Early alteration of coronary hemodynamics in late restenosis after coronary angioplasty

It is not known whether changes in coronary hemodynamics may antedate the development of restenosis after percutaneous coronary transluminal angioplasty (PTCA). The purpose of this study was to evaluate the early change in coronary microvascular function in patients with late restenosis after PTCA. Coronary hemodynamics were studied in series before, immediately after, 2 weeks and 3 months after successful PTCA in 12 male patients with a single lesion of the left anterior descending coronary artery. In each patient, great cardiac venous flow (GCVF) and oxygen content were measured both at baseline and during hyperemia induced by adenosine infusion. The sequential changes of coronary hemodynamics were compared between patients with and without restenosis at 3 months after PTCA. Basic characteristics did not differ between the patients with (n = 6) and those without restenosis (n = 6). Luminal diameter stenosis (in percentage) was also similar between the two groups both before (79.2 +/- 18.4% vs 83.0 +/- 9.6%, p = NS) and up to 2 weeks after PTCA (25.8 +/- 10.9% vs 28.5 +/- 7.9%, p = NS). In patients without restenosis, basal and hyperemic GCVF was unchanged up to 2 weeks after PTCA. There was a significant increase in CFR 3 months after PTCA. In patients with restenosis, basal GCVF was significantly increased and hyperemic GCVF was unchanged immediately after PTCA. However, 2 weeks after PTCA, basal GCVF was decreased while luminal diameter was still preserved. In comparison with those without restenosis, patients with restenosis had significantly lower CFR before (1.98 +/- 0.42 vs 2.69 +/- 0.46, p = 0.019), immediately after (1.47 +/- 0.27 vs 2.24 +/- 0.47, p = 0.006) and 3 months after PTCA (1.51 +/- 0.32 vs 3.40 +/- 0.54, p = 0.001). In patients without restenosis, the recovery of coronary microvascular function was delayed up to 3 months after PTCA. In patients with late restenosis, basal coronary microvascular tone was altered within 2 weeks after PTCA suggesting early deterioration of coronary microvascular function before the development of angiographic restenosis.     

Limited role of coronary angioplasty and stenting in coronary spastic angina with organic stenosis

OBJECTIVES: We investigated the efficacy of percutaneous coronary intervention (PCI) in patients with coronary spastic angina (CSA) and severe organic stenosis. BACKGROUND: Coronary spasm occurs at the site of organic stenosis in most patients with CSA and severe stenosis, whereas multivessel spasm occurs frequently in those with normal coronary arteries. The incidence of multivessel spasm and the efficacy of PCI in patients with CSA and severe stenosis have not been fully elucidated. METHODS: Forty-five patients with CSA and severe stenosis underwent spasm provocative testing with intracoronary acetylcholine before and 7 +/- 3 months after PCI (20 patients had angioplasty and 25 patients had stenting), when all patients were free of restenosis. RESULTS: Spasm was induced at the site of severe stenosis in 30 patients (66.7%) with (n = 12) or without (n = 18) spasm induced in another vessel. In the remaining 15 patients, spasm was induced at a different site in the stenotic vessel and/or in another vessel. Repeat provocative tests were performed in 43 of 45 patients. Although spasm was never induced at exactly the same site of the initial stenosis that had been dilated, spasm was induced at a different site in the dilated vessel and/or in another vessel, in 33 (76.7%) of 43 patients. Multivessel spasm occurred in 28 (62.2%) of 45 patients on one or both provocations. CONCLUSIONS: Spasm was frequently induced at a site different from the initial stenosis, even in the absence of restenosis after PCI. Calcium antagonists should be continued in most patients with CSA who show no restenosis after PCI.     

Percutaneous transluminal coronary angioplasty of the left coronary artery in patients with chronic occlusion of the right coronary artery: clinical and functional results.

The safety and therapeutic benefits of percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery, the left circumflex coronary artery or both were assessed in 61 patients with chronic (greater than 3 months) occlusion of the right coronary artery. Recanalization of the right coronary artery was not performed before dilatation of left coronary artery lesions. All lesions could be dilated without an acute ischemic event in the catheterization laboratory. However, three patients underwent coronary artery bypass surgery within the first 8 days after coronary angioplasty. There were no in-hospital deaths. Of the remaining 58 patients, 51 (88%) had repeat angiography at a mean of 5.2 +/- 2.5 months. Patients were divided into two groups according to the presence (n = 17) or absence (n = 34) of restenosis defined as greater than or equal to 50% diameter stenosis at the dilated site. Baseline characteristics were comparable. The mean value for angina functional class at follow-up was significantly better in the group without than in the group with restenosis (0.4 +/- 0.6 vs 2.1 +/- 1.1, respectively; p less than 0.001). Sixty-five percent of the patients without restenosis were asymptomatic at follow-up. Seventy-five percent of the predicted maximal physical capacity was reached by 76% of the patients without restenosis compared with 33% in the group with restenosis (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous transluminal coronary angioplasty after non-Q-wave acute myocardial infarction

The value of percutaneous transluminal coronary angioplasty (PTCA) for ischemia after a non-Q-wave acute myocardial infarction (AMI) was assessed prospectively in 33 consecutive patients. In 30 patients the indication for the procedure was post-AMI angina and 3 patients underwent PTCA for silent ischemia. A total of 43 lesions were attempted at 63 +/- 94 days after the non-Q-wave AMI. Primary PTCA success was obtained in 30 (91%) patients and no major complications occurred. Angiographic evaluation was performed either for symptoms or for protocol (7 +/- 1 months after PTCA) in 28 (93%) of the 30 patients with successful PTCA, but 2 patients (7%) who were asymptomatic refused the repeat angiogram. Twenty (71%) had no restenosis and 8 (29%) had restenosis. Of these, 5 patients with restenosis underwent a successful repeat PTCA (6 +/- 1 months after the initial procedure). At the last clinical follow-up (17 +/- 8 months), 2 of the 30 (7%) patients successfully dilated presented with stable angina despite medical treatment, whereas the rest (93%) remained asymptomatic. During the study period no patient died, had an AMI or required coronary artery bypass grafting. Thus, selected patients with ischemia after a non-Q-wave AMI, a "high-risk population," can be effectively treated with PTCA with an initial success rate and angiographic restenosis rate similar to that of the general PTCA population and appear to have sustained symptomatic benefit remaining free of subsequent cardiac events.     

Coronary vasospastic activity at sites of percutaneous transluminal coronary angioplasty: evaluation using intracoronary acetylcholine administration]

To investigate coronary vasospastic activity after percutaneous transluminal coronary angioplasty (PTCA), we performed intracoronary injection of acetylcholine in 55 patients, mean 3.3 months after successful PTCA. Coronary spasm was defined as transient total or subtotal occlusion of the PTCA sites. Sixty-nine lesions of the 55 patients were examined to determine whether spasm was provoked by incremental doses of acetylcholine. Restenosis was defined as coronary luminal narrowing of > or = 50% after nitroglycerin or isosorbide dinitrate. Twenty of the 55 patients (36%) and 23 of the 69 lesions (33%) had coronary spasm. There was no correlation between the incidence of coronary spasm and the interval from PTCA to the acetylcholine test. The spasm was provoked in 17 lesions of the 50 non-restenotic lesions (34%) and was also provoked in 6 of the 19 restenotic lesions (32%). On the other hand, restenoses occurred in 6 of the 23 spastic lesions (26%) and in 13 of the 43 non-spastic lesions (28%). There was no correlation between the incidence of coronary spasm and the occurrence of restenoses. Twenty-four patients had undergone acetylcholine provocative test before PTCA. Among these 24 patients, 11 had coronary spasm before PTCA, and 7 had coronary spasticity after PTCA. Four patients who had positive evidence of coronary spasm before PTCA did not show negative spasm after PTCA. On the other hand, 3 patients who did not show evidence of coronary spasm showed positive evidence of coronary spasm after PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of lovastatin on progression of non-dilated and dilated coronary segments and on restenosis in patients after PTCA. The cholesterol lowering atherosclerosis PTCA trial (CLAPT)

OBJECTIVES: The Cholesterol Lowering Atherosclerosis PTCA Trial (CLAPT) is a prospective, randomized trial with blinded angiographic end-points to assess the effect of 2-year's treatment with lovastatin initiated 4 weeks prior to PTCA, compared to usual care on non-dilated coronary segments and on dilated coronary lesions in male patients with total cholesterol between 200 and 300 mg. dl(-1)who underwent elective PTCA. METHODS and RESULTS: Two hundred and twenty six patients were randomized 4 weeks prior to PTCA to special care (diet plus lovastatin n=112) or usual care (diet; n=114). One hundred and ninety-nine patients underwent PTCA at baseline and were finally included in the study. Quantitative coronary angiographic assessment was performed on blinded cinefilms at baseline (PTCA) and repeated after 4 and 24 months in 91% and 81% of the patients. The primary end-point was a change in the mean segment diameter of non-dilated segments. The mean lovastatin dose was 33 mg. day(-1). Total- and LDL-cholesterol decreased by 21% and 29% in the special care group and by 7% and 11% in the usual care patients.After 2 years, the mean segment diameter of non-dilated segments decreased by 0.03 mm in the usual care group and 0.004 mm in the special care group (P=0.27). The decrease in the mean segment diameter of dilated lesions was 0.17 mm (usual care) and 0.06 mm (special care) (P=0.04) after 4 months; 0.16 mm (usual care) and 0. 002 mm (special care) after 24 months, respectively (P=0.05). In both groups, the mean segment diameter of dilated lesions increased between 4 and 24 months after PTCA compared to a decrease in mean segment diameter of non-dilated segments (P<0.05). Restenosis (>50% diameter stenosis at follow-up) occurred in 28.4% of usual care and 22.2% of special care patients (P=0.17).CONCLUSIONS: Lovastatin reduced the progression of dilated lesions in men with elective PTCA. Independent of treatment allocation, the dilated lesions regressed and the non-dilated segments progressed during the study follow-up. Four weeks of pre-treatment with lovastatin did not influence the rate of restenosis. Lovastatin had no statistically significant effect on non-dilated segments.     

Increased plasma antigen levels of monocyte chemoattractant protein-1 in patients with restenosis after percutaneous transluminal coronary angioplasty

Monocyte chemoattractant protein-1 (MCP-1) plays an important role in the progression of atherosclerosis in coronary arteries. To examine whether or not plasma antigen levels of MCP-1 are related to restenosis after percutaneous transluminal coronary angioplasty (PTCA), the plasma antigen levels of MCP-1 were measured by enzyme-linked immunosorbent assay (pg/ml) before, 24 and 48 h, and 3 months after elective PTCA for stable exertional angina performed between June 1997 and March 1998. Restenosis was defined as recurrence of stenosis greater than 50% of the diameter in the dilated segment at 3-month follow-up angiography. There were no differences in plasma MCP-1 antigen levels before and at 24 h after PTCA between restenosis (R; n=27) and no-restenosis (N; n=43) groups (R vs N: 633+/-35 vs 589+/-34, and 669+/-41 vs 575+/-36 pg/ml before and at 24 h after PTCA, respectively), but plasma MCP-1 antigen levels were higher at 48 h and 3 months after PTCA in the R than in N group (R vs N: 678+/-41 vs 558+/-35, and 735+/-35 vs 571+/-32 pg/ml at 48 h and 3 months after PTCA, respectively). These data suggest that the MCP-1 production and macrophage accumulation in the balloon-injured site is partially associated with restenosis after PTCA.     

Increased frequency of restenosis in patients continuing to smoke cigarettes after percutaneous transluminal coronary angioplasty

The influence of continued cigarette smoking on restenosis after percutaneous transluminal coronary angioplasty (PTCA) was retrospectively determined through a study of 160 patients with primary success who underwent follow-up angiography after a mean of 7 +/- 7 months. The average number of narrowings at risk for restenosis was 1.7/patient in the 84 patients who continued to smoke (group 1) and 1.9/patient in the 76 patients who stopped smoking at the time of PTCA (group 2) (difference not significant). The 2 patient groups at baseline were similar with respect to gender, frequency of diabetes mellitus, number of pack/year smoking, angina class and number of diseased coronary arteries. The location of the dilated narrowings, the residual luminal diameter stenosis and the transstenotic gradient after the procedure were similar in both groups. The recurrence of angina greater than or equal to class II was the reason for restudy in 43% and 36% of group 1 and group 2 patients, respectively. Restenosis, defined as the presence of greater than or equal to 50% narrowing at the site of previous successful dilatation at follow-up angiography, was significantly higher in group 1 compared with group 2 patients (55% vs 38%, p = 0.03). Continued smoking was selected as an independent predictor of restenosis by logistic regression analysis. The incidence of coronary artery disease progression (14% vs 10%) was not significantly different between the 2 groups. In conclusion, continued smoking after successful PTCA is associated with an increased risk of restenosis. The higher restenosis rate in smokers emphasizes the need to strengthen educational programs after PTCA.     

QT interval dispersion as a new marker of restenosis after percutaneous transluminal coronary angioplasty of isolated single-vessel coronary artery stenosis

BACKGROUND: There are no reliable non-invasive markers of restenosis after percutaneous transluminal coronary angioplasty (PTCA). The aim of our study was to measure changes in QT interval dispersion after PTCA and to determine whether restenosis subsequently affects QT interval dispersion. METHODS AND RESULTS: Fifty-six consecutive patients - 41 men and 15 women (mean age: 56.2 +/-8.3 years) - with isolated stenosis of the left anterior descending artery who underwent successful PTCA were studied. A symptom-limited treadmill exercise test was performed within 7 days after PTCA and then again before repeated angiography. Repeated coronary angiography revealed restenosis in 15 patients (26.8%) and no signs of significant stenosis in 41 patients (73.2%). QT interval dispersion in the group of patients with restenosis measured before exercise increased from baseline 34 +/- 7 to 49 +/- 15 ms after 6 months (p < 0.01) and QT interval dispersion measured immediately after exercise increased from baseline 38 +/- 4 to 68 +/- 21 ms after 6 months (p < 0.001). In contrast, patients without restenosis showed no significant changes in QT interval dispersion measured before (baseline: 34 +/- 9 ms; after 6 months 33 +/- 12 ms; p = NS) and immediately after exercise (baseline: 34 +/- 12 ms; after 6 months: 33 +/- 10; p = NS). When QT interval dispersion > or =60 ms (measured 6 months after PTCA procedure) was considered as a potential marker of restenosis, this indicator had very high sensitivity and specificity when measured immediately after exercise (80 and 95% respectively). CONCLUSIONS: QT interval dispersion significantly increases in the group of patients with documented restenosis and may be a simple, non-invasive marker of restenosis. However, further studies are needed to confirm this observation.     

Angiographic patterns of restenosis after angioplasty of multiple coronary arteries

To assess angiographic patterns of restenosis after percutaneous transluminal coronary angioplasty (PTCA) of multiple coronary arteries, angiograms were reviewed in 40 patients with clinical recurrence after PTCA of multiple arteries. Clinical recurrence was defined as return of symptoms after successful PTCA of more than 1 major artery or branch and angiographic evidence of restenosis of 1 or more lesions. In these 40 patients, 83 arteries (2.1 arteries per patient) and 103 narrowings (2.6 narrowings per patient) were successfully dilated. Restenosis developed in 57 of 83 arteries at risk (69%): 23 patients (58%) had restenosis in only 1 artery and 17 (42%) in 2 arteries. Restenosis occurred in 63 of 103 lesions at risk (61%): 20 patients (50%) had restenosis of 1 narrowing, 17 (43%) had restenosis of 2 narrowings and 3 (7%) had recurrence of 3 narrowings. Only 13 patients (33%) had restenosis of all narrowings dilated. Predictors of restenosis of individual narrowings were: higher pre-PTCA percent stenosis (87 +/- 10% in narrowings with restenosis vs 82 +/- 10% in narrowings without, p less than 0.02), and higher degree of residual stenosis after PTCA (46 +/- 13% in narrowings with restenosis vs 36 +/- 12% in narrowings without, p less than 0.001). Balloon size or inflation pressure did not predict recurrence of narrowings. Repeat PTCA was successful in 97% of cases attempted (33 of 34), 3 patients underwent elective bypass surgery and 3 were managed with medical therapy. Most patients with clinical recurrence after PTCA of multiple arteries do not have restenosis of multiple arteries or narrowings, and only one-third will have recurrence of all narrowings.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Frankfurt experience in restenosis after coronary angioplasty

Three hundred and thirty-three of 356 patients underwent angiographic follow-up from 1 to 18 months (mean 5.6 months) after percutaneous transluminal coronary angioplasty (PTCA). This is a reangiography rate of 94%. Recurrence rate after the first PTCA was 15% (n = 289). Restenosis rate was defined as an increase from immediate post-PTCA stenosis of more than 30%, or the loss of at least half of the initial gain in luminal diameter. Patients who needed a second angioplasty due to restenosis (n = 30) had a restenosis rate of 33%. Patients with angioplasty in the aortocoronary bypass (n = 14) had a restenosis rate of 45%. All patients were treated before, during and at least 4 to 6 months after the procedure with 60 to 100 mg of isosorbide dinitrate daily plus 160 to 360 mg of verapamil or 100 to 150 mg of gallopamil and 1.5 g of acetylsalicylic acid. In a second retrospective study 111 of 399 patients had the acetylsalicylic acid therapy discontinued or decreased. Forty-two of them developed restenosis (38%), whereas only 49 of 288 patients who continued to receive 1.5 g aspirin developed restenosis (17%). The restenosis rate was 32% in those who received the reduced dose of aspirin. Thus, a large dose of acetylsalicylic acid given before, during and 4 to 6 months after the procedure seems to be necessary to achieve a low rate of restenosis after PTCA.     

Prior restenosis predicts restenosis after coronary angioplasty of a new significant narrowing

To determine the influence of a history of restenosis on subsequent restenosis after percutaneous transluminal coronary angioplasty (PTCA) of a new significant narrowing, the records of 100 patients who underwent successful PTCA at another site ("new narrowing PTCA") greater than or equal to 2 months after successful initial PTCA were retrospectively reviewed. Patients were grouped according to whether initial PTCA resulted in restenosis, which was determined by angiographic follow-up greater than or equal to 3 months after initial PTCA. Patients in group 1 did not have restenosis after initial PTCA (n = 50), whereas patients in group 2 did (n = 40). All patients were followed for recurrent symptoms, with serial exercise tests, for greater than or equal to 6 months after new narrowing PTCA. Clinically suspected and angiographically confirmed restenosis occurred in 11 of 50 (22%) patients and 12 of 63 (19%) narrowings in group 1, and in 20 of 40 (50%) patients and 22 of 48 (46%) narrowings in group 2 (p less than 0.01 for patients, p less than 0.002 for narrowings). Multivariate analysis identified that prior restenosis (p less than 0.02, odds ratio 3.4), left anterior descending artery location of stenosis (p less than 0.04, odds ratio 3.0), and severity of stenosis before PTCA (p less than 0.02, odds ratio 1.8) were independently associated with restenosis after new narrowing PTCA. In conclusion, prior restenosis is an independent risk factor for subsequent restenosis after new narrowing PTCA.     

Repeat coronary angioplasty for restenosis: results and predictors of follow-up clinical events

To determine the predictors of long-term outcome after repeat percutaneous transluminal coronary angioplasty (PTCA), we analyzed the immediate and follow-up results of 144 patients who underwent a second PTCA procedure for restenosis of a previously successfully dilated lesion. Clinical success was obtained in 94% of patients. Emergency coronary bypass graft surgery was required in two patients (1%). Of the 136 successfully treated patients, 126 were followed for a duration of 6 to 36 months (mean 16, median 12 months). The follow-up coronary events (mutually exclusive) included cardiac death (2%), nonfatal myocardial infarction (2%), coronary bypass surgery (15%), and third PTCA (9%). According to results of Cox regression analysis, the independent variables associated with an increased risk of recurrent coronary events after repeat PTCA were: dilatation of a proximal left anterior descending artery stenosis at both initial and second PTCA (p = 0.001), time interval between the initial and the second PTCA less than or equal to 3 months (p = 0.001), multiple versus single-lesion redilatation at the time of repeat PTCA (p = 0.002), and the presence of diabetes mellitus (p = 0.005). Thus repeat PTCA for restenosis is a safe and efficacious procedure, and it provides excellent long-term outcome in the majority of patients. Dilatation of a proximal left anterior descending artery lesion, a short time interval between the first and second PTCA procedures, diabetes mellitus, and redilatation of multiple lesions are predictors of recurrent clinical events after a second PTCA. Repeat PTCA should be considered carefully for patients falling within a high-risk profile for recurrent events after the procedure.     

Percutaneous transluminal coronary angioplasty in patients with spasm superimposed on atherosclerotic narrowing

Of 552 patients undergoing percutaneous transluminal coronary angioplasty 102 had coronary artery spasm superimposed on atherosclerotic narrowing. Coronary angioplasty was successful in 97 (95%). The patients were discharged on a regimen of nifedipine (40-60 mg/day). Seventy six patients were symptom free 6-8 months after the procedure. Restenosis was detected in 35% of patients. Coronary artery spasm was provoked in 38 (44%) of the 87 patients who underwent an ergometrine maleate test. Twenty seven of the 34 patients with restenosis had a provocation test and coronary artery spasm was superimposed on restenosis in 22 (81.5%). Coronary angioplasty is feasible in patients with coronary artery spasm superimposed on atherosclerotic narrowing but the rate of restenosis is high and coronary artery spasm could have a role in the pathogenesis of restenosis.     

Angiographic findings when chest pain recurs after successful percutaneous transluminal coronary angioplasty

Angiographic and clinical characteristics of 102 consecutive patients who underwent coronary cineangiography for assessment of recurrent angina pectoris after successful percutaneous transluminal coronary angioplasty (PTCA) were reviewed. Based on angiographic findings, patients were classified as having restenosis (n = 63), development of new, significant coronary stenosis (n = 15), incomplete revascularization (n = 9) or no significant coronary artery disease (n = 15). Eighteen clinical and technical characteristics of the study group were analyzed as predictors of angiographic outcome. The groups did not differ in terms of age, gender, number of inflations performed, peak inflation pressure or in the pre- or post-PTCA stenosis or gradient. The time from PTCA to onset of recurrent angina was the most powerful predictor of angiographic outcome. Patients in whom symptoms developed within 1 month of PTCA usually had incomplete revascularization or no coronary narrowing. Restenosis was the most common explanation for chest pain 1 to 6 months after PTCA. Angina recurring more than 6 months after PTCA was usually due to development of new, significant coronary artery narrowings.     

Percutaneous transluminal coronary angioplasty in patients with spasm superimposed on atherosclerotic narrowing.

Of 552 patients undergoing percutaneous transluminal coronary angioplasty 102 had coronary artery spasm superimposed on atherosclerotic narrowing. Coronary angioplasty was successful in 97 (95%). The patients were discharged on a regimen of nifedipine (40-60 mg/day). Seventy six patients were symptom free 6-8 months after the procedure. Restenosis was detected in 35% of patients. Coronary artery spasm was provoked in 38 (44%) of the 87 patients who underwent an ergometrine maleate test. Twenty seven of the 34 patients with restenosis had a provocation test and coronary artery spasm was superimposed on restenosis in 22 (81.5%). Coronary angioplasty is feasible in patients with coronary artery spasm superimposed on atherosclerotic narrowing but the rate of restenosis is high and coronary artery spasm could have a role in the pathogenesis of restenosis.     

Role of percutaneous transluminal coronary angioplasty in patients with variant angina and coexistent coronary stenosis refractory to maximal medical therapy

Percutaneous transluminal coronary angioplasty (PTCA) was performed with initial success in 7 patients with variant angina and significant (greater than 60%) coronary stenosis. The mean degree of stenosis was reduced from 77 +/- 12% to 29 +/- 15% and the mean systolic pressure gradient from 78 +/- 18 to 25 +/- 9 mmHg. Apart from a reversible spasm in one patient, PTCA was free of acute complications. Despite long-term treatment with nifedipine, nitrates, and warfarin (patients 1 to 5) or aspirin (patients 6 and 7) restenoses occurred in 4 of 7 patients. An aortocoronary bypass was necessary in 2 patients, 3 respectively 6 weeks after PTCA because of tighter restenoses than before PTCA. Another patient underwent successful repeat angioplasty after 6 weeks and remained improved. During a mean follow-up observation of 21 months (6 to 30 months), 4 patients were asymptomatic, even without medication. In one of these patients, the follow-up angiography (6 months after PTCA) demonstrated a restenosis. These results suggest that PTCA demonstrated a restenosis. These results suggest that PTCA can be performed without a higher risk of acute complications in patients with variant angina. Although the recurrence rate is high in these patients, sustained clinical improvement was achieved in a substantial percentage of patients in our study.     

Influence of continued smoking and some biological risk factors on restenosis after percutaneous transluminal coronary angioplasty

Objectives. To identify possible biological risk factors for restenosis following successful percutaneous transluminal coronary angioplasty (PTCA) in patients having single or multivessel disease. The effect of continued smoking on restenosis was also evaluated.
Design. In this prospective smoking controlled study all subjects had a routine angiographic restudy after 6 months. The biological risk factors assessed before angioplasty were adrenaline, endothelin, fibrinogen, lipoprotein (a) and tissue plasminogen activator.
Subjects. The study population consisted of 122 patients of whom 25% were current smokers.
Main outcome measures. Angiographic restenosis was defined as at least 50% diameter stenosis on the follow-up angiogram after an initially successful procedure.
Results. Restenosis was observed in 43% of patients. The restenosis rate was significantly lower among current smokers, but they were significantly younger and also had significantly less dilated stenoses. Multivariate analysis revealed the number of dilated stenoses, the mean inflation time, post-PTCA percentage diameter stenosis and left anterior descending coronary artery to be predictive of restenosis, while continued smoking was not. When only the lesion with the greatest loss in luminal diameter of each patient was considered, the multiple linear regression analysis revealed high endothelin level to be predictive of restenosis.
Conclusions. This study revealed high endothelin levels to be predictive of luminal narrowing after angioplasty. In addition, the number of dilated stenoses, the mean inflation time, post-PTCA percentage diameter stenosis and stenosis location in the left anterior descending artery were found to be predictive of restenosis. However, continued smoking after angioplasty did not emerge as a risk factor for restenosis.     

Restenosis after successful coronary angioplasty in single vessel disease

One hundred and ninety five patients who underwent successful percutaneous transluminal coronary angioplasty (PTCA) for single vessel disease and have been followed up for more than 6 months are being reported. Angiography was done routinely in first 20 patients (Group 1) 8 to 15 weeks (mean 9.6 weeks) after PTCA. Restenosis (loss of 50% of the initial improvement in luminal diameter) was seen in 4 patients (20%). The remaining 175 patients (Group II) have been followed up clinically and subjected to serial exercise testing. Coronary angiography was performed only if symptoms and/or objective evidence of ischemia recurred. In this group, restenosis suspected clinically and confirmed by angiography occurred in 37 patients (21%), 2 to 23 weeks (mean 12.5 weeks) after PTCA. The restenosis rate for the entire patient population was 21%. In general the restenosed lesions were longer and tighter than the lesions before PTCA. A comparison of 41 patients with restenosis with those who did not have clinical restenosis revealed a proximal left anterior descending artery (LAD) involvement (66% vs 31%, p = 0.01), crescendo unstable angina (37% vs 16% p = 0.05), length of pre PTCA stenotic lesion greater than or equal to 1 cm (41% vs 27.5%, p less than 0.05), absence of intimal haziness in immediate post PTCA angiogram (27% vs 16%, p less than 0.05) and residual stenosis greater than or equal to 25%, (34% vs 14% p less than 0.05) in the restenosis group. Repeat PTCA was done in 30 patients with a 96% success rate; 4 patients required coronary artery bypass grafting (CABG). Restenosis after PTCA is a significant problem in our experience.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical and angiographic course after coronary angioplasty. Analysis of predictor factors of restenosis]

In order to know the restenosis rate and its predictive factors and the short-term clinical outcome (6-12 months) after coronary angioplasty (PTCA), we prospectively followed 200 consecutive patients with 231 coronary stenoses successfully dilated (residual stenosis < 50%). Patients have been clinically and angiographically followed 6-9 months after the procedure. Forty-nine clinical, hemodynamic, angiographic and technical variables were analyzed. Restenosis (stenosis > or = 50% in late angiographic control) rate was 51.5%, and 61% of the study population was symptomless. Variables associated with restenosis in the univariate analysis were: pre-PTCA positive exercise test (p = 0.004); stenosis severity pre-PTCA (p = 0.04); eccentricity (p < 0.0001) and irregularity (p < 0.0001) of the pre-PTCA stenosis; total dilation time (p = 0.02) and post-PTCA dissection (p = 0.002). The multivariate analysis revealed the following variables as independent predictors of restenosis: presence of dissection after PTCA, eccentricity and irregularity of pre-PTCA stenosis, positive pre-PTCA stress test and duration of symptoms before the procedure. These data suggest that the probability of restenosis after PTCA is predominantly determined by the characteristics of the lesion being dilated and the degree of intimal injury produced during the procedure. These variables could define high and low risk populations and may modify PTCA indications and follow up strategies.