Percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty, first performed in man in 1977, has been used increasingly in selected patients with angina pectoris due to coronary atherosclerosis. Patients with single-vessel coronary artery disease in whom the stenosis is relatively proximal, noncalcified, discrete, and tapered rather than eccentric are the best candidates for the procedure. Objective evidence of coronary insufficiency documented by scintigraphy or exercise testing allows objective follow-up. Patients must be candidates for coronary artery bypass graft surgery since a complication might require immediate operation. Clinical experience indicates that 60%-85% of patients chosen for coronary angioplasty can have their coronary stenoses successfully dilated. Symptomatic improvement occurs in almost 90% of successful dilatations. Follow-up studies have shown persistent vessel patency for more than 1 year. From 3% to 8% of patients have needed urgent coronary artery bypass graft surgery because of coronary insufficiency developing at the time of angioplasty. Mortality has been less than 1%. The initial favorable experience with coronary angioplasty indicates that it should continue to be evaluated. The limits of patient selection for the procedure and long-term results require further compilation of data.     

Percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) has revolutionized the treatment of patients with coronary disease. As many as 25 per cent of those requiring myocardial revascularization can now undergo PTCA instead of bypass surgery. This article reviews PTCA techniques, clinical results, case selection, complications, recent advances in equipment design, restenosis rate, use in acute myocardial infarction, and PTCA of coronary bypass grafts.     

Percutaneous transluminal renal angioplasty

One to 2 percent of the 25,000,000 hypertensive patients in the United States have renovascular hypertension. Until recently, the treatment of choice for a patient with an ischemic, renin-producing kidney that caused hypertension involved a major abdominal operation. Percutaneous catheter techniques are now available that permit correction of a renal artery stenosis under fluoroscopic guidance. This percutaneous transluminal angioplasty procedure has received much attention, but to date no long-term follow-up studies are available. Because of the limited life-expectancy of patients with a generalized arteriosclerotic process and the relatively high risk of operative procedures in this group of patients, it would seem appropriate to consider percutaneous transluminal renal angioplasty as an alternative method in the management of the patient with renovascular hypertension.     

Percutaneous transluminal angioplasty: surgeon's view

The balloon-tipped catheter for percutaneous transluminal angioplasty (PTA) is a potentially dangerous weapon. Safe use requires considerable technical skill. Complications have already caused significant risk to, and loss of, limbs and life. Although there is no question that the incidence of successful dilatation in competent hands is quite high, the risks of complication are still not completely known. Any new procedure must be compared with existing effective modes of treatment, in this case, surgical revascularization. Therefore, this new procedure must be examined and compared in terms of acute hemodynamic effectiveness, mortality and morbidity, specific indications, long-term results (durability), and consequences of long-term failure. Pertinent surgical experience is reported to provide data for this comparison and information from which some predictions about percutaneous angioplasty can be made. Although complete information about these issues is needed before we can confidently accept balloon catheter angioplasty as a therapeutic procedure and assign it its proper role, cautious and judicious application of angioplasty should proceed with some definite guidelines.     

Percutaneous transluminal angioplasty: general principles

The introduction and availability of balloon catheters has been responsible for the recent popularity of percutaneous transluminal angioplasty (PTA) in the United States. Available balloon catheters are either double-lumen or coaxial systems. Most balloons are made of polyvinyl but one manufacturer has produced an angioplasty catheter made of specially treated polyethylene, which exhibits higher tensile and yield strength in comparison to polyvinyl. Automatic pressure injectors are necessary for the coaxial balloon system. They are not used with single catheters and larger balloons. Devices monitoring balloon inflation pressures are now available and they should be used. There is no consensus on the use of anticoagulant therapy in conjunction with PTA. Complications of PTA are few and easy to manage. Noninvasive hemodynamic studies (Doppler and pulse volume recordings) are necessary during PTA and for evaluation of long-term patency. PTA should be performed by experienced angiographers in hospitals with adequate angiographic and vascular surgical facilities. Decisions about PTA and subsequent patient management are best made in consultation with the patient's primary physician, a vascular radiologist, and a vascular surgeon.     

Percutaneous transluminal angioplasty of the renal arteries: double- catheter technique

A technique is described for angioplasty of the renal arteries using two catheters in a patient with two renal arteries to the left kidney. Injury to the nonstenotic supplemental artery during balloon dilatation of the stenotic main artery was avoided with the use of this technique.     

Percutaneous transluminal angioplasty following endarterectomy

Recurrent occlusive disease was found by noninvasive methods and confirmed arteriographically in 7 patients who had undergone endarterectomy for stenosis of one [5] or both iliac arteries [1] or the subclavian artery [1]. Three patients with iliac artery stenosis had percutaneous transluminal angioplasty (PTA) 1 to 5 years after endarterectomy. One patient with stenosis of the external iliac artery had PTA 4 years after endarterectomy, and dilatation was repeated 7 months later because of recurrence. One patient had 2 endarterectomies and 2 PTAs within 8 years for stenosis of the right common iliac artery. One patient had recanalization of the left common iliac artery 6 years after endarterectomy with low-dose streptokinase followed by PTA. Another patient underwent endarterectomy of the left subclavian artery 3 months after PTA and required further dilatation at 5 and 10 months because of recurrence. The authors conclude that endarterectomy does not preclude PTA (or vice versa) in patients with recurrent arterial occlusive disease.     

Percutaneous transluminal laser angioplasty]

Percutaneous transluminal laser angioplasty (PTLA) has been carried out on 63 peripheral arterial occlusive lesions in 43 patients. Most patients complained of intermittent claudication. The sites of lesions are the iliac artery (28 lesions or 44.4%), the femoropopliteal artery (30 lesions or 47.6%), and the below knee artery (5 lesions or 8.0%). There are 54 lesions (85.7%) that showed over 70% stenosis, with 19 of them complete occlusions (30.2%). Out of 63 lesions, 16 lesions or 25.4% had occlusions of over 10 cm. A Nd:YAG laser (1.06 microns, continuous wave) was used for the vaporization of atheromatous plaque and old thrombus. The laser was irradiated by increments of 1 to 2 seconds at 80W using the non-contact method, at 10-25W using the contact method with a ceramic tip and at 10-15W with a bare laser fiber. Balloon dilatation was then utilized. The initial success rate was 85.7%. The 5 year cumulative patency rate after PTLA is 88.4% in total cases, 88.7% in the iliac artery, 86.1% in the femoropopliteal artery, and 100% in the below knee artery. The 5 year cumulative patency rate for stenosis of the iliac artery is 91.0%, and it is 92% for stenosis of the femoropopliteal artery, and 81% for occlusion of the femoropopliteal artery. PTLA seems to have improved the cumulative patency rate when compared with that of conventional PTA.     

Percutaneous transluminal angioplasty after renal transplantation

Renal artery stenosis is a frequent complication of kidney transplantation (10%). Percutaneous transluminal angioplasty (PTA) has recently been proposed as a potential therapeutic procedure. Twelve transplant patients with arterial stenosis underwent PTA. The procedure was successful in 10 cases (83.3%). Restenosis occurred in 2 patients (16.7%); both of them underwent PTA successfully. No complications occurred. A considerable improvement in glomerular filtration rate and a reduction in high blood pressure were observed in all patients after successful PTA. The authors believe PTA to be the therapy of choice in the treatment of arterial stenoses in kidney transplant patients.     

Percutaneous transluminal aortic angioplasty: Early and late results

Percutaneous transluminal angioplasty of the infrarenal abdominal aorta (13 patients) and its bifurcation (15 patients) was performed in 28 patients with a total of 32 dilatation procedures. The group consisted of 16 female and 12 male patients and initial successful dilatation was achieved in all Recurrence within 1 month requiring bypass surgery occurred in 1 patient. Three patients were lost to follow-up. Long-term follow-up in the remaining 24 patients ranged from 1 to 9 years with a mean of 4.5 years. During the follow-up period, repeat angioplasty of the original stenosis was performed in 3 patients and another patient underwent dilatation of a new lesion which developed in the aorta. According to clinical and noninvasive studies, these 4 patients, as well as the other 20, have maintained patency of the treated lesions and are symptom free. No immediate complications requiring surgery occurred. We conclude that angioplasty is the initial treatment of choice in focal lesions of the distal abdominal aorta and its bifurcation.