous transluminal coronary angioplasty (PTCA) have worse acute outcomes than those undergoing elective CABG, with a higher incidence of Q wave myocardial infarction (MI) and a higher operative mortality. In patients with otherwise refractory abrupt closure, maintenance of antegrade coronary blood flow using perfusion catheters lessens the incidence of Q wave MI and lowers peak creatinine phosphokinase. Direct maintenance of coronary flow thus appears to provide more definitive control of myocardial ischemia than purely adjunctive measures, such as intra-aortic balloon pumping, cardiopulmonary support, or coronary sinus retroperfusion. Although the recent introduction of coronary stents holds great promise for definitive percutaneous reversal of abrupt closure and a dramatic decrease in the incidence of emergency CABG for failed PTCA, maintenance of antegrade flow via perfusion technology remains the cornerstone of management in reducing the perioperative mortality and morbidity of patients who still require emergency bypass surgery after failed PTCA.     

Complications prior to revascularization among patients waiting for coronary artery bypass grafting and percutaneous transluminal coronary angioplasty

AIM: To describe the occurrence of death, development of acute myocardialinfarction and need for hospitalization among patients on thewaiting list for coronary artery by pass grafting and percutaneoustransluminal coronary angioplasty. PATIENTS AND METHODS: All the patients on the waiting list for possible coronary revascularizationin September 1990 in western Sweden. RESULTS: Of 718 patients waiting for either coronary artery bypass graftingor percutaneous transluminal coronary angioplasty, 15 (2.1%)died between the actual week in September 1990 and prior torevascularization and 12 (1.7%) developed a non-fatal acutemyocardial infarction during the same period. All 15 patientswho died before undergoing revascularization died a cardiacdeath. Death and/or the development of an acute myocardial infarctionwas significantly more frequent among the elderly, among patientswith a low ejection fraction and among patients with a historyof diabetes mellitus. In all, 29% required hospitalization priorto the procedure. The most common reason was symptoms of anginapectoris requiring hospitalization in 23% of the patients. CONCLUSION: Among patients on the waiting list before either coronary arterybypass grafting or percutaneous transluminal coronary angioplasty,15 (2.1%) died prior to the procedure and 1.7% developed a non-fatalacute myocardial infarction. The risk of either death or developingan acute myocardial infarction was highest among patients inthe older age groups, among patients with a history of diabetesmellitus and among patients with a lower ejection fraction.     

Coronary angioplasty in patients with previous coronary artery bypass grafting.

Between 1982 and 1990, in 134 patients with prior coronary artery bypass grafting and recurrent angina, repeat coronary angiography and balloon angioplasty of stenoses in grafts or native arteries were attempted. Mean age of grafts was 45.6 months, range three days to twelve years. At the time of angioplasty, 6 patients had one-vessel-disease, 33 had two-vessel-disease, and 95 had three-vessel-disease. A total of 182 lesions were dilated: 55 venous grafts, 3 internal mammary artery grafts, and 124 native vessels. Forty-nine of 55 (89%) venous grafts could be successfully dilated, and in 3 internal mammary artery grafts, a stenosis reduction greater than 50% was achieved. In 65 of 88 (74%) grafted native arteries, dilation success was achieved. Twenty-seven of 36 (75%) patients with prior bypass surgery to other arteries had successful angioplasty of nongrafted native arteries. Three patients underwent emergency bypass surgery after dissection and acute occlusion: one of them died in cardiogenic shock secondary to acute myocardial infarction. The angiographic success rate in grafts was slightly higher than in native arteries (90% vs 74%). These data indicate that percutaneous transluminal coronary angioplasty in patients after bypass surgery is possible at a low risk (3%) and constitutes an effective therapy in symptomatic patients.     

Successful rotational coronary ablation following failed balloon angioplasty

Rotational coronary ablation was utilized in two cases in which balloon angioplasty initially failed. In both cases, the balloon could not be fully expanded despite using high (18 Bar) inflation pressure. Rotational coronary ablation debulked the lesion, in each instance, and permitted successful balloon angioplasty to be accomplished without difficulty. These cases illustrate the point that complementary deployment of devices may not only improve the primary success of percutaneous coronary interventions, but also may widen its scope.     

Benefit of the perfusion catheter for emergency coronary artery grafting after failed percutaneous transluminal coronary angioplasty

Of 2,102 consecutive patients who underwent percutaneous transluminal coronary angioplasty, 31 (1.5%) had emergency coronary bypass grafting for failed angioplasty. To determine the potential impact of different therapeutic strategies for controlling associated myocardial ischemia, 3 groups were analyzed. Group 1 comprised 11 patients (36%) in whom a "bailout" catheter was used to maintain anterograde coronary perfusion, group 2 included 16 patients (52%) in whom only intraaortic balloon counterpulsation was used and group 3 contained 4 patients (13%) in whom neither bailout catheter nor intraaortic balloon was used. Despite a longer average time to cardiopulmonary bypass, patients managed with the bailout catheter had a significantly lower incidence of Q-wave myocardial infarctions (9 vs 75%, p less than 0.05) compared with patients managed with intraaortic balloon counterpulsation alone. Those managed with the bailout catheter also had more consistent resolution of ST elevation and greater use of internal mammary artery grafts than patients supported by intraaortic balloon counterpulsation alone.     

Clinical efficacy of emergency bypass surgery for failed coronary angioplasty

The clinical and angiographic variables of 26 coronary artery disease patients at the University of Alberta Hospitals requiring emergency coronary artery bypass grafting (CABG) for failed percutaneous transluminal coronary angioplasty (PTCA) were reviewed. Emergency CABG was judged necessary in 2% of 1300 consecutive patients undergoing PTCA. The most frequent indication for an emergency operation was dissection and acute closure of eccentric bend point target lesions associated with clinically severe, unremitting chest pain and ST-T abnormalities suggestive of impending myocardial infarction. The mortality rate for the combined procedures of failed PTCA and CABG was low (3.8%). The incidence of periprocedural infarction was high (61%); it was, however, associated with a benign clinical course and electrocardiographic evidence of significant reversibility of acute phase damage. Thus, overall, emergency CABG appears to be a clinically efficacious treatment for patients with threatened or impending infarction as a consequence of failed PTCA.     

Coronary angioplasty in patients with prior coronary artery bypass surgery: all prior coronary artery bypass surgery patients and patients more than 5 years after coronary bypass surgery

Percutaneous transluminal coronary angioplasty (PTCA) has been used successfully in patients who have had prior bypass surgery (CABG) as a means of revascularizing the myocardium and avoiding repeat myocardial revascularization. However, angioplasty has been considered inappropriate as a means of dilating old saphenous vein grafts. The first section of this article details the authors' experience with PTCA of prior CABG patients, and the second section discusses the results of PTCA in the subset of patients 5 or more years after their last coronary bypass surgery. These data may make individuals rethink the appropriateness of PTCA in old saphenous vein grafts.