Failed Percutaneous Transluminal Coronary Angioplasty Research Articles

Emergency repair of coronary perforation following percutaneous transluminal coronary angioplasty failure: a high-risk choice?

Coronary perforation is a recognized hazard following cardiac catheterization and may lead to a catastrophic outcome. Prompt decision-making following diagnosis is of key importance. Whether to perform prolonged attempts at percutaneous repair or to promptly refer the patient for emergency surgery soon after diagnosis still remains a matter of debate. We report the case of a 78-year-old woman suffering from coronary artery perforation during left anterior descending coronary artery percutaneous transluminal coronary angioplasty-stenting, who underwent unsuccessful multiple prolonged attempts at percutaneous repair followed by subsequent successful emergency surgery.

Predictors of Mortality Following Rescue Percutaneous Intervention

Rescue percutaneous transluminal coronary angioplasty (PTCA) is a mechanical reperfusion strategy aimed at achieving patency of the infarct-related artery after failed thrombolysis. However, in randomized studies the indication for rescue PTCA was per protocol rather than based on clinical criteria. The aim of this study was to determine predictors of mortality at 30 days following rescue percutaneous intervention. Seventy-one consecutive patients who underwent rescue PTCA were included. Mean age was 61 (11) years, 80% were men and 9.8% had diabetes. The infarct-related artery was the left anterior descending artery in the 46.5%, and the mean percentage of stenoses was 91.0 (11.6)%. A stent was implanted in 97.2% and TIMI II-III flow was obtained in the 97.2% of the patients. Overall mortality was 9.8% at 30 days follow-up and 11.3% at 1 year follow-up. In the multivariate analysis, the independent predictors of mortality at 30 days were age (OR=1.2, 95% CI: 1.03-1.5, P=.001), Killip class III-IV (OR=20.1; 95% CI: 1.7-500; P=.003), PTCA failure (OR=indeterminate; P=.04) and left anterior descending artery involvement (OR=12.6; 95% CI: 0.7-214.9; P=.04). Rescue PTCA is effective in restoring blood flow in the infarct-related artery in the majority of patients in whom thrombolysis failed. The independent predictors of mortality were similar to those previously reported in acute myocardial infarction.

Nicardipine or nitroglycerin in patients with failed percutaneous coronary angioplasty: effect on myocardial diastolic function

Objective: To evaluate whether intracoronary vasodilators can improve diastolic function in 32 patients with failed percutaneous transluminal coronary angioplasty (PTCA). Design: Clinical trial. Setting: Single-institution, academic hospital. Participants: Failed PTCA patients undergoing emergency coronary artery bypass grafting surgery. Interventions: Patients were divided into 2 groups: group A received 0.1 mg of intracoronary nicardipine, and group B received 20 μg of intracoronary nitroglycerin. Both drugs were administrated via a coronary dilatation perfusion catheter inserted in the catheterization laboratory by the cardiologist. Subsequently, they were continuously infused via the side port of the introducer of the pulmonary artery catheter and titrated to keep systolic blood pressure at about two thirds of the control value. Transesophageal echocardiography (Power Vision/6000, 9-mm 5MHZ Probe; Toshiba, Elmsford, NY) was used in this study. Measurements and main results: Left ventricular ejection fraction, cardiac index, tissue Doppler imaging velocity of the left ventricle and mitral annulus, and troponin levels were measured before and after administration of the 2 vasodilators and after cardiopulmonary bypass. Diastolic dysfunction was found preoperatively in all the patients and responded only to intracoronary nicardipine. Ea of mitral annulus velocity significantly increased in group A patients from 7.5 ± 0.02 to 11.8 ± 0.01 ( p < 0.005) and decreased in group B patients from 8.0 ± 0.03 to 7.5 ± 0.02 after nicardipine or nitroglycerin administration. Left ventricular ejection fraction and cardiac index increased significantly ( p < 0.005) only after nicardipine administration. Troponin levels were significantly lower in group A than in group B patients ( p < 0.005). Conclusion: Intracoronary nicardipine improves diastolic function and myocardial flow velocity in patients with failed PTCA undergoing emergency coronary artery bypass graft surgery.

Emergency surgery after unsuccessful coronary angioplasty: a review of 15 years’ experience

Background Emergency coronary artery bypass grafting (CABG) is occasionally necessary for failed percutaneous transluminal coronary angioplasty (PTCA). The aim of this study was to assess the outcome of patients receiving emergency CABG after unsuccessful PTCA over a 15-year study period. Methods From January 1982 through December 1996, 74 patients underwent emergency CABG after unsuccessful PTCA (crash group). This group was compared with a matched group of 74 patients having primary elective CABG (control group). Results All 74 crash group patients were to have PTCA of one coronary system. After PTCA failure, 58 patients (78.3%) developed electrocardiographic changes of evolving acute myocardial infarction (AMI). The overall rate of AMI was 8.1% for the crash group and 2.7% for the control group. Two patients in the crash group died, with no deaths in the control group. There was no significant difference between mean in-hospital length of stay. Conclusions With prompt, aggressive, and complete myocardial revascularization, patients who required emergency CABG after PTCA failure had an outcome not significantly different from that of patients having elective CABG.

Surgical injury of rat arteries: genetic control of the remodelling process.

Remodelling and restenosis are complex biological processes responsible for bypass and percutaneous transluminal coronary angioplasty failures which are likely to affect many hundreds of genes. We evaluated the effectiveness of topically applied antisense oligonucleotides in reducing the translation of the messenger RNA for the transcription factor c-myc and in reducing stenosis. Surgery was performed under sterile conditions; 60 Wistar-Kyoto male rats were anaesthetized by ketamine. The carotid arteries were isolated through a median incision in the anterior neck region. At the same point, 0.5 mm longitudinal incisions were performed. Haemostasis was obtained by an adventitial 8.0 stitch. Thirty animals were given 150 microg of c-myc antisense oligonucleotide (Group A) while the other 30 animals received 150 microg of c-myc control sense oligonucleotide (Group B). Oligo molecules were locally applied through 100 microl of 20% pluronic gel. Rats were sacrificed at 30 days; carotid arteries were explanted and stained. Qualitative histological analysis was performed in all cases; serial sections were made every 25 micro in seven consecutive rats for each group. Morphometric analysis was also performed, luminal and medial area values recorded and the ratio between the two areas calculated. Data from each animal were compared with the corresponding contralateral carotid artery and expressed as mean+/-standard deviation. Statistical comparison between the two groups was carried out by one-way ANOVA text. Qualitative histological analysis showed marked remodelling with complete disarray of vessel wall, neointima accumulation and evidence of elastic fibres in the adventitia of all animals of Group B versus Group A. Morphometric analysis showed a significant reduction in the lumen area in Group A animals together with increased values of the medial area versus Group B animals. In addition, the ratio between the lumen and medial area was significantly higher in Group A than in Group B (2.61+/-0.18 versus 1.14+/-0.33, P<0.0001). c-myc antisense oligonucleotides applied intraoperatively can reduce post-operative stenosis.

Emergency coronary artery bypass grafting after failed coronary angioplasty: what has changed in a decade?

Background. We assessed the impact of patient and procedural characteristics on the outcome after emergency coronary artery bypass grafting (CABG) for failed percutaneous transluminal coronary angioplasty (PTCA) and temporal changes in these factors. Methods. Patients who underwent PTCA and subsequent emergency CABG were identified from the databases of the Departments of Cardiology and Cardiothoracic Surgery. Results. Two periods of clinical practice were compared. In 1989 to 1993, 2,880 PTCAs were performed, 64 patients underwent emergency CABG (2.3%), and 7 patients died (10.9%). During 1994 to 1998, 46 patients of 3,801 PTCAs underwent emergency CABG (1.2%, p < 0.01), and 7 patients died (15.2%, NS). The average rate of stenting increased from 0.8% to 24% in 1994 to 1998 as well as the frequency of arterial bypass grafts (0% vs 39%). In the latter period, patients were older, were more often females, had more cardiovascular risk factors, a higher Cleveland score (each p < 0.05), and suffered more often from periprocedural myocardial infarctions ( p < 0.001) and nonfatal periprocedural complications ( p < 0.01). Conclusions. Although the frequency of emergency CABG after failed PTCA declined, perioperative mortality tended to increase according to an unfavorable shift in patient risk factors and morbidity.

Early Myocardial Resuscitation via Coronary Sinus Retroperfusion

Between January 1996 and December 1998, 9 patients needed emergency surgical revascularization after percutaneous transluminal coronary angioplasty failure. The mean age of these 6 men and 3 women was 64 ± 4.2 years. Under anesthesia and partial cardiopulmonary bypass, a cardioplegia needle was inserted into the ascending aorta and a retrograde cardioplegia cannula was introduced transatrially into the coronary sinus. Coronary sinus retroperfusion was performed during graft harvesting for revascularization. There was 1 death (11.1%) from multiorgan failure in a patient who had required cardiopulmonary resuscitation preoperatively. There was evidence of new myocardial infarction in 2 patients (22.2%) and the other 7 made a good recovery.

Emergency coronary artery bypass surgery after failed percutaneous transluminal coronary angioplasty.

Coronary complications caused by percutaneous transluminal coronary angioplasty (PTCA) may necessitate emergency coronary artery bypass grafting (CABG). In 1994-1998, 132 patients (1.5% of the patients registered in the Danish PTCA registry) underwent CABG within 24 h because of angioplasty complications. We reviewed the files of 86 patients who had emergency operations within 6 h and found that 35% suffered from 1-vessel disease. Fifty-eight percent were taken directly to the operating room from the cardiovascular laboratory, and 13% were given preoperative cardiovascular resuscitation. The vessels most frequently injured were the right coronary artery and the left anterior descending branch (LAD). The patients received a mean of 2.4 coronary bypasses each. Forty-three percent of the patients with lesions of the left main coronary artery and/or the LAD received a vein graft to the LAD. A perioperative Q-wave myocardial infarction developed in 51% of the patients. The in-hospital mortality rate was 12%. These results are inferior to those obtained after elective surgery. Local cardiothoracic backup is vital when PTCA is performed in an unselected patient group.

Platelet Glycoprotein IIb/IIIa Inhibitors

Glycoprotein IIb/IIIa (GPIIb-IIIa) complexes (integrin αIIbβ3) mediate platelet aggregation by binding fibrinogen or von Willebrand factor (vWF), protein cofactors that form bridges between adjacent platelets. The cross-linked adhesive proteins assemble platelets into the aggregate. Agents that block the function of the GPIIb-IIIa complex of platelets constitute a powerful new generation of antithrombotic drugs.1 Among the short- and long-term aims of such drugs are (1) to provide immediate relief in the case of ongoing arterial thrombosis and (2) to eliminate excessive platelet reactivity in diseased vessels so that occlusive thrombi and restenosis do not occur, while allowing sufficient hemostasis to prevent spontaneous bleeding. It should be emphasized that stenosis and partial occlusion are both prothrombotic, with increased shear stress promoting platelet activation. Under these conditions, vWF plays a major role in the mediation of thrombus formation, interacting with GPIIb-IIIa and the adhesion receptor GPIb.2 Otherwise, fibrinogen is the major cofactor of platelet aggregation, essentially binding through a dodecapeptide sequence (aa400 to aa411) present at the carboxy terminus of each γ chain. Binding of vWF and other adhesive proteins, such as fibronectin, to GPIIb-IIIa is mediated by the Arg-Gly-Asp (RGD) sequence, a universal mediator of cellular interactions with the extracellular matrix.1 2 3 Anti–GPIIb-IIIa drugs block this final step of the platelet aggregation process. They also block the “outside-in” signaling that follows the binding of adhesive proteins to activated GPIIb-IIIa and the onset of platelet aggregation.3 This signaling may promote events such as secretion, clot retraction, and the expression of procoagulant activity; therefore, its inhibition extends the influence of anti–GPIIb-IIIa drugs beyond the blocking of platelet-to-platelet cohesion. The present review will mostly be illustrated by results obtained with abciximab (c7E3 Fab, ReoPro), a chimeric antibody fragment that is the most widely used of the new …

Favorable impact of stents after emergent coronary artery bypass for failed angioplasty

Background. This study was undertaken to determine the impact of the use and availability of coronary stents on outcomes in patients requiring emergent coronary artery bypass graft (CABG) surgery following a failed percutaneous transluminal coronary angioplasty (PTCA).Methods. Patients were divided into two groups based on the year of their CABG for a failed PTCA and the availability of stents: group 1, 1992 to 1994, stents not available (n = 34); and group 2, 1995 to 1997, stents available (n = 26).Results. CABG patients in the group where stents were not available were more likely to have had an abrupt coronary occlusion (26 of 34 versus 3 of 26; p < 0.0001) and less likely to have had a dissection (8 of 34 versus 23 of 26; p < 0.0001) as their indication for emergent CABG. Patients in the stent era had a lower incidence of perioperative myocardial infarction (5 of 26 versus 17 of 34; p < 0.01) and a decreased mortality rate (0 of 26 versus 6 of 34; p< 0.03). In the 9 patients where stents were employed, patency of the lumen was restored in 8 patients and there was only 1 myocardial infarction.Conclusions. Stents have had a favorable impact on patients requiring an emergent CABG following a failed PTCA.

Rescue Angioplasty After Failed Thrombolysis: Technical and Clinical Outcomes in a Large Thrombolysis Trial

Objectives. We sought to assess the angiographic outcome, complication rates and clinical features of percutaneous transluminal coronary angioplasty (PTCA) after failed thrombolysis for acute myocardial infarction.Background. “Rescue angioplasty” refers to mechanical reopening of an occluded infarct-related artery (IRA) after failed intravenous thrombolysis. Although the procedure is commonly performed, data describing its technical and clinical outcome are sparse. Early reports suggested that rescue PTCA is less often successful and produces more complications than primary PTCA. Other reports have described beneficial effects of successful rescue PTCA but adverse outcomes when PTCA is unsuccessful.Methods. Using data from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) angiographic substudy, we compared clinical and angiographic outcomes of 198 patients selected for a rescue PTCA attempt with those of 266 patients with failed thrombolysis but managed conservatively and, for reference, with those of 1,058 patients with successful thrombolysis.Results. Patients offered rescue PTCA had more impaired left ventricular function than those in whom closed vessels were managed conservatively. Rescue successfully opened 88.4% of closed arteries, with 68% attaining Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow. The interventions did not increase catheterization laboratory or postprocedural complication rates. Multivariate analysis identified severe heart failure to be a determinant of a failed rescue attempt. Successful rescue PTCA resulted in superior left ventricular function and 30-day mortality outcomes, comparable to outcomes in patients with closed IRAs managed conservatively, but less favorable than in patients in whom thrombolytic therapy was initially successful. The mortality rate after a failed rescue attempt was 30.4%; however, five of the seven patients who died after failed rescue PTCA were in cardiogenic shock before the procedure.Conclusions. Rescue PTCA tends to be selected for patients with clinical predictors of a poor outcome. It is effective in restoring patency. Patients who die after a failed rescue attempt are often already in extremis before the angioplasty attempt.

Coronary artery bypass surgery without cardiopulmonary bypass

In the years 1994 and 1995, 1087 patients underwent coronary artery bypass grafting at our institution. Of these, 297 were operated on without cardiopulmonary bypass. 239 were male, and 58 were female. Their ages ranged from 28 to 81 years (54.43 ± 9.63). Of the total, 294 were operated on electively, two as a coronary reoperations, and one as an emergency after a failed percutaneous transluminal coronary angioplasty procedure. In all patients complete revascularization was the aim, and a cardiopulmonary bypass team was kept on standby. Median sternotomy was performed as the exposure in all patients, except a patient who underwent a coronary reoperation through a left thoracotomy incision. The average of the distal anastomoses was 1.51 ± 0.6, ranging from 1 to 3. The left internal thoracic artery was used in 292 operations, which was an individual graft in 284, a sequential graft in five, and a free graft in four. Major complications in the early postoperative period were noted in three patients as reoperation for excessive bleeding. One patient had reoperation for left internal thoracic artery spasm, and one patient had lower extremity ischemia caused by intraoartic balloon counterpulsation. Hospital mortality was 0.3% with one patient. It is our belief that in selected cases coronary artery bypass grafting without cardiopulmonary bypass is a safe procedure with the advantage of improvement in recovery during the postoperative period.

Factors Influencing Mortality After Emergency Coronary Artery Bypass Grafting for Failed Percutaneous Transluminal Coronary Angioplasty

Background. Emergency coronary artery bypass grafting after failed percutaneous transluminal coronary angioplasty is associated with increased mortality. Methods. From 1981 through 1995, 117 patients at our institution underwent emergency coronary artery bypass grafting after failed percutaneous transluminal coronary angioplasty, with an in-hospital mortality rate of 13.6%. Univariate and multivariate analyses were used to identify the factors that influenced the risk of death. Results. Univariate analysis revealed that patients who died more often were women and had chronic renal failure, lower ejection fractions, and more diffuse coronary artery disease; less often received an internal mammary artery graft or an antegrade perfusion catheter; required inotropic support in the cardiac catheterization laboratory; and experienced myocardial infarction. Multivariate analysis demonstrated that the need for inotropic support in the cardiac catheterization laboratory was the best predictor of perioperative death. Conclusions. Patients with a reduced ejection fraction in whom percutaneous transluminal coronary angioplasty fails, antegrade perfusion does not produce a response, and myocardial infarction occurs are more likely to die after coronary artery bypass grafting. The risk appears to be highest for patients who require inotropic support in the cardiac catheterization laboratory.

Frequency and Predictors of Major In-hospital Ischemic Complications After Planned and Unplanned New-Device Angioplasty From the New Approaches to Coronary Intervention (NACI) Registry

The purpose of this study was to determine the frequency and predictors of major in-hospital ischemic complications after planned and unplanned procedures with new angioplasty devices from the New Approaches to Coronary Intervention (NACI) registry. The NACI registry is a multicenter, voluntary reporting of consecutive patients undergoing new-device angioplasty procedures using atherectomy catheters, stents, or lasers. This registry affords the opportunity to evaluate the performance of new angioplasty devices during elective and urgent circumstances. The study population consisted of 3,340 patients with 3,733 lesions (2,921 in native coronary arteries and 812 in saphenous vein grafts [SVGs], who were treated with new devices over a 3.5-year period and had their angiograms analyzed independently at a central angiographic core laboratory. Their in-hospital course and multivariate predictors of the complications in planned and unplanned procedures, further divided into native and SVG lesions, were evaluated. In 82.2% of native coronary artery lesions and 96.9% of SVG lesions, the procedure with a device had been planned due to unfavorable lesion characteristics for PTCA. In the remaining lesions, device use was unplanned, and was performed mainly to treat a suboptimal result (59–80.4%) after percutaneous transluminal coronary angioplasty (PTCA), and less frequently after important complications of PTCA including abrupt closure and PTCA failure. In native artery cohort, major in-hospital ischemic complications (death, Q-wave myocardial infarction [MI], or emergency coronary artery bypass surgery) occurred in 2.7% of the planned and 9.9% of the unplanned procedures (p <0.001), whereas in SVG such complications occurred in 3.6% of the planned and 8.7% of unplanned procedures (p = 0.21). Multivariate analysis revealed several predictors of major ischemic complications from planned native coronary artery device use: post-MI angina (odds ratio = 2.83); severe concomitant noncardiac disease (odds ratio = 2.5); multivessel disease (odds ratio = 1.75); and de novo lesions (odds ratio = 2.3). Multivariate predictors of major complications in unplanned native coronary artery procedures included high surgical risk (odds ratio = 3.08), and tortuous lesion (odds ratio = 2.41). In SVG lesions, the independent predictors of major complications for planned procedures included age (odds ratio = 1.09), high surgical risk (odds ratio = 4.34), and thrombus (odds ratio = 2.62). In native and SVG lesions, rates of major complications of planned procedures was acceptable (2.7–3.67%), but unplanned use of a new device was associated with a significantly higher rate of in-hospital complications (≃9%). Multivariate predictors for major ischemic complications included both clinical and lesion characteristics, and differed for native versus SVG lesions, as well as for planned versus unplanned procedures.

Economic Impact of Angioplasty Salvage Techniques, With an Emphasis on Coronary Stents: A Method Incorporating Costs, Revenues, Clinical Effectiveness and Payer Mix

Objectives. We sought to broaden assessment of the economic impact of percutaneous transluminal coronary angioplasty (PTCA) revascularization salvage strategies by taking into account costs, revenues, the off-setting effects of prevented clinical complications and the effects of payer mix.Background. Previous economic analyses of PTCA have focused on the direct costs of treatment but have not accounted either for associated revenues or for the ability of costly salvage techniques such as coronary stenting to reduce even costlier complications.Methods. Procedural costs, revenues and contribution margins (i.e., “profit”) were measured for 765 consecutive PTCA cases to assess the economic impact of salvage techniques (prolonged heparin administration, thrombolysis, intracoronary stenting or use of perfusion balloon catheters) and clinical complications (myocardial infarction, coronary artery bypass graft surgery [CABG] or acute vessel closure with repeat PTCA). To assess the economic impact of various salvage techniques for failed PTCA, we used actual 1995 financial data as well as models of various mixes of fee-for-service, diagnosis-related group (DRG) and capitated payers.Results. Under fee-for-service arrangements, most salvage techniques were profitable for the hospital. Stents were profitable at almost any level of clinical effectiveness. Under DRG-based systems, most salvage techniques such as stenting produced a financial loss to the hospital because one complication (CABG) remained profitable. Under capitated arrangements, stenting and other salvage modalities were profitable only if they were clinically effective in preventing complications in >50% of cases in which they were used.Conclusions. The economic impact of PTCA salvage techniques depends on their clinical effectiveness, costs and revenues. In reimbursement systems dominated by DRG payers, salvage techniques are not rewarded, whereas complications are. Under capitated systems, the level of clinical effectiveness needed to achieve cost savings is probably not achievable in current practice. Further studies are needed to define equitable reimbursement schedules that will promote clinically effective practice.

Cardiac troponin I to diagnose percutaneous transluminal coronary angioplasty-related myocardial injury

The purposes of the present study were to evaluate cardiac troponin I (cTnI) in the diagnosis of percutaneous transluminal coronary angioplasty (PTCA)-related myocardial injury in comparison with cardiac troponin T (cTnT) and creatine kinase (CK) MB mass concentration, and to investigate the frequency of myocardial injury, as indicated by myocardial protein release, after clinically symptomless side-branch occlusion (SBO) which may occur in the proximity of the attempted stenosis. The final study population comprised 80 patients undergoing elective, single vessel PTCA. Blood samples were drawn before, 6, 24 and 48 h after PTCA. cTnI, cTnT and CKMB mass baseline values were within the reference intervals in all patients (cTnI < 0.1 μg/l, cTnI < 0.2 μg/l, CKMB < 5 μg/l). Two patients presented with primary failure of PTCA, and visually successful PTCA was performed in all remaining patients. Seven patients (four with SBO) subsequently developed acute myocardial infarction (AMI). Symptomless SBO occurred in 16 patients. In controls ( n = 55) there were no significant increases in cTnI, cTnT, or CKMB concentrations compared with baseline values, and all markers stayed within their reference intervals. In half the patients with symptomless SBO ( n = 8) all markers were slightly to moderately increased, in two additional patients only CKMB was elevated (cTnI: 0.1–1.0 μg/l; cTnT: 0.25–0.81 μg/l and CKMB: 7.9–25.6 μg/l). In the majority of patients with primary failure or AMI we found pronounced increases in all tested markers (cTnI: 0.2–12.0 μg/l; cTnT: 0.44–12.10 μg/l; CKMB: 19.2–423.0 μg/l). The results of this study indicate that cTnI is comparably useful to cTnT or CKMB mass for diagnosing myocardial injury in PTCA patients. From our results a preference for one of the tested parameters cannot be clearly derived. Post-procedural cTnI, cTnT, and CKMB mass values are not higher than baseline values in uncomplicated cases, whereas AMI after PTCA leads to pronounced marker increases. SBO, even when symptomless, leads frequently (in about half the patients) to slight marker increases.

Rescue angioplasty in the thrombolysis in myocardial infarction (TIMI) 4 trial

Rescue percutaneous transluminal coronary angioplasty (PTCA) has been used to establish reperfusion after failed thrombolysis, and the goal of this study was to examine the angiographic and clinical outcomes after rescue PTCA performed for an occluded artery 90 minutes after thrombolysis. Four hundred two patients with acute myocardial infarction were randomized to receive either anistreplase (APSAC), recombinant tissue plasminogen activator, or their combination in the Thrombolysis in Myocardial Infarction (TIMI) 4 trial. The angiographic and clinical outcomes of patients with a patent artery 90 minutes after thrombolysis were compared with those of patients with an occluded artery treated in a nonrandomized fashion with either rescue or no rescue PTCA. At 90 minutes, the number of frames required to opacify standard landmarks (corrected TIMI frame count) was significantly lower (i.e., flow was faster) after successful rescue PTCA (27 ± 11) than that in patent arteries after successful thrombolysis (39 ± 20, p < 0.001), and the incidence of TIMI grade 3 flow was correspondingly higher after successful rescue PTCA (87% vs 65%, p = 0.002). In-hospital adverse outcomes (death, recurrent acute myocardial infarction, severe congestive heart failure, cardiogenic shock or an ejection fraction < 40%) occurred in 29% of successful rescue PTCAs and in 83% of failed rescue PTCAs (p = 0.01). Among all patients in whom rescue PTCA was performed (successes and failures combined), 35% of patients experienced an adverse outcome, which was the same as the 35% incidence observed in patients not undergoing rescue PTCA (p = IMS) and tended to be higher than the 23% incidence observed in patients with patent arteries (p = 0.07). Although successful rescue PTCA for an occluded artery at 90 minutes results in restoration of flow that is superior to that of successful thrombolysis, the incidence of adverse events for the strategy of rescue PTCA as a whole was the same as that of undertaking no PTCA.

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

Retrieval of a Migrated Coronary Stent by Cardiopulmonary Bypass

Coronary stents are devices capable of reducing the rate of restenosis after percutaneous transluminal coronary angioplasty (PTCA), and salvaging a failed PTCA, which means successfully managing a threatened closure after an unsuccessful balloon angioplasty. The basic principal is to avoid complications by pressing the intimal and medial flaps of the coronary artery against the vessel wall. This mechanism reduces the risk of thrombus formation and thus reduces the risk of acute closure and emergency bypass surgery 1. Although a series of benefits may be pointed out, there are some complications with this procedure such as femoral artery bleeding and/or formation of a pseudoaneuryms, stent malposition, migration and thrombosis 2. We report a clinical case of unsuccessful balloon expandable stent deployment with the risk of endangering the normal circumflex artery and of systemic embolization; the patient had also a femoral artery pseudoaneurysm and extensive hematoma due to aggressive anticoagulation therapy.

Multiple early percutaneous transluminal coronary angioplasty failures related to lupus anticoagulant

Multiple early percutaneous transluminal coronary angioplasty failures related to lupus anticoagulant