Percutaneous transluminal coronary angioplasty (PTCA) without on-site surgical facilities

Background: Numerous publications from European and Canadian centres have documented the feasibility of performing percutaneous transluminal coronary angioplasty (PTCA) without on-site surgical facilities. The absolute need for surgical standby has been changing especially with the introduction of coronary stent for bailout situations. This practice may be applicable in Australian centres especially in the environment of long waiting lists and cost containment. Aim: To review the safety of performing PTCA by experienced operators in two Melbourne hospitals without on-site surgical facilities. Methods: We reviewed data of all patients who had PTCA electively (with low and moderate risks) between July 1996 and January 1997 and in the setting of acute myocardial infarction (AMI) from January 1996 to January 1997. Surgical standby was available as ‘next available room’ basis in nearby centres. Immediate outcome before discharge was documented and follow up from three to six months in 80% of all surviving patients. Results: There were 46 elective PTCA and 41 PTCA for AMI. PTCA was successful in 82 (94%) patients. Among the elective cases, seven patients were already inpatients with unstable or postinfarct angina. Thirteen patients had stents deployed with three for acute closure. Abciximab (Reopro) was given to eight patients. Two patients had acute closure in the laboratory which could not be reopened, but did not require emergency coronary artery bypass grafting (CABG). There were four inhospital deaths (three related to AMI and one died of a noncoronary cause). Conclusion: PTCA can be performed electively in a selected group of patients with coronary artery disease and as a primary procedure for AMI without on-site surgical standby. (AustNZJMed 1998; 28: 165–171.)     

Percutaneous rescue transluminal coronary angioplasty

Rescue angioplasty is an operation performed in the acute stage of myocardial infarction where systemic thrombolysis did not lead to opening of the artery. Investigations made in recent years indicate the benefit of rescue angioplasty only in those patients where the infarcted artery is patent several hours after evidence that thrombolysis failed. At the same time they provide evidence of the increasing safety and technical success of the operation. The authors present a brief review of the literature pertaining to the development of views, and emphasize the need of early and correct indication.     

Percutaneous transluminal coronary angioplasty of coronary artery embolism.

A 35-yr-old woman with known valvular heart disease presented with acute myocardial infarction. Angiography demonstrated a totally occluded distal left anterior descending coronary artery. Though initially successful, angioplasty ultimately failed to maintain arterial patency, leaving a more distal total occlusion after several balloon inflations. In spite of this, PTCA possibly provided a more localized infarction via a peripheral mobilization of the embolus.     

Percutaneous transluminal coronary angioplasty in octogenarians

OBJECTIVE: To assess the safety and short- and long-term outcomes of percutaneous transluminal coronary angioplasty in octogenarians. DESIGN: Retrospective chart review of clinical series. SETTING: Referral-based university medical center. PATIENTS: Consecutive series of 54 octogenarian patients (mean age, 82.4 years) who had percutaneous transluminal coronary angioplasty between March 1980 and December 1988. Of these patients, 91% presented with severe angina (Canadian Cardiovascular Society Class III or IV); 59% had unstable angina. Twenty-six patients (48%) had had a previous myocardial infarction and 15 (28%) had had previous coronary artery bypass surgery. Multivessel disease was present in 44 patients (81%). Follow-up ranged from 1 to 50 months (mean, 19 months). INTERVENTION: Percutaneous transluminal coronary angioplasty. MEASUREMENTS and MAIN RESULTS: The angiographic success rate was 50 of 54 (93%; 95% CI, 81% to 98%) and the clinical success rate was 49 of 54 (91%; CI, 79% to 97%). Two patients had procedure-related myocardial infarction. Two patients died in the hospital, 1 from cardiac tamponade because of pacemaker perforation and 1 from cardiogenic shock after a myocardial infarction despite successful angioplasty. During the follow-up period 4 patients required bypass surgery, 2 had myocardial infarction, and 7 died (4 deaths were cardiac). Eleven patients (20%) had re-stenosis, 7 of whom were managed with repeat angioplasty, including 1 patient who had four procedures. At follow-up, 42 of 45 survivors (93%) were asymptomatic or had class II angina. The Kaplan-Meier survival for all patients, including those who died in the hospital, was 87% at 1 year and 80% at 3 years. Cumulative freedom from major cardiac events (death, myocardial infarction, or coronary bypass surgery) was 81% at 1 year and 78% at 3 years. CONCLUSIONS: Percutaneous transluminal coronary angioplasty can be done in octogenarians with a high rate of angiographic and clinical success, low complication rate, and a favorable long-term (3-year) outcome. As such, it is a treatment option in managing advanced coronary artery disease in this fragile group of patients.     

Percutaneous transluminal coronary angioplasty in hypothyroidism

PURPOSE: To determine the risks of percutaneous transluminal coronary angioplasty (PTCA) in hypothyroid individuals. PATIENTS AND METHODS: In a retrospective cohort study, 13 patients with primary hypothyroidism were identified among 382 consecutive PTCA cases in 1987. Twenty-two euthyroid PTCA control subjects and 13 hypothyroid patients who underwent coronary artery bypass surgery (CAB) were identified for comparison. RESULTS: Hypothyroid and euthyroid PTCA patients had similar mean ages, numbers of prior and recent acute myocardial infarctions, diseased coronary arteries, coronary arteries dilated, and serum cholesterol levels. There were no significant differences in procedure-related mortality (0% versus 0%); coronary artery dissection (23% versus 23%); reocclusion (8% versus 5%); bradycardia (0% versus 0%); heart failure (0% versus 5%); hypotension (31% versus 27%); myocardial infarction (8% versus 0%); gastrointestinal dysfunction (0% versus 0%); neuropsychiatric disturbance (15% versus 9%); hyponatremia (23% versus 23%); hypothermia (0% versus 0%); or fever (15% versus 5%). Hematoma formation tended to be more frequent in the hypothyroid group (38% versus 18%, p = 0.18). Similar results were obtained when the subgroup of more severely hypothyroid patients (thyrotropin level more than 20 mU/L, n = 7) was examined. Compared to hypothyroid CAB patients, hypothyroid PTCA patients had less incidence of heart failure (0% versus 31%, p less than 0.025); neuropsychiatric disturbance (15% versus 54%, p less than 0.025); hyponatremia (23% versus 62%, p less than 0.05); gastrointestinal dysfunction (0% versus 23%, p less than 0.025); and fever (15% versus 62%, p less than 0.001). CONCLUSION: PTCA can be performed in hypothyroid patients without increased mortality or major morbidity, and when appropriate, may be preferred to bypass surgery for coronary revascularization in patients intolerant of full thyroid hormone replacement.     

Percutaneous transluminal coronary angioplasty of coronary artery embolism

A 35-yr-old woman with known valvular heart disease presented with acute myocardial infarction. Angiography demonstrated a totally occluded distal left anterior descending coronary artery. Though initially successful, angioplasty ultimately failed to maintain arterial patency, leaving a more distal total occlusion after several balloon inflations. In spite of this, PTCA possibly provided a more localized infarction via a peripheral mobilization of the embolus.     

Percutaneous brachial approach for transluminal coronary angioplasty

Transluminal coronary angioplasty from the arm is performed generally with cutdown and brachial arteriotomy. We describe a brachial percutaneous technique for coronary angioplasty, almost similar to the femoral one, with a special focus on the prevention of induced vasoconstriction. Our preliminary results are satisfactory and without complications: 13 procedures in 11 patients have been performed over a 30 month period, with the sheaths left in place for 4-6 h after the procedure. This method could be an easy alternative to the Sones technique for operators who are essentially familiar with the femoral percutaneous arterial approach.