Results of Stent Supported Percutaneous Transluminal Coronary Angioplasty in Octogenarians With Coronary Artery Disease

Between January 1995 and July 1998, percutaneous transluminal coronary angioplasty was performed on 27 lesions in 24 octogenarians. Half of the patients were African American. Women comprised 67% of the study group. Patients with unstable angina and myocardial infarction constituted 54% of the cohort. Two-thirds of the patients (83%) had single vessel disease with predominant class A and B lesion complexity of the angioplasty site. Acute success rate was 92%. Stents were successfully placed in 11 subjects (46%). None had acute myocardial infarction, emergency coronary artery bypass surgery, or stroke as a complication of the procedure. One patient presenting with acute myocardial infarction complicated by cardiogenic shock, died. Significant bleeding complications requiring blood transfusions occurred in 17% of patients. Of the patients, 23 (96%) were discharged in a clinically stable condition. Follow up during a two year period was completed in 21 patients (88%). One patient died of cancer. Four subjects (19%) underwent repeat percutaneous transluminal coronary angioplasty. One other patient had recurrent chest pain requiring multiple hospitalizations. The remaining 16 patients (76%) remained free of recurrence of angina. We concluded that percutaneous transluminal coronary angioplasty with stent placement can be performed in octogenarians with a high rate of clinical and angiographic success with an acceptable range of morbidity and mortality, and favorable long term (two year) outcome.     

Immediate and long-term clinical outcome of coronary angioplasty in patients aged 35 years or less.

OBJECTIVE--To study the immediate and long-term clinical success of percutaneous transluminal coronary angioplasty in patients aged 35 years or less. DESIGN--Patients undergoing percutaneous transluminal angioplasty were prospectively entered into a dedicated database. Clinical and angiographic data on all patients aged 35 years or less were reviewed. Follow up data were collected by interview during outpatient visits, by questionnaire, or from referring physicians. SETTING--A tertiary referral cardiac centre. PATIENTS--57 patients aged 35 years or less (median 33, range 22-35) underwent coronary angioplasty because of unstable angina (32 patients), stable angina (23 patients), acute myocardial infarction (1 patient), and documented ischaemia in a cardiac transplant patient. RESULTS--The primary clinical success rate (reduction in diameter stenosis to < 50% without in-hospital events) was 88%. A major procedure related complication occurred in 5 patients (9%): one patient died, two patients sustained an acute myocardial infarction, two patients underwent emergency bypass surgery, and in three patients repeat angioplasty was performed before hospital discharge. In 2 patients (4%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 60 lesions were attempted (balloon angioplasty in 57, directional atherectomy in 2). The initial angiographic success rate was 92%. The median (SD) follow up was 4.7 (3.0) years. During follow up 7 patients (12%) died, 10 sustained a myocardial infarction (18%), and 28 patients (49%) underwent repeat revascularisation (coronary artery bypass grafting in 7 (12%) and repeat angioplasty in 21 (37%)). The estimated 5 year survival and event-free survival (Kaplan-Meier method) was 87 (9)% and 50 (13)%, respectively. Multivariate logistic regression analysis showed that hypertension and the extent of vessel disease were the only independent predictive factors for event free survival. CONCLUSIONS--In young patients coronary angioplasty had a high immediate success rate but many needed repeat revascularisation procedures during the follow up period and survival was not improved. Coronary angioplasty in young patients should be regarded as a palliative procedure.     

Coronary angioplasty in unstable angina. Immediate and short-term results

We report the results of percutaneous transluminal coronary angioplasty (PTCA) in 67 consecutive patients with unstable angina. Twenty patients had new onset (less than 2 months) angina, 33 patients had crescendo angina and 14 had early postinfarction angina. Fifty-one patients had one-vessel disease, 12 patients had two-vessel disease and two patients had three-vessel disease; two patients had a stenosis of a venous graft. In cases with multivessel disease, we performed only the dilatation of the ischaemia-related vessel identified by morphologic features of coronary lesion and electrocardiographic changes during chest pain. The procedure was successful in 54 cases (80.6%). Seven patients (10.4%) had major complications. Emergency coronary artery bypass graft surgery was performed in 6 cases (8.9%) because of occlusion of the left anterior descending artery; despite emergency operation one patient died and two patients sustained a myocardial infarction. One patient had occlusion of the right coronary artery and inferior myocardial infarction. In all patients in whom angioplasty was successful unstable angina disappeared. At 6 months follow-up there were no infarctions or deaths but 14 of 42 patients (33%) had recurrent angina. Restenosis occurred in 16 of 33 patients (48%) who had repeat coronary angiography. Four patients with recurrence of unstable angina had repeat angioplasty; it was successful in 3 cases. One patient died of refractory cardiac arrest. The mortality rate of 71 procedures performed in 67 patients was 2.8% (2/71) and the overall myocardial infarction rate was 4.2% (3/71).(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of percutaneous transluminal coronary angioplasty for unstable angina pectoris in patients 70 years of age and older

Between November 1980 and November 1985, 54 patients ages greater than or equal to 70 years underwent percutaneous transluminal coronary angioplasty for unstable angina, defined as recent-onset (less than 1 month) angina, new onset of rest angina (greater than or equal to 2 episodes) or accelerating class III or IV angina. In these 20 men and 34 women, disease was 1-vessel in 34 (63%) and multivessel in 20 (37%). The mean (+/- standard deviation) ejection fraction was 0.62 +/- 0.12. Angioplasty was successful in 43 patients (80%). In the 11 unsuccessful cases, emergency coronary artery bypass grafting for acute occlusion was performed in 3 and elective coronary artery bypass surgery in 8. There were no deaths. Two patients (4%) sustained Q-wave myocardial infarctions. The mean duration of follow-up for the total group was 37 months (6 to 73 months). Of the 43 patients with successful dilation, 4 died, 1 had an non-Q-wave myocardial infarction and 8 had symptomatic restenosis (4 underwent successful repeat angioplasty, 1 had repeat percutaneous transluminal coronary angioplasty and then bypass surgery, 1 had repeat bypass surgery alone and 2 had medical therapy). At last follow-up, 3 patients had stable class III or IV angina and 31 patients (72%) were angina-free.     

Immediate and long term results of percutaneous coronary angioplasty in patients aged 70 and over.

OBJECTIVE--To study the immediate and long term clinical success of percutaneous transluminal coronary balloon angioplasty in patients over 70 years old. DESIGN--Patients undergoing percutaneous transluminal angioplasty were prospectively entered in a specially designed database. The clinical and angiographic data of all patients over 70 were reviewed. Follow up data were collected by interview, during outpatient visits, by questionnaire, or through the referring physician. SETTING--A tertiary referral cardiac centre. PATIENTS--166 patients over 70 (median 73, range 70-84) underwent coronary angioplasty because of unstable angina (81 patients), stable angina (76 patients), or acute myocardial infarction (nine patients). RESULTS--The initial clinical success rate was 86% (142 of 166 patients). A major procedural complication occurred in 10 patients (6%): four patients (2%) died, six patients (4%) underwent emergency bypass surgery, and five patients (3%) sustained an acute myocardial infarction. In 14 patients (8%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 226 lesions were attempted. The initial angiographic success rate was 192 out of 226 lesions (85%). The median follow up was 21 (range 0.5-66) months. Sixteen patients (10%) died during follow up, eight patients (5%) sustained a non-fatal myocardial infarction, 21 patients (13%) underwent a second or third balloon dilatation, and 17 patients (10%) underwent elective bypass surgery. Of the 146 survivors, 99 patients (68%) had sustained clinical improvement. The estimated survival at four years (Kaplan-Meier method) was 89 (SD 4)%. The event free survival at four years for the total study population was 61 (8)%. Multivariate logistic regression analysis showed that the extent of vessel disease was the only independent predictive factor for event free survival: the event free survival rate was 81 (10)% at four years for patients with single vessel disease, compared with 45 (12)% for patients with multivessel disease. CONCLUSIONS--Coronary angioplasty in patients over 70 was a safe and effective treatment for obstructive coronary artery disease. The extent of vessel disease, and not the completeness of revascularisation, was the only independent predictive factor for event free survival.     

Immediate and long term results of percutaneous coronary angioplasty in patients aged 70 and over.

OBJECTIVE--To study the immediate and long term clinical success of percutaneous transluminal coronary balloon angioplasty in patients over 70 years old. DESIGN--Patients undergoing percutaneous transluminal angioplasty were prospectively entered in a specially designed database. The clinical and angiographic data of all patients over 70 were reviewed. Follow up data were collected by interview, during outpatient visits, by questionnaire, or through the referring physician. SETTING--A tertiary referral cardiac centre. PATIENTS--166 patients over 70 (median 73, range 70-84) underwent coronary angioplasty because of unstable angina (81 patients), stable angina (76 patients), or acute myocardial infarction (nine patients). RESULTS--The initial clinical success rate was 86% (142 of 166 patients). A major procedural complication occurred in 10 patients (6%): four patients (2%) died, six patients (4%) underwent emergency bypass surgery, and five patients (3%) sustained an acute myocardial infarction. In 14 patients (8%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 226 lesions were attempted. The initial angiographic success rate was 192 out of 226 lesions (85%). The median follow up was 21 (range 0.5-66) months. Sixteen patients (10%) died during follow up, eight patients (5%) sustained a non-fatal myocardial infarction, 21 patients (13%) underwent a second or third balloon dilatation, and 17 patients (10%) underwent elective bypass surgery. Of the 146 survivors, 99 patients (68%) had sustained clinical improvement. The estimated survival at four years (Kaplan-Meier method) was 89 (SD 4)%. The event free survival at four years for the total study population was 61 (8)%. Multivariate logistic regression analysis showed that the extent of vessel disease was the only independent predictive factor for event free survival: the event free survival rate was 81 (10)% at four years for patients with single vessel disease, compared with 45 (12)% for patients with multivessel disease. CONCLUSIONS--Coronary angioplasty in patients over 70 was a safe and effective treatment for obstructive coronary artery disease. The extent of vessel disease, and not the completeness of revascularisation, was the only independent predictive factor for event free survival.     

Coronary angioplasty for medically refractory unstable angina within 30 days of acute myocardial infarction

Percutaneous transluminal coronary angioplasty (PTCA) has been used with good results in selected patients with unstable angina. The population with recent (less than or equal to 30 days) infarction and unstable angina is a subject of controversy. This report reviews the results of angioplasty of 84 vessels in 66 patients with medically refractory unstable angina who had documented myocardial infarction within 30 days of the procedure. Of these 66 patients, 54 had rest angina. Of the 66 patients with angioplasties, 58 patients (88%) had successful procedures. Two patients had technically unsuccessful results in the only vessel attempted; one went to elective surgery and recovered uneventfully and the other patient was in cardiogenic shock at the time of the procedure and died 12 hours later. There were three acute occlusions of infarct-related arteries that were managed medically. There were two (3%) emergency coronary artery bypass graft (CABG) procedures. There were two (3%) deaths during the index hospitalization. Of the 58 of 66 patients with technically successful angioplasty, all 58 had no more rest angina, and 46 had a satisfactory predischarge exercise test. All 46 were without angina at exercise. In follow-up ranging from 4 months to 36 months (14 months mean), there have been six cases of restenosis with recurrence of angina treated successfully with repeat angioplasty. There have been five late bypass surgeries. There have been three late deaths. These data, generated by a single operator in a Veterans Administration (VA) center, support the use of angioplasty in patients with unstable angina and recent myocardial infarction. The data suggest that a VA prospective randomized trial of PTCA versus CABG for post-infarction angina may be feasible.     

Percutaneous transluminal coronary angioplasty in unstable angina: comparison with stable angina

Percutaneous transluminal coronary angioplasty was performed in 25 patients with unstable angina and in a similar group of 25 patients with stable angina. The frequency of single, double, and triple vessel disease was identical in each group. Technical success was achieved in 22 (81%) out of 27 attempts in those with unstable angina and in 14 (52%) out of 27 attempts in those with stable angina. Vessel occlusion occurred in nine patients, necessitating emergency bypass surgery in four. There was evidence of myocardial infarction in three patients in each group and one patient in the unstable group subsequently died. Twenty eight of 32 successfully treated patients were followed up by means of repeat coronary arteriography, exercise electrocardiography, and clinical assessment after a mean (SD) interval of 14 (7) months. There was angiographic evidence of restenosis in 32% (seven of 22) of lesions in the unstable group and 44% (four of nine) of lesions in the stable group. There were no late infarctions or deaths during the follow up period. These results support the growing evidence that angioplasty can be carried out safely and effectively in patients with unstable angina.     

Percutaneous transluminal coronary angioplasty in unstable angina: comparison with stable angina.

Percutaneous transluminal coronary angioplasty was performed in 25 patients with unstable angina and in a similar group of 25 patients with stable angina. The frequency of single, double, and triple vessel disease was identical in each group. Technical success was achieved in 22 (81%) out of 27 attempts in those with unstable angina and in 14 (52%) out of 27 attempts in those with stable angina. Vessel occlusion occurred in nine patients, necessitating emergency bypass surgery in four. There was evidence of myocardial infarction in three patients in each group and one patient in the unstable group subsequently died. Twenty eight of 32 successfully treated patients were followed up by means of repeat coronary arteriography, exercise electrocardiography, and clinical assessment after a mean (SD) interval of 14 (7) months. There was angiographic evidence of restenosis in 32% (seven of 22) of lesions in the unstable group and 44% (four of nine) of lesions in the stable group. There were no late infarctions or deaths during the follow up period. These results support the growing evidence that angioplasty can be carried out safely and effectively in patients with unstable angina.     

Clinical and angiographic assessment 6 months after double vessel percutaneous coronary angioplasty

Percutaneous transluminal coronary angioplasty is an accepted treatment for selected patients with single vessel disease but has not been rigorously evaluated in patients with double vessel disease. Among 769 patients undergoing transluminal coronary angioplasty between 1980 and 1984, 74 with double vessel stenosis of 50% or more underwent double vessel coronary angioplasty. Primary success was obtained for both lesions in 63 patients (85%), for one lesion in 11 patients (15%) and for 137 (93%) of 148 segments overall. Except for myocardial infarction in one patient, no serious complication occurred. Before coronary angioplasty, 15 patients had unstable angina, 14 had Canadian Cardiovascular Society class III and 32 class I to II effort angina and only 2 were asymptomatic. Six months after coronary angioplasty, 27 were asymptomatic, 27 had class I to II and 5 had class III effort angina and 2 had sustained an episode of unstable angina. During the follow-up study, two patients had an infarction and one had coronary artery bypass surgery. Coronary arteriography was performed at a mean of 5.5 +/- 2.1 months after coronary angioplasty in all but three patients. Restenosis was found in 30 (23%) of 132 segments with angiographic control. Restenosis was present in one vessel in 17 patients and in both vessels in 4; 40 patients (66%) had no restenosis. Of the 34 patients with definite or probable angina, 50% had restenosis and 19% of patients with restenosis were symptom free.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intracoronary urokinase as an adjunct to percutaneous transluminal coronary angioplasty in patients with complex coronary narrowings or angioplasty-induced complications.

The effectiveness of intracoronary urokinase infusion as an adjunct to percutaneous transluminal coronary angioplasty (PTCA) was studied in 50 patients who underwent angioplasty for complex coronary narrowings or had thromboembolic complications during PTCA (29 [58%] men, 3 [6%] stable and 37 [74%] unstable angina, and 16 [32%] prior coronary bypass surgery). The primary indications for intracoronary urokinase infusion were intracoronary thrombus in 27 patients (54%), distal coronary embolization in 9 (18%), and abrupt reclosure in 14 (28%). Urokinase was infused in a mean (+/- standard deviation) dosage of 399,000 +/- 194,000 IU (range 150,000 to 1,000,000) at an average rate of 5,000 to 20,000 IU/min. Angiographic success was achieved in 43 patients (86%). Complications included the need for urgent bypass surgery in 3 patients, Q-wave myocardial infarction in 2, and non-Q-wave myocardial infarction in 12 (8 of whom had peak creatine kinase less than twice the upper normal limit). The incidence of myocardial infarction was significantly higher in patients with vein grafts (69%) than in those with PTCA of native vessels (14%). Two patients died (1 massive gastrointestinal necrosis 24 hours after angioplasty, and 1 after urgent bypass surgery). Mean (+/- standard deviation) fibrinogen levels were 355 +/- 73 mg/dl before urokinase infusion, and 361 +/- 70, twelve hours afterward. Three patients had local bleeding, but no transfusions were needed. It is concluded that intracoronary urokinase is a safe and effective adjunct to PTCA in patients with associated thrombi and may improve the success rate in angioplasty complicated by thrombus formation.     

Percutaneous transluminal coronary angioplasty in the setting of large intracoronary thrombi

A cohort of 112 consecutive patients with angiographically defined intracoronary thrombi was treated with percutaneous transluminal coronary angioplasty and followed prospectively to determine early and late outcomes. Coronary angioplasty using a treatment modality of intravenous and intracoronary heparin, antiplatelet agents and prolonged inflations with oversized balloons (balloon:vessel ratio, 1.2:1) resulted in clinical success in 103 patients (92%) at hospital discharge. No periprocedural thrombolytic therapy was used and prolonged pretreatment with heparin was not routinely used. Four patients (3.5%) required elective coronary bypass surgery, and 4 patients (3.5%) required emergency coronary artery bypass grafting because of abrupt closure. Late clinical follow-up (mean 7 months) was available in 99 of the 103 successfully treated patients (96%). Seventy-three percent of patients were asymptomatic at follow-up, and 27% had class I or II angina. No patients had a late myocardial infarction. Elective coronary artery bypass surgery was required in 3 patients (3%) and repeat coronary angioplasty in 17 patients (17%). There were 2 late cardiac deaths at 7 months. Ninety-four patients (95%) had an event free follow-up defined as absence of coronary artery bypass surgery, myocardial infarction or death. In conclusion, coronary angioplasty alone, using intracoronary heparin and prolonged balloon inflations with relatively oversized balloons may be helpful to achieve a high initial success rate, low incidence of in-hospital complications and excellent long-term results in patients with intracoronary thrombus.     

Clinical outcome 5 years after attempted percutaneous transluminal coronary angioplasty in 427 patients

This study was performed to define the 5 year clinical status of 427 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) in 1981. Their mean age was 54 +/- 10 years (+/- 1 SD). Sixty-one percent had unstable angina, 23% had prior myocardial infarction, 86% had one-vessel disease, and 92% had normal left ventricular function. Sixty-seven percent of patients had left anterior descending artery stenosis. Angiographic success was achieved in 84% of patients. Coronary bypass surgery was required in 9.6% of patients, in 5.9% as an emergency procedure. There were no in-hospital deaths. Follow-up at 5 years was 100% complete. There were 15 late deaths (96.3 +/- 1.0% survival), including seven of cardiac cause (98.1 +/- 0.7% cardiac survival). Myocardial infarction occurred in 24 patients (94% freedom from myocardial infarction), coronary bypass surgery was required in 63 (84% freedom from bypass surgery), and 365 patients (85%) were asymptomatic at follow-up. At 5 years, 83 patients (20%) had required an additional PTCA. Unstable angina pectoris and proximal left anterior descending coronary artery stenoses were present in 162 patients. The overall survival and cardiac survival in this subset was 94.4 +/- 1.8% and 98.1 +/- 1.1%, respectively. The excellent survival and low event rates over 5 years in this population support the concept that PTCA is safe and effective for patients with symptomatic angina pectoris, single-vessel disease, and normal left ventricular function.     

Immediate and short-term results of a 1988-1989 coronary angioplasty registry

To determine the relevance of recent refinements in angioplasty technology to our particular practice, the records of 507 consecutive patients undergoing a first percutaneous transluminal coronary angioplasty (PTCA) at our center between October 1988 and May 1989 were reviewed. At the time of PTCA, 41% of these patients had class IV angina and 44% were identified as having multivessel disease. Dilatation was attempted in 734 lesions (mean 1.5 per patient), of which 95 (13%) were chronic total occlusions. Overall, 69% of the 734 lesions were judged anatomically complex, and, in dilating these lesions, a rail-type device was used almost exclusively. Successful dilatation was achieved in 659 of the 734 (90%) attempted lesions. There were low incidences of the major complications of death (0.4%), myocardial infarction (1.8%) and emergency bypass surgery (1.8%). Acute rethrombosis occurred in 54 patients (11%). In these patients, initial strategy of repeat dilatation was successful in 38 of 47 patients (81%). Overall, primary clinical success at PTCA was achieved in 480 patients (95%). At a mean follow-up of 7.5 +/- 1.5 months in 497 of the study patients, the event-free rate (freedom from cardiac death, myocardial infarction, repeat PTCA or coronary bypass surgery or recurrence of severe [class III to IV] angina) was 71%. In conclusion, despite the often complex coronary disease in patients currently presenting to our center, a high initial success rate and acceptable short-term outcome of PTCA was achieved.     

Initial and long-term results of coronary angioplasty and coronary bypass surgery in patients of 75 or older.

OBJECTIVE--To evaluate clinical outcome after percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients of 75 or older who underwent either procedure between 1980 and 1987. SUBJECTS--93 patients aged 75-89 with angina pectoris class III-IV (Canadian Cardiovascular Society) who underwent PTCA and 81 patients aged 75-84 with angina class III-IV who underwent CABG. Follow up was 8.2 years in the PTCA group and 8.3 years in the CABG group. MAIN OUTCOME MEASURES--In-hospital complications and survival at follow up. RESULTS--Primary success rate for PTCA was 84% (78/93). Two patients died, two had emergency CABG, three had a myocardial infarction, and one had a cerebrovascular accident. PTCA failed in seven patients (five underwent elective CABG and two were treated conservatively). Median hospital stay was 4.3 days. Primary success rate for CABG was 63% (53/81). Six patients died, two had a cerebrovascular accident, eight had a myocardial infarction, 10 had a rethoracotomy, and four the adult respiratory distress syndrome. Median hospital stay was 14.2 days. In the PTCA group during follow up eight patients died, three had a non-fatal myocardial infarction, two had elective CABG, 10 had repeat PTCA, and four had recurrence of angina. Sixty four patients were free of angina (69%). In the CABG group during follow up eight patients died, one had a non-fatal myocardial infarction, six had PTCA, and three had recurrence of angina. Fifty seven patients were free of angina AP (70%). Actuarial survival after 10 years was 92% for PTCA and 91% for CABG. CONCLUSIONS--PTCA is safe in elderly patients. The complication rate is lower and hospital stay significantly shorter compared with CABG (p < 0.05). Long-term follow up showed no significant difference between PTCA and CABG.     

Percutaneous transluminal coronary angioplasty in unstable and stable angina pectoris: a comparison of immediate success and complications.

To determine the success rate and the safety of percutaneous transluminal coronary angioplasty in patients with unstable angina pectoris (group 1) versus stable angina (group 2), we studied 299 consecutive patients who underwent coronary angioplasty of 373 consecutive lesions. Of these patients, 149 had unstable angina pectoris and dilation of 188 arteries. The success rate was high and similar in both groups (95 and 93%, respectively). The groups did not differ in regard to the lesion characteristics, vessels and number of sites dilated except for an increase in the presence of thrombus in the unstable angina group (p < 0.03). Although there was a higher incidence of coronary thrombus and more acute myocardial infarction in group 1, the major complication rate did not differ from that of group 2 and was low in both of them (3 and 2%, respectively). No deaths occurred. Six patients (3 in each group) needed urgent coronary artery bypass grafting while 3 additional patients developed acute Q-wave myocardial infarction (all of them in group 1). Thus, percutaneous transluminal coronary angioplasty is a safe and successful procedure in patients with unstable angina as well as in patients with stable angina pectoris.     

Percutaneous transluminal angioplasty of saphenous vein graft stenosis: long-term follow-up

Percutaneous transluminal angioplasty was used to treat 101 patients with saphenous vein bypass graft stenosis at a mean of 50.1 months (range 2 to 196) after coronary artery bypass surgery. The patients presented between March 1981 and April 1987. A total of 107 saphenous vein grafts were dilated at 117 sites. The primary success rate was 91.8%. The incidence of cardiac complications was 7.1%. There were no cardiac complications in 53 patients with grafts implanted less than 36 months before angioplasty (Group 1). The 48 patients with grafts implanted for greater than 36 months (Group 2) had a 12.5% incidence rate of myocardial infarction, a 4% incidence rate of emergent bypass surgery and a 4% incidence rate of death for an overall cardiac complication rate of 14.9% (p less than 0.01). Follow-up was obtained at a mean of 16.8 +/- 13.9 months (range 1 to 54) in 87 patients (97% of successful cases). Repeat coronary angiography was performed in 49 patients and revealed restenosis in 30 patients (61.2%), with no difference in recurrence rates for proximal, mid or distal graft sites. Clinical recurrence (defined as recurrence of symptoms, myocardial infarction, repeat angioplasty, surgery or death) was 33.1% for Group 1 patients and 64.1% for Group 2 patients (p less than 0.01). The complication and recurrence rates of saphenous vein graft angiography are significantly higher when performed for late (greater than 36 months) vein graft failure. All therapeutic options should be carefully examined before proceeding with angioplasty for saphenous vein graft stenosis in this type of patient.     

Contraindications for percutaneous transluminal coronary angioplasty in treatment of unstable angina pectoris

In recent years, the indications for percutaneous transluminal coronary angioplasty have expanded to include multivessel disease, unstable angina pectoris, stenosis of coronary bypass grafts, and recent total coronary occlusion. To evaluate our experience in using percutaneous transluminal coronary angioplasty to treat unstable angina, we reviewed the records of the patients who underwent this procedure at our hospital between January 1983 and December 1986. Of the 689 patients who underwent balloon angioplasty during the study period, 454 had stable angina and 235 had unstable angina; of the latter group, 34 (14.5%) required emergency coronary artery bypass grafting after balloon angioplasty failed. This outcome was associated with 2 risk factors: previous myocardial infarction and triple-vessel disease. Our data suggest that, in cases of unstable angina pectoris, percutaneous transluminal coronary angioplasty should be reserved for patients with single-vessel disease and no evidence of previous myocardial infarction. They also lend credence to the conclusion that the disease process in unstable angina is different from that in stable angina, and that therapy should be directed towards reducing platelet aggregation and correcting global ischemia, rather than towards balloon angioplasty of "culprit lesions."     

Transluminal angioplasty of the coronary vessels in patients with pluritruncular unstable angina

Between October, 1979 and August, 1987, 489 patients with multivessel coronary disease and unstable angina underwent transluminal angioplasty of coronary arteries with the following results: primary success in 90 p. 100 of the patients, emergency bypass surgery of occlusive dissection in 1.8 p. 100, myocardial infarction in 2.9 p. 100, death in 1.4 p. 100. These results were similar to those obtained in 369 patients with stable angina whose coronary vessels were dilated by the same group during the same period. The death rate was significantly higher in elderly people and in women. 398/489 patients were followed up for 2 to 45 months: 1.8 p. 100 died, 2 p. 100 developed myocardial infarction and 2.3 p. 100 underwent coronary bypass. 46 patients had repeat angioplasty for restenosis. After single or repeat angioplasty, 68 p. 100 of the primary success patients followed up were asymptomatic, and 73 p. 100 had lasting clinical improvement. Among 221 patients studied with different numbers of vessels treated, the degree of revascularization did not make any significant difference in the percentage of symptom-free patients. Data from the literature concerning the medical treatment of unstable angina indicate a high incidence of complications and a mediocre long-term functional benefit, while data concerning surgical treatment show a better long-term functional result. Compared with these two types of treatment, transluminal coronary angioplasty appears as a satisfactory method to treat unstable angina in patients with multivessel coronary disease.     

Repeat coronary angioplasty as treatment for restenosis.

Repeat coronary angioplasty has become the standard approach to a first restenosis. However, the long-term outcome of such a strategy is not well defined. In the present study, 465 patients (mean age 58 years [range 27 to 79], 53% with multivessel disease) underwent a second angioplasty procedure at the same site. The procedure was successful in 96.8% with a 1.5% rate of in-hospital bypass surgery, a 0.9% incidence rate of myocardial infarction and no procedural deaths. Four hundred sixty-three patients (99.6%) were followed up for a mean of 40.5 months. Forty-nine patients (10.6%) underwent a third angioplasty procedure at the same site, 55 (11.8%) had coronary bypass surgery and 33 (7.1%) underwent angioplasty at a different site. During follow-up, 12 patients (2.6%) sustained a myocardial infarction and 21 (4.5%) died including 13 (2.8%) with cardiac death. Of the 442 surviving patients, 88% experienced sustained functional improvement and 78% were free of angina. The actuarial 5-year cardiac survival rate was 96% and the rate of freedom from cardiac death and myocardial infarction was 92%. For the subgroup of 49 patients who had a third angioplasty procedure at the same site, the success rate was 93.9% with a 2% incidence rate of myocardial infarction. There were no in-hospital deaths or coronary artery bypass operations. The mean follow-up interval for this subgroup was 30.5 months with a 22.4% cross-over rate to coronary bypass surgery, a 4.1% incidence rate of myocardial infarction and a 2% cardiac mortality rate. At last follow-up, 89% of patients had sustained functional improvement and 76% were free of angina. The combined angiographic and clinical restenosis rate was 48%. Repeat angioplasty as treatment for restenosis is an effective approach associated with a high success rate, low incidence of procedural complications, and sustained functional improvement in combination with an acceptable rate of bypass surgery. However, there is a trend toward diminished angioplasty efficacy after a second restenosis. Thus, decisions for further revascularization should be made after careful review of available options.