Angiographic Evolution Research Articles

1000–32 Spontaneous Evolution of Nonocclusive Coronary Dissection After PTCA: A 6 Month Angiographic Follow-up Study

We have previously shown that, when good distal flow is maintained, dissection after PTCA has a favourable short term (24 hrs) evolution and does not require bail-out interventions or CABG. To evaluate the long term (6 months) clinical and angiographic evolution of non occlusive dissection, we submitted 129 consecutive patients (103 male, mean age 53 ± 11 yrs) undergoing elective PTCA (147 lesions, 66 LAD, 49 CX, 32 DX) to repeat angiography 24 hrs and 6 months after the procedure. Lesions were measured by QCA and coronary dissection was graded using the NHLBI classification (types A-E; Huber Am J Cardiol 1991;68: 467). Mean stenosis was 85 ± 11% before and 25 ± 7% immediately after PTCA (p < 0.001). Residual stenosis was not significantly different at the 24 hrs restudy (24 ± 9%). Non occlusive coronary dissection (flow TIMI grade 3 in all pts) was seen in 49/147 lesions (33%) and evolved as follows: Dissection (tot) Immediate 49 (33%) 24 hrs 41 (28%) 6 months 18 (12%) A 33 27 10 B 10 8 5 C 4 4 2 D 2 2 1 At the 6 month follow-up study, restenosis was seen in 51/147 lesions (34%), of which 5/49 (10%) had dissection and 46/106 (43%) did not. No cardiovascular events or recurrence of symptoms were recorded in the absence of restenosis. Therefore 1) nonocclusive dissection after PTCA usually improves after 6 month; 2) in the absence of flow impairment and ischemia this complication does not require any further intervention; 3) non occlusive dissection is not associated with increased incidence of restenosis.

Evolution of coronary stenoses is related to baseline severity—a prospective quantitative angiographic analysis in patients with moderate coronary disease

A correlation of the angiographic evolution of coronary stenoses (stenosis diameter > or = 20%) with morphological stenosis parameters at baseline could help to identify the risk of progressive stenoses. Therefore, the data of the prospective INTACT study (International Nifedipine Trial on Antiatherosclerotic Therapy) were reviewed. In 348 patients with moderate coronary artery disease, standardized coronary angiograms were taken 3 years apart and were quantitatively analysed. Changes in the minimal diameter of the 1063 preexisting coronary stenoses compared between both angiograms were set in relation to a number of conventional stenosis parameters at baseline. Regression analysis demonstrated a significant correlation of the changes in minimal diameter with baseline % diameter stenosis (r = 0.30; P < 0.001), minimal diameter (r = -0.28; P < 0.001) and reference diameter of stenoses (r = -0.14; P < 0.001). The changes were not correlated with stenosis length and plaque area. The baseline parameters of 22 preexisting stenoses progressing to occlusions differed from those remaining patent only with regard to the % diameter stenosis (43 +/- 9% vs 39 +/- 11%; P < 0.05). Additional progression of coronary disease became manifest through development of 228 stenoses and 19 occlusions at arterial sites free from definitive stenoses in the baseline angiograms. Thus, progression of atherosclerosis predominantly occurred in mild preexisting coronary stenoses and developed at previously angiographically normal sites. Since the conventional angiographic parameters analysed in this study failed to identify individual arterial sites with an increased risk for progression, definition of new angiographic parameters or application of new techniques seem mandatory to this end.

Dissecting aneurysms of the vertebrobasilar system: Study of 16 cases

In the last 14 years we have encountered 16 patients with spontaneous intracranial dissections of the vertebrobasilar (VB) system (mean age was 46 years and male/female ratio was 10/6). VB dissections presented in eight cases with subarachnoid bleeding and in eight with brainstem, cerebellar, or cerebral ischemia. Three patients had multiple dissections. Ten dissections occurred in the vertebral artery (two extended to the basilar artery), three in the posterior cerebral artery (one bilateral), two in the basilar artery, and one in the posterior inferior cerebellar artery. The angiographic configuration included “string” sign, “pearl and string” sign, fusiform dilation, and double lumen. The following angiographic evolution (available in 11 cases) was that of complete healing (three cases), partial resolution (five cases), progression (one case), and unimproving (two cases). Three patients died (two due to recurrent subarachnoid hemorrhage): two patients were explored surgically (one had further intravascular therapeutic embolization), and the rest were treated conservatively. Not all dissecting aneurysms fared in the same manner, depending either on the location in the VB circulation or on the variable vascular configuration: treatment should be fitted to the timing of diagnosis.

Serial angiographic observations after successful directional coronary atherectomy

This study focuses on the early and late angiographic evolution observed in 82 patients with coronary artery disease who were successfully treated by directional coronary atherectomy (DCA) without adjunctive balloon angioplasty. Qualitative inspections and quantitative measurements were obtained from a selected angled-view projection in the following conditions: (1) before treatment; (2) immediately after treatment; (3) the day after atherectomy; (4) 1 month after; and (5) 6 months after. The appearance of the treated segment 24 hours after the procedure did not differ in 79 patients from that observed immediately after DCA; silent total occlusion occurred in two patients, and one had an aneurysm at the site of resection (all three patients were excluded from the analysis). At the 1-month study restenosis developed in 3 (3.6%) patients; the remaining 76 had identical appearances, with no evidence of renarrowing of the lumen. However, from 1 to 6 months after the procedure restenosis developed in 35 of the remaining 76 (46%) patients, and 41 patients were free of restenosis and symptoms. These findings, which show that early elastic recoil does not occur after successful DCA, are different from the changes observed after balloon angioplasty. At the 1-month observation restenosis is an infrequent but possible phenomenon (3.8%). From this point the healing of the arterial wall leads to no or mild renarrowing (late success); an exaggerated proliferative response produces restenosis.

Value and Limits of Doppler Ultrasound and M-Mode Echocardiography in the Assessment of the Efficacy of Fibrinolysis in Pulmonary Embolism

The efficacy of fibrinolytic therapies in pulmonary embolism (PE) was prospectively studied by Doppler echocardiography (DE). The evolution of the imaging and Doppler echographic parameters was compared with the angiographic evolution. Twenty-two patients presenting a severe PE with a vascular obstruction percentage (VOP) of more than 40% were included in the study. The following parameters were recorded before and after thrombolysis: the systolic pulmonary arterial pressure (sPAP) was assessed from the tricuspid regurgitation (TR) flow using continuous-wave (CW) Doppler, and the right and left ventricular diastolic diameters (RVD and LVD) were measured using echographie M-mode examination. All the PE were severe (VOP = 68 ± 10%) with pulmonary hypertension (sPAP = 53.5 ± 10 mm Hg). The improvement of the VOP averages 34%. The average sPAP dropped from 53.5 ± 10 to 34.5 ± 11 mm Hg and the RVD from 31.5 ± 6.5 to 25 ± 5.5 mm. The LVD rose from 39.5 ± 7 to 43.5 ± 6 mm. The RV/LV ratio dropped from 0.82 to 0.59 (p < 0.005). In 6 cases, the treatment was proved inefficient at the angiographic control with an improvement of the VOP inferior to 20%. The persistence of a pulmonary hypertension at the control CW signed an angiographic failure of the fibrinolysis. Whereas the regression of the pulmonary hypertension was an inconstant sign of an angiographic success, the reduction of the right ventricular diameter was a sure indication of a significant pulmonary reperfusion.

Immediate and follow-up results of transluminal balloon dilation for discrete subaortic stenosis

This study presents the findings in 33 patients with discrete subaortic stenosis who were treated by percutaneous balloon dilation and were followed up for 2 months to 6.2 years (mean 34 ± 21 months). The mean age was 13 ± 11 years; 10 (30%) were female and 23 (70%) male. Associated malformations were observed in nine patients (27%). All patients underwent noninvasive studies and cardiac catheterization. The mean valve to membrane distance was 4.5 ± 2 mm/m2.After balloon dilation, the pressure gradient from the left ventricle to the aorta decreased from 68 ± 30 to 20 ± 13 mm Hg (p < 0.00001); there were no significant changes in the degree of aortic regurgitation. A fluttering and widely mobile remaining membrane was clearly visualized after dilation. Better immediate results were obtained in patients with a smaller baseline gradient, a larger aortic anulus and a longer valve to membrane distance.Serial follow-up echographic studies were available in 30 patients, and 18 hemodynamic reevaluations were performed in 13 patients. However, seven patients who demonstrated restenosis underwent redilation at a mean of 29 ± 17 months after the first dilation. Redilation in six of the seven patients obtained benefits similar to those observed at the first dilation. Only one patient with unsuccessful redilation required surgery. The mean value of the last explored residual gradient (on hemodynamic or Doppler study) in the remaining 32 patients was 21 ± 10 mm Hg. No significant changes were observed in the angiographic evolution of aortic regurgitation.In conclusion, percutaneous balloon dilation may be a useful complement to surgical therapy in patients with a thin discrete subaortic stenosis. However, close follow-up is needed.

Angiographic Evolution of Coronary Atherosclerosis in Patients Receiving Propranolol: A Two-Year Follow-Up

To test whether propranolol may influence the progression of coronary atherosclerosis. Repeat coronary angiography after two year treatment and evaluation of changes in coronary narrowings. Subjects with effort angina of recent onset requiring coronary angiography and medical treatment. 80 untreated patients, with a greater than or equal to 50 percent focal narrowing on a major coronary branch associated or not with a less than 50 percent stenosis of other major branches. They were randomized to isosorbide dinitrate (40 mg bid) (group 1, control group) or to propranolol (80 mg qid) (group 2, treatment group). At restudy, there were more diseased vessels and These narrowings per patient in both groups. Multivessel involvement and greater than or equal to 50 percent obstructions were also augmented. These changes were not statistically significant. Patients with progression of the stenotic tracts (both greater than or equal to 50 percent and less than 50 percent were 19 (48 percent) in group 1 and 28 (70 percent) in group 2 (p less than 0.05). Narrowings with progression were 25 in group 1 and 48 in group 2. Thirteen narrowings in group 1 and 15 in group 2 were newly detected at restudy. Eighteen patients (45 percent) in group 1 and nine (23 percent) in group 2 had a steady disease. Smoking, high blood pressure, family history of coronary disease, blood glucose values and lipid levels were considered; the only significant group differences were 31 percent rise of total triglyceride and 23 percent decrease of HDL cholesterol in patients who were treated with propranolol. Propranolol showed an adverse influence on coronary atherosclerosis, regarding the evolution of both greater than or equal to 50 percent and less than 50 percent narrowings and not the formation of new stenoses. Changes in serum lipid values might have a role.

Effects of isosorbide dinitrates intravenously in high doses over a short period in anterior acute myocardial infarction

The effects of intravenous isosorbide dinitrate administered in high doses over a short period of time in 17 patients (14 men, 3 women, mean age 67 years) with anterior wall acute myocardial infarction were evaluated. Patients were classified into 2 groups based on the electrocardiographic pattern of acute ischemia. Patients presented with anterior acute myocardial infarction; an electrocardiographic pattern of third-degree ischemia demonstrated a more favorable electrocardiographic and radionuclear angiographic evolution than similar patients who presented with an electrocardiographic pattern of second-degree ischemia.

Angiographic evolution of coronary atherosclerosis in non-operated patients.

Repeat coronary arteriography was performed in 100 patients with angiographically proven coronary artery disease, because of worsening symptoms (n = 67), persistent stable angina (n = 22) or other reasons (n = 11). The mean interval between the studies was 34.6 months (range 6-99). No patient had interim coronary artery bypass surgery. Progression of coronary artery disease was demonstrated in 60 patients and was correlated in bivariate analysis with the time interval between coronary arteriograms (P less than 0.0001) and with the interim clinical evolution (P less than 0.01). The incidence of progression was similar in the coronary arteries. Moderate lesions (40-70% narrowing) had the highest progression percentages. New significant lesions in previously normal arterial segments were rare. A multivariate analysis of 18 possible predictors revealed three independent variables correlated with progression of coronary artery disease: time interval (P less than 0.0001) and change in functional class (P less than 0.02) between coronary arteriograms, as well as the presence of clinical diabetes (P less than 0.03). Other risk factors and a change of individual risk factors between coronary arteriograms were not correlated with progression of coronary artery disease. Using the results of the multivariate analysis, the evolution of coronary artery disease was correctly predicted in only 72 patients. Following the repeat coronary arteriogram, coronary artery bypass surgery was proposed to 62 patients, 26 of whom needed more distal anastomoses for optimal myocardial revascularization. Because of the important therapeutic implications and the lack of reliable predictors, an aggressive follow-up of patients with known coronary artery disease seems warranted.

Exercise electrocardiography and myocardial scintigraphy in the serial evaluation of the results of percutaneous transluminal coronary angioplasty.

The diagnostic value of exercise electrocardiography using 14 leads and thallium-201 scintigraphy were evaluated in 54 of 70 patients who underwent percutaneous transluminal coronary angioplasty (PTCA), both in the initial assessment and serial follow-up of patients after PTCA. Of the 45 patients who had successful PTCA, 36 had complete noninvasive studies performed before and 1 month after PTCA. The use of clinical symptoms in conjunction with the physiologic data, ECG and myocardial scintigram acquired during exercise provide important short-term data on the angiographic evolution of PTCA results. The noninvasive tests may be useful in determining guidelines for repeat angiography in patients who have had PTCA. (JMT)