Angiographic Success Rate Research Articles

Treatment Strategies for Long and Calcified Lesions

This study discusses the treatment strategies used to approach long lesions, lesions in small vessels, and calcified lesions. Traditional treatment strategies for these lesion subtypes have yielded high acute complication rates and poor long‐term outcome. A prospective analysis of 160 lesions was performed using intravascular ultrasound (IVUS) guided PTCA for the treatment of long lesions and lesions in small vessels, while a retrospective analysis of 106 calcified lesions was performed that were treated with the combination of rotablation and stenting. Acute and short‐term results of TVUS guided PTCA with spot stenting show a 30‐day major adverse cardiac event rate (MACE) of 5% with a high procedural success rate (96%), while the long‐term outcome resulted in an agiographic restenosis rate of 17.4% and a target lesion revascularization rate of 13%. The combination of rotablation and stenting also rendered results in calcified lesions of a 93% angiographic success rate and a long‐term outcome of restenosis of 22.5%. Optimal coronary stenting after rotational atherectomy in calcified lesions can be performed with a high success rate, an acceptable rate of procedural complications, and a low rate of stent thrombosis. This approach was associated with a low incidence of angiographic restenosis compared with results obtained with other interventional approaches. IVUS guided PTCA with spot stenting allows safe treatment of long lesions and lesions in small vessels. Short‐term and long‐term outcomes including 6‐month MACE and angiographic restenosis appear to be better than results achieved in historical controls that utilize balloon angioplasty alone or stents in a manner where the lesion is covered from the proximal normal segment to the distal normal segment.

Balloon angioplasty for the treatment of coronary in-stent restenosis: immediate results and 6-month angiographic recurrent restenosis rate

Objectives. The purpose of this prospective study was to evaluate the immediate results and the 6-month angiographic recurrent restenosis rate after balloon angioplasty for in-stent restenosis.Background. Despite excellent immediate and mid-term results, 20% to 30% of patients with coronary stent implantation will present an angiographic restenosis and may require additional treatment. The optimal treatment for in-stent restenosis is still unclear.Methods. Quantitative coronary angiography (QCA) analyses were performed before and after stent implantation, before and after balloon angioplasty for in-stent restenosis and on a 6-month systematic coronary angiogram to assess the recurrent angiographic restenosis rate.Results. Balloon angioplasty was performed in 52 patients presenting in-stent restenosis. In-stent restenosis was either diffuse (≥ 10 mm) inside the stent (71%) or focal (29%). Mean stent length was 16 ± 7 mm. Balloon diameter of 2.98 ± 0.37 mm and maximal inflation pressure of 10 ± 3 atm were used for balloon angioplasty. Angiographic success rate was 100% without any complication. Acute gain was lower after balloon angioplasty for in-stent restenosis than after stent implantation: 1.19 ± 0.60 mm vs. 1.75 ± 0.68 mm (p = 0.0002). At 6-month follow-up, 60% of patients were asymptomatic and no patient died. Eighteen patients (35%) had repeat target vessel revascularization. Angiographic restenosis rate was 54%. Recurrent restenosis rate was higher when in-stent restenosis was diffuse: 63% vs. 31% when focal, p = 0.046.Conclusions. Although balloon angioplasty for in-stent restenosis can be safely and successfully performed, it leads to less immediate stenosis improvement than at time of stent implantation and carries a high recurrent angiographic restenosis rate at 6 months, in particular in diffuse in-stent restenosis lesions.

“Rescue” abciximab for complicated percutaneous transluminal coronary angioplasty

We studied the in-hospital outcome of 138 consecutive patients who received abciximab as a "rescue" intervention for complicated coronary angioplasty in a high-risk clinical setting. "Rescue" treatment with abciximab was associated with clinical and angiographic success rates of 83% and 84%, respectively, whereas the risk of bleeding was higher in patients of low body weight.

Treatment of complex and "undilatable" coronary stenosis using rotational atherectomy with adjunctive or complementary balloon angioplasty

We studied 32 patients who had complex lesions or morphologic characteristics associated with poor outcome utilizing conventional PTCA, such as ostial stenosis, calcified lesions, long or diffuse lesions, restenotic lesions or Lesions which can not be crossed or dilnted with a balloon. These 32 patients underwent 72 procedures in which rotational atherectomy and adjuncrive or complementary PTCAwereperformedin 33 vessels to treat 50lesions. Theywere mainly (87.5Vo) in the left anteriordescendiig coronary artery' According to modffied ACC/AHA lesion classification, there were 19 type B2 lesions (38.0Vo) and 3l type C lesiois (62.0Vo). Plain balloon angioplasty was also performed in additional 22 lesions .Of the 32 patients, 19 were mnle and 13 femate. Their ages ranged from 42 to 79 years. The majority presented with Canadian Cardiovasculai Society angina class III or IV. The left ventricular eiectionfractionwas 507o in 17 pati.ents (53.1 Eo), 30 - 50% in l0 patients (31.3Vo) and 3dVo in 5 patients (I5.6qo). In 3 patients rotational atherectomy was performedwith the aid of intra-aortic balloon pumping for hemodynamic stabi1zation. single vessel disease was Present in 7 patients (21.9Vo), double vessel disease in 19 patients (59.4Vo) and triple vessel disease in 6 patients (lg.77o). Angiographic and procedural success rates were l00Vo. However, largely, success criteriawas achieved after adjunctive or complementary PTCA had been performed. Complex and undilatable coronary stenosis may be treated with rotational atherectomy and adjunctive or complementary PTCA.

Direct percutaneous transluminal coronary angioplasty in acute myocardial infarction. Predictors of short-term outcome and the impact of coronary stenting. Study Group of The Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK).

Direct percutaneous transluminal coronary angioplasty (PTCA) is widely accepted in the treatment of acute myocardial infarction since excellent results had been reported from several small randomized trials. Less favourable results were observed in large-scale registries. In particular, the use of stents in acute myocardial infarction has become common practice without documented evidence of clinical efficacy. Data were analysed from a registry of all consecutive percutaneous transluminal coronary angioplasty procedures from 62 centres in Germany, including 2331 direct percutaneous transluminal coronary angioplasty in acute myocardial infarction from July 1994 to April 1997. The overall angiographic success rate of percutaneous transluminal coronary angioplasty, defined as complete antegrade perfusion of the infarct vessel, was 87%. In-hospital mortality was 11.2%. The most important predictor of death was the presence of cardiogenic shock in 15% of patients, of whom 52% died. Mortality in patients without shock was 3.9%. Failed percutaneous transluminal coronary angioplasty was associated with a mortality of 36%. Further independent predictors of death were older age, multivessel disease, and anterior myocardial infarction. Stents were used in 4.1% of the procedures in 1994, increasing to 53% in 1997. However, this was not accompanied by improved clinical outcome. Mortality with coronary stenting was 9.9% vs 11.6% without stents (ns). Direct percutaneous transluminal coronary angioplasty is a valuable treatment strategy in acute myocardial infarction, although the results are less exceptional than reported from some highly specialized centres. Failed percutaneous transluminal coronary angioplasty seems to be harmful, thus outweighing much of the benefit from successful procedures. Stents did not improve the clinical outcome significantly, despite technically successful placement in 98%. Mortality from cardiogenic shock continues to be excessively high despite direct PTCA.

Operator volume and outcomes in 12,998 percutaneous coronary interventions. Northern New England Cardiovascular Disease Study Group.

We sought to determine whether there is a relation between operator volume and outcomes for percutaneous coronary interventions (PCIs). A 1993 American College of Cardiology/American Heart Association task force stated that cardiologists should perform > or = 75 procedures/year to maintain competency in PCIs; however, there were limited data available to support this statement. Data were collected from 1990 through 1993 on 12,988 PCIs (12,118 consecutive hospital admissions) performed by 31 cardiologists at two hospitals in New Hampshire and two in Maine and one hospital in Massachusetts supporting these procedures. Operators were categorized into terciles based on annualized volume of procedures. Univariate and multivariate regression analyses were used to control for case-mix. Successful outcomes included angiographic success (all lesions attempted dilated to < 50% residual stenosis) and clinical success (at least one lesion dilated to < 50% residual stenosis and no adverse outcomes). In-hospital adverse outcomes included coronary artery bypass graft surgery (CABG), myocardial infarction (MI) and death. After adjustment for case-mix, higher angiographic (low, middle and high terciles: 84.7%, 86.1% and 90.3%, p-trend 0.006) and clinical success rates (85.8%, 88.0% and 90.7%, p-trend 0.025), with fewer referrals to CABG (4.54%, 3.75% and 2.49%, p-trend <0.001), were seen as operator volume increased. There was a trend toward higher MI rates for high volume operators (2.00%, 1.98% and 2.57%, p-trend 0.06); all terciles had similar in-hospital mortality rates (1.09%, 0.96% and 1.05%, p-trend 0.8). There is a significant relation between operator volume and outcomes in PCIs. Efforts should be directed toward understanding why high volume operators are more successful and encounter fewer adverse outcomes.

Multiple coronary stenting in unstable angina: early and late clinical outcomes.

We examined clinical outcomes in 110 consecutive patients with unstable angina who underwent multiple coronary stenting over a 32-mo period. The main outcome measures were death, stroke, myocardial infarction, bypass surgery, and repeat angioplasty. The angiographic success rate was 100%, and the procedural success rate was 96%. There were no in-hospital deaths and five (4.5%) patients had a myocardial infarction prior to discharge. There were four (3.6%) stent thromboses with one (0.9%) patient requiring urgent bypass surgery and two (1.8%) requiring repeat angioplasty. At late follow-up (11.9+/-7.1 mo), there was (0.9%) death and three patients (2.8%) suffered myocardial infarction. Three (2.8%) patients underwent late bypass surgery and five (4.6%) had a repeat angioplasty. At follow-up, 86% of patients were event free. We conclude that multiple coronary stenting in unstable angina may be performed with a high procedural success rate and good long-term outcome.

Resultados de la angioplastia primaria en pacientes con enfermedad multivaso

In patients with acute myocardial infarction treated with primary angioplasty, multivessel disease is associated with a higher mortality. However, if higher mortality is simply due to a higher prevalence of cardiogenic shock or if multivessel disease is an independent risk factor remains unclear. To study if multivessel disease constitute an independent prognostic factor in patients with acute myocardial infarction treated with primary angioplasty, and to ascertain possible mechanisms contributing to the worse prognosis found in these patients. Between august 1991 and october 1996, 312 patients with acute myocardial infarction were treated with primary angioplasty in our center. Characteristics and in-hospital outcome of patients with or without multivessel disease were compared. Patients with multivessel disease (n = 158; 51%) were older (64 +/- 11 vs 61 +/- 13 years; p = 0.017), less often smokers (60% vs. 76%; p = 0.006) and had a higher prevalence of diabetes (35% vs. 20%; p = 0.007), hypertension (54% vs. 39%; p = 0.012), prior acute myocardial infarction (29% vs. 5%; p < 0.001), prior coronary bypass (2% vs. 0%; p = 0.042) and Killip class IV at admission (19% vs. 8%; p < 0.001). Angiographic success rate was not different in patients with or without multivessel disease (89% vs. 92%; NS). Patients with multivessel disease had a higher in-hospital mortality (21% vs. 7%; p < 0.001), need of revascularization (17% vs. 3%; p < 0.001) and incidence of severe mitral regurgitation, (5% vs. 0%; p < 0.001), second or third atrioventricular blockade (10% vs. 1%; p < 0.001) and severe bleeding (4% vs. 1%; p = 0.089). After excluding patients with Killip class III or IV at admission, mortality was also higher in patients with multivessel disease (9% vs. 2%; p = 0.009). Multivariate analysis showed the following independent risk factors for mortality: age > 65 years, Killip class IV and multivessel disease. In patients with acute myocardial infarction treated with primary angioplasty, multivessel disease is associated with higher mortality. This is due not only to a higher prevalence of cardiogenic shock at admission, but also to a worse baseline profile, a higher incidence of complications and a more frequent need of revascularization.

Balloon Angioplasty and Stent-Supported Angioplasty for Acute Myocardial Infarction

Background:Although the superior reperfusion and improved clinical outcome following angioplasty for acute myocardial infarction (AMI) have been well known, 10 to 15% of reinfarction and recurrent ischemia in hospital are main limitation of primary percutaneous transluminal coronary angioplasty (PTCA). This study was undertaken to examine the safety and feasibility of stent-supported primary angioplasty in acute myocardial infarction. Methods:Between July 1995 and Jun. 1997, 32 patients underwent direct or rescue PTCA, including patients with cardiogenicc shock. After PTCA, stentingwas attempted in patient with dissection or having more than 30% of residual stenosis. Result:In patient with direct PTCA, angiographic success rate was obtained in 91%(30/32). Stenting was attempted in 15 of 30 patients. These patients had suboptimal results (8 patients), nonocclusive dissection (3 patients) and acute occlusion (2 patient). Thrombolysis in myocardial infarction (TIMI) grade 3 flow was restored in 28 patients (93%). In one patient no-reflow phenomena was observed following stent insertion. Despite intra-aortic balloon pumping, there was one death during the hopitalization due to cardiogenic shock following PTCA. Subacute stent thrombosis developed in two patients. 27 patients (90%) were event-free and clinically improved through out the follow up period (11.5±5.2 month). Quantitative angiography showed excellent angiographic result after stenting compared with balloon PTCA (2.4±0.6 mm vs. 3.4±0.3 mm p<0.01). Conclusion:After failure of initial angioplasty, coronary stenting can be a supportive therapeutic strategy. Coronary stenting results in a high degree of angiographic success, a low incidence of subacute thrombosis. (Korean Circulation J 1998;28(7):1185-1191)

Immediate and Long Term Outcome of Single Long Stent for Long Complex Coronary Artery Stenosis Compared to Multiple Conventional Stent.

Coronary stenting for long complex lesion is effective but associated with complication. We compared the results of stenting between with multiple conventional stenting group (group A and with single long stenting group (group B. Fifty patients were prospectively and randomly enrolled:25 patients for each group. Each group showed no significant differences of clinical characteristics. One patient died of heart failure in each group, not associated with the procedure itself. One patient had cerebrovascular accident in each group. Five patients had major bleeding (2, group A;3, group B. Angiographic success rate was 100% in each group and proce- dural success rate was 96% and 100% in group A and B, respectively. Angiographic and clinical restenosis rate at 6 months follow-up were 60%, 36% in group A and 65%, 44% in group B, respectively (P=NS. Multivariate analysis showed that several factors affected the angiographic restenosis rate as follows;a male gender (M: F=76.9%:25.0%, p<0.001, b AMI (AMI:stable angina pectoris=72.7%:66.7%, p<0.001, c lesion length d residual stenosis. In conclusion, there were no statistical differences of restenosis and complication rate bet- ween the two groups. Our data support single long stenting is acceptable and economically more favorable for long diffuse lesion, compared to multiple conventional stenting. (Korean Circulation J 1998;28(9 :1465-1472

Early and intermediate term clinical outcome after multiple coronary stenting.

To examine the immediate and intermediate term clinical outcome of multiple coronary stenting. Consecutive patients were prospectively entered on a dedicated database. Follow up information was obtained from outpatient and telephone interviews with patients and family physicians. A tertiary referral centre. 140 consecutive patients underwent multiple coronary stenting between April 1994 and November 1996. Most patients had unstable coronary syndromes. Death, cerebrovascular accidents, myocardial infarction (MI), coronary artery bypass surgery (CABG), and repeat angioplasty (PTCA). The angiographic success rate was 100% and the clinical procedural success rate 93%. The mean (SD) follow up was 11.9 (7.2) months (range 2-32). The mean (SD) number of stents per patient was 2.4 (0.7). The mean (SD) number of lesions treated per patient was 1.4 (0.6). There were four in-hospital deaths (2.9%) and five patients (3.6%) had an MI before hospital discharge. All in-hospital deaths occurred in patients presenting with an acute MI and cardiogenic shock. Three patients (2.2%) had a late MI. One patient with stent thrombosis underwent emergency CABG. Three patients (2.2%) underwent late CABG. Eight patients (5.7%) had a repeat PTCA. Eighty three patients (61.5%) were asymptomatic at follow up and 121 (86.4%) were free from major clinical events. In an era of increased operator experience, high pressure stent deployment, and reduced anticoagulation with antiplatelet treatment alone, multiple coronary stenting may be performed with a high procedural success rate and good intermediate term outcome.

Initial Results after Implantation of Coronary Artery Stents with Antiplatelet Agents

Backgound：The placement of stents in coronary arteries has been shown to reduce acute closure and restenosis in comparison to balloon angioplasty. However, clinical use of intracoronary stents is impeded by the subacute stent thrombosis and hemorrhagic complications associated with the anticoagulant regimen. It’ s known that the complete stent deployment with high pressure inflation and new antiplatelet agents are effective in reduction of subacute thrombosis and hemorrhage. So we evaluated initial results (success and complication rate after high pressure-stent deployment with new anticoagulation protocol. Methods：One hundred and ninety one patients with 201 lesions were treated with 231 stents of various types. The high pressure balloon inflation and antiplatelets agents were used in all cases. Final high pressure balloon inflation guided by IVUS were performed in 23 consecutive cases with incomplete stent deployment according to angiographic findings. Results：1 The indications of stenting (n＝210 were De novo in 124 (59%, bailout procedure in 57 (27%, suboptimal result after PTCA in 19 (8%, and restenosis after PTCA in 14 (6%. The location of lesions were LAD in 101, RCA in 67, circumflex in 28, ramus intermedius in 3, and LMT artery in 2 lesions. Angiographic morphologic characteristics were type A in 2, type B in 158 (B1：57, B2：101, and type C in 22 lesions. 2 The angiographic and clinical success rate was 96% (192/201 and 92% (186/201 respectively. 3 In angiographic analysis, the baseline average reference vessel dirmeter was 3.33±0.35 mm. Baseline minimum lumen diameter(MLD was 0.58±0.29 mm, with baseline percent diameter stenosis of 82.86±8.64%. The final stent diameter was 3.37±0.29 mm, with mean final percent stenosis of 0.63±8.25. The mean MLD after stenting was significantly increased (p 12atm (p<0.001. The length of lesions in GR Ⅰ (cook, GR Ⅱ, and Micro Ⅱ stents were significantly longer than ones in PS, Cordis, Wiktor, Nir (p<0.001. 4 In intravascular ultrasound analysis, the mean lumen CSA at the tightest point within stent increased 11%, from 8.4±2.4 mm 2 at the intial intravascular ultrasound to 9.4±2.1 mm 2 at the final intravascular ultrasound (p<0.001. 5 The procedural andpostprocedural complications were 2 acute closures associated with AMI and emergent CABG, 1 subacute closure which was revascularized by bail out stenting, 5 major hemorrhage requiring transfusion associated with 1 CVA and 2 metabolic acidosis induced by acute renal failure, and 5

New devices enhance hospital results of coronary angioplasty.

After rigorous screening by means of registries and controlled trials, various atherectomy devices, excimer laser catheters, and endoluminal stents were approved for general clinical use. Few data are available describing their safety and effectiveness after approval. This analysis was undertaken to assess the impact on patient outcomes of the unrestricted clinical application of new transcatheter devices for coronary angioplasty. Thirty-six cardiologists performed 3,113 transcatheter procedures during 1995. Each chose the transcatheter modality best suited to the clinical and angiographic features of the patient. Baseline clinical and angiographic data and initial outcome were recorded by cardiac catheterization laboratory personnel. In-hospital events were obtained by independent chart review. Balloon angioplasty alone was employed in 1,089 (35.0%) patients. A stent was deployed after balloon angioplasty in 1,029 (33.1%) patients. An atherectomy or laser device was used without stent support in 631 (20.3%) patients, and stent support was added in an additional 364 (11.7%) patients. In all three new device categories the angiographic success (final luminal narrowing <50%) rate was better than in balloon angioplasty for type-C lesions and for chronic occlusions. The frequency of adverse events in the aggregate was not increased with device use, but the frequency of coronary artery bypass surgery was reduced with stent use. The frequency of non-Q-wave myocardial infarction was greater with devices than with balloon angioplasty alone. After adjustment for the differences in baseline clinical and angiographic variables by means of multivariate analysis, each of the three new device categories was independently associated with an increased chance of angiographic and procedural success compared to balloon angioplasty. The availability of new transcatheter devices for clinical practice enhances patient outcomes during hospitalization for the procedure.

High-Speed Rotational Atherectomy of Human Coronary Stenoses: Acute and One-Year Outcomes From the New Approaches to Coronary Intervention (NACI) Registry

High-speed rotational atherectomy (RA) is a new percutaneous procedure for treatment of coronary stenoses that operates by the unique mechanism of plaque abrasion. This article reports acute (in-hospital) outcomes and 1-year follow-up in a large cohort of patients treated with this device by NACI investigators. A total of 525 patients with 670 lesions treated with RA form the substrate of this report. Patients tended to be older (mean age 64.8 years) than those in previously reported series of percutaneous transluminal coronary angioplasty (PTCA), with more extensive disease and more complex lesions. Calcification was present in 54% of lesions, and eccentricity in 41%. Balloon angioplasty postdilation was performed after RA in 88% of cases. Angiographic and procedural success (angiographic success without death, Q-wave myocardial infarction [MI] or emergency coronary artery bypass graft [CABG] surgery) rates were 89% and 88%, respectively. Acute in-hospital events included 4 deaths (1%) and 1 emergency CABG surgery (0.4%). MI occurred in 6% of patients, consisting predominantly of non–Q-wave MI (5%). After RA, angiographic complications included coronary dissection (12%), abrupt closure (5%), side branch occlusion (3%), and distal embolization (3%). Most of these were resolved after postdilation except for coronary dissection, which was present in 15% of lesions treated. Mean length of stay was 3 days. At 1-year follow-up, 27% of patients required target lesion revascularization and 30% had experienced death, Q-wave MI, or target lesion revascularization. Preprocedural characteristics that independently predicted 1-year death, Q-wave MI, or target lesion revascularization were male gender, high risk for surgery, target lesions that were proximal to or in bifurcations, eccentric, long, or highly stenosed. RA, even when applied to lesions of traditionally unfavorable morphology, appears to provide reasonable procedural and angiographic success rates. Restenosis and progression of disease contribute to subsequent clinical and procedural events.

Bailout and Corrective Use of Gianturco-Roubin Flex Stents After Percutaneous Transluminal Coronary Angioplasty: Operator Reports and Angiographic Core Laboratory Verification From the National Heart, Lung, and Blood Institute/New Approaches to Coronary Intervention Registry

Objectives. We sought to determine the in-hospital clinical outcome and angiographic results of patients prospectively entered into the National Heart, Lung, and Blood Institute/New Approaches to Coronary Intervention (NHLBI/NACI) Registry who received Gianturco-Roubin stents as an unplanned new device.Background. Between August 1990 and March 1994, nine centers implanted Gianturco-Roubin flex stents as an unplanned new device in the initial treatment of 350 patients (389 lesions) who were prospectively enrolled in the NHLBI/NACI Registry.Methods. Patients undergoing implantation of the Gianturco-Roubin flex stent were prospectively entered into the Gianturco-Roubin stent portion of the NHLBI/NACI Registry. Only subjects receiving the Gianturco-Roubin stent as a new device in an unplanned fashion are included.Results. The mean age of the patient group was 61.8 years, and the majority of the patients were men. A history of percutaneous transluminal coronary angioplasty (PTCA) was present in 35.4% of the group, and 16.9% had previous coronary artery bypass graft surgery. Unstable angina was present in 67.7%. Double- or triple-vessel coronary artery disease was present in 55.4%, and the average ejection fraction was 58%. The presence of thrombus was noted in 7.3%, and 7.2% had moderate to severe tortuosity of the lesion. The angiographic success rate was 92%. Individual clinical sites reported that 66.3% of the stents were placed after suboptimal PTCA, 20.3% for abrupt closure and 13.4% for some other technical PTCA failure. Major in-hospital events occurred in 9.7% of patients, including death in 1.7%, Q wave myocardial infarction in 3.1% and emergency bypass surgery in 6%. Abrupt closure of a stented segment occurred in 3.1% of patients at a mean of 3.9 days. Cerebrovascular accident occurred in 0.3%, and transfusion was required in 10.6%. Vascular events with surgical repair occurred in 8.6% of patients.Conclusions. Despite these complications, the use of this device for the treatment of a failed or suboptimal PTCA result remains promising given the adverse outcome of abrupt closure with conventional (nonstent) treatment.(J Am Coll Cardiol 1997;29:934–40)© 1997 by the American College of Cardiology

Results of percutaneous transluminal coronary angioplasty in unstable angina and non-Q-wave myocardial infarction. Observations from the TIMI IIIB Trial.

This report describes the results of percutaneous transluminal coronary angioplasty (PTCA) in the Thrombolysis in Myocardial Ischemia (TIMI) IIIB Investigation. PTCA was performed before hospital discharge in 444 of 1473 patients with either unstable angina pectoris or non-Q-wave myocardial infarction (NQWMI) enrolled in TIMI IIIB. Angiographic success was observed in 96.1% of patients. For the entire cohort, the cumulative incidences of death and infarction at 1 year were 2.0% and 8.2%, respectively. The periprocedural incidence of myocardial infarction was 2.7%; emergency coronary bypass surgery, 1.4%; and death, 0.5%. By 1 year of follow-up, 122 patients (28.0%, Kaplan-Meier) had an additional revascularization procedure, 75 (61.5%) had PTCA only, 30 (24.6%) had coronary bypass surgery only, and 17 (13.9%) had both procedures. The results of PTCA were not improved by routine pretreatment with intravenous tissue plasminogen activator (TPA). Periprocedural myocardial infarction was more common among patients receiving TPA than placebo (odds ratio [OR], 2.19; P = .03) and among those with unstable angina than those with NQWMI (OR, 15.5; P = .007). No difference in outcome was observed when patients were analyzed according to age (OR, 1.06; P = .092) or sex (OR, 1.54; P = .51). Variables predictive of poor outcome were PTCA within the first 24 hours of enrollment, PTCA site being the left anterior descending coronary artery, and unsuccessful angiography. In TIMI IIIB, PTCA was performed for patients with unstable angina and NQWMI with a very high rate of angiographic success and a low incidence of complications. By 1 year, repeat revascularization was performed in 28.0% of patients. Routine pretreatment with thrombolysis did not enhance outcome.

Excimer laser angioplasty versus balloon angioplasty in functional and total coronary occlusions

Registries of excimer laser coronary angioplasty have reported good results in the treatment of complex coronary artery disease, including total or subtotal coronary occlusions. One hundred three patients (103 lesions) with a functional or total coronary occlusion were included in a randomized trial (Amsterdam-Rotterdam [AMRO] trial, total of 308 patients), 49 patients were allocated to laser angioplasty and 54 patients to balloon angioplasty. The primary clinical end points were death, myocardial infarction, coronary bypass surgery, or repeated coronary angioplasty of the randomized segment during a 6-month follow-up period. The primary angiographic end point was the minimal lumen diameter at follow-up in relation to the baseline value (net gain), as determined by an automated contour-detection algorithm. Laser angioplasty was followed by balloon angioplasty in all procedures. The angiographic success rate was 65% in patients treated with excimer laser-assisted balloon angioplasty compared with 61% in patients treated with balloon angioplasty alone. No deaths occurred. There were no significant differences between the laser angioplasty group and the balloon angioplasty group in the incidence of myocardial infarctions (1 patient vs 3, respectively, p = 0.36), coronary bypass surgery (4 patients vs 2, respectively, p = 0.34), repeat angioplasty (10 patients vs 8, respectively, p = 0.46) or primary clinical end point (15 patients vs 12, respectively, p = 0.34). The net gain in minimal lumen diameter and restenosis rate (>50% diameter stenosis at follow-up) were 0.81 ± 0.74 mm and 66.7%, respectively, in patients treated with laser angioplasty compared with 1.04 ± 0.68 mm and 48.5%, respectively, in patients treated with balloon angioplasty (p = 0.59 and p = 0.15, respectively). Excimer laser-assisted balloon angioplasty demonstrated no benefit over balloon angioplasty with respect to initial and long-term clinical and angiographic outcome in the treatment of patients with functional or total coronary occlusions of >10 mm in length.

Ten-year follow-up of percutaneous transluminal coronary angioplasty for proximal left anterior descending coronary artery stenosis in 351 patients

Objectives. We sought to evaluate the short- and long-term results of balloon angioplasty for stenoses in the proximal left anterior descending coronary artery.Background. Both the supposedly high rate of acute complications and relatively poor long-term results of balloon angioplasty for stenoses in the proximal left anterior descending coronary artery have led to a search for alternative interventional techniques.Methods. We analyzed the success rates and long-term follow-up results in 351 consecutive patients who underwent balloon angioplasty for stenosis of the left anterior descending coronary artery proximal to its first side branch. The power of the study was >80% in detecting a difference of 9% in the proportion of patients who survived at 10 years, assuming an 80% survival rate in the control group.Results. There were 60 ostial and 291 nonostial stenoses. Follow-up lasted a median of 85 months (range 0 to 137) and was 100% complete. The angiographic success rate was 90.9%. The clinical success rate was 86.3%. Nine patients (2.6%) died, 17 (4.8%) needed emergency coronary artery bypass graft surgery, and 10 (2.8%) developed a myocardial infarction. Several patients had subsequent complications. The success and complication rates were not significantly different for patients with ostial and nonostial stenoses. Ten years after balloon angioplasty, freedom from mortality was 80%, freedom from cardiac death was 87%, freedom from myocardial infarction was 84%, freedom from vessel-related reinterventions was 66%, and freedom from angina pectoris was 33%. There were more reinterventions for ostial stenoses, with a 1-year relative risk of ostial versus nonostial stenoses for related reinterventions of 1.7 (95% confidence interval 1 to 2.8, p = 0.049).Conclusions. More than 10 years ago, balloon angioplasty for stenoses in the proximal left anterior descending coronary artery, either ostial or nonostial, had a high success rate. Although the long-term results are satisfactory, ostial stenoses are associated with a higher early clinical restenosis rate requiring more reinterventions.

“Bailout” coronary stenting in patients with a recent myocardial infarction

In summary, patients who underwent bailout intracoronary stenting within 7 days of a myocardial infarction had lower clinical and angiographic success rates and a higher incidence of emergent coronary artery bypass graft surgery than patients who underwent bailout stenting without a history of a recent myocardial infarction. In addition, there was a trend toward more cardiac events after discharge in the patients who received stents after a recent myocardial infarction.

Randomised trial of excimer laser angioplasty versus balloon angioplasty for treatment of obstructive coronary artery disease

Summary Background Excimer laser coronary angioplasty is reported to give excellent procedural results for treatment of complex coronary lesions, but this method has not been compared with balloon angioplasty in a randomised trial. Methods Patients (n=308) with stable angina and coronary lesions longer than 10 mm on visual assessment were included. 151 patients (158 lesions) were assigned randomly to laser angioplasty and 157 (167 lesions) to balloon angioplasty. The primary clinical endpoints were death, myocardial infarction, coronary bypass surgery, or repeat coronary angioplasty of the randomised segment during 6 months of follow-up. The primary angiographic end-point was the minimal lumen diameter at follow-up in relation to the baseline value (net gain), as determined by quantitative coronary angiography. Findings Laser angioplasty was followed by balloon angioplasty in 98% of procedures. The angiographic success rate was 80% in patients treated with laser angioplasty compared with 79% in patients treated with balloon angioplasty. There were no deaths. Myocardial infarction, coronary bypass surgery, and repeat angioplasty occurred in 4·6%, 10·6%, and 21·2%, respectively, of the patients in the laser angioplasty group compared with 5·7%, 10·8%, and 18·5% of the balloon angioplasty group. Net mean (SD) gain in minimal lumen diameter was 0·40 (0·69) mm in patients treated with laser angioplasty and 0·48 (0·66) mm in those treated with balloon angioplasty (p=0·34). The restenosis rate (>50% diameter stenosis) was 51·6% in the laser angioplasty group versus 41·3% in the balloon angioplasty group (p=0·13). Interpretation Excimer laser angioplasty followed by balloon angioplasty provides no benefit additional to balloon angioplasty alone with respect to the initial and long-term clinical and angiographic outcome in the treatment of obstructive coronary artery disease.