Good Angiographic Result Research Articles

Percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease using a transluminal endatherectomy catheter (TEC): Initial results and angiographic follow-up

To evaluate the clinical results of percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease. Rotational atherectomy was performed in 39 patients aged 39-87 years (mean 66.6 years). A total of 71 lesions (43 stenoses and 28 occlusions) were treated in 40 limbs. Additional balloon angioplasty was required in 54% of lesions. Fifteen patients (37.5%) presented in Fontaine stage II, 10 patients (25%) in Fontaine stage III and 15 patients (37.5%) in Fontaine stage IV. Rotational atherectomy at 750 rpm was carried out over a 0.014-inch guidewire with continuous aspiration into a vacuum bottle. Follow-up angiography and color flow Doppler examinations were performed in 22 patients (23 limbs) after a mean period of 6 months (range 2-14 months). There was one primary technical failure. In 36 of 40 lesions there was a good angiographic result with residual stenoses in less than 30%. In 70 lesions treated by rotational atherectomy, however, 54% showed residual stenoses of 30%-50% and these cases required additional balloon angioplasty. The mean ankle-brachial index improved significantly (p << 0.001) from 0.49 before the procedure to 1.01 after the procedure. A single distal embolus, related to primary recanalization, occurred and there were two large inguinal hematomas. Cumulative clinical patency after 6 months was 83.8% and cumulative angiographic patency after 6 months was 79.1%. Percutaneous rotational atherectomy is a promising approach for the treatment of chronic peripheral vascular disease. Further prospective, randomized studies are necessary to compare percutaneous transluminal angioplasty with this new technical approach.

Distortion of Palmaz-Schatz stent geometry following side-branch balloon dilation through the stent in a rabbit model.

The compromise of side-branches following coronary angioplasty of the parent vessel remains a limitation of the procedure. Reports of dilation through a Palmaz-Schatz stent to salvage a compromised side-branch covered by the stent have been made. We examined the distortion of stent geometry which occurs following this procedure in a rabbit model. Palmaz-Schatz stents were placed at the aortoiliac bifurcation in 7 rabbits and the contralateral iliac artery was dilated through the stent. Despite good angiographic results, varied degrees of stent distortion were noted on gross pathologic analysis. Most distortion occurred when the arteries were dilated through the ends of the struts or through the "diamonds," and least distortion occurred during dilation through the mid-artriculation site. While good stent depolyment is thought to be necessary for improved outcomes, the distortion of stents after balloon dilation through the stent, despite good angiographic results, may have negative implications for both short- and long-term outcomes.

Distortion of Palmaz‐Schatz stent geometry following side‐branch balloon dilation through the stent in a rabbit model

The compromise of side-branches following coronary angioplasty of the parent vessel remains a limitation of the procedure. Reports of dilation through a Palmaz-Schatz stent to salvage a compromised side-branch covered by the stent have been made. We examined the distortion of stent geometry which occurs following this procedure in a rabbit model. Palmaz-Schatz stents were placed at the aortoiliac bifurcation in 7 rabbits and the contralateral iliac artery was dilated through the stent. Despite good angiographic results, varied degrees of stent distortion were noted on gross pathologic analysis. Most distortion occurred when the arteries were dilated through the ends of the struts or through the “diamonds,” and least distortion occurred during dilation through the mid-articulation site. While good stent deployment is thought to be necessary for improved outcomes, the distortion of stents after balloon dilation through the stent, despite good angiographic results, may have negative implications for both short- and long-term outcomes. Cathet. Cardiovasc. Diagn. 40:422–426, 1997. © 1997 Wiley-Liss, Inc.

The predictive value of angiographic results for the outcome of percutaneous transluminal angioplasty in stenosed femoral bypass grafts.

To assess the predictive value of immediate angiographic results after percutaneous transluminal angioplasty (PTA) for stenoses in femoral bypass grafts using duplex ultrasound (DUS) criteria. A 1-year follow-up with DUS was performed in 38 patients with 50 stenoses in 41 grafts, treated with PTA for a graft stenosis. The indication for PTA according to DUS criteria was a severe stenosis in 43 lesions, and a moderate stenosis in 7 lesions. In the moderate stenosis group 3 patients showed claudication and 1 patient had a nonhealing ulcer. For the purposes of statistical evaluation, primary patency was considered present if the graft was not occluded. The graft was considered to have failed when it was found to be occluded on DUS, or when secondary interventions (surgery, repeat PTA) were performed. After 1 year the cumulative primary patency rate was 44% [95% confidence interval (CI) 27.8-59.8]. Stenoses with initially good angiographic results after PTA (< 30% residual stenosis) were 2.9 times more likely to be patent at 1 year than stenoses with initially poor or moderate angiographic results (hazard ratio 2.9, 95% CI 1.3-6.4, p = 0.007). A poor or moderate angiographic result immediately following PTA was prognostic for poor long-term results and may indicate a requirement for earlier surgical intervention.

Intracranial pressure changes induced during papaverine infusion for treatment of vasospasm

The authors reviewed the cases of 21 patients who received intraarterial infusions of papaverine to determine the drug's effects on intracranial pressure (ICP), mean arterial blood pressure, pulse rate, and cerebral perfusion pressure (CPP). The study focused on patients with aneurysmal subarachnoid hemorrhage who developed clinical signs and symptoms of vasospasm, which was documented by cerebral angiography. In 18 patients, an average dose of 300 mg papaverine was administered over 20 to 35 minutes using a No. 5 French catheter inserted into the high cervical internal carotid artery or vertebral artery. Two other patients received superselective infusions via a microcatheter placed in the anterior cerebral artery. Sixteen patients (76%) experienced good angiographic results, and 11 (52%) obtained objective clinical improvement within 48 hours. Significant elevations in ICP, blood pressure, and pulse rate were noted during papaverine infusion. In contrast, no statistically significant sustained change in CPP was observed, although it tended to decrease during papaverine infusion. In one elderly patient, infusion of the common carotid artery resulted in profound bradycardia and hypotension with a subsequent significant increase in ICP and a marked decrease in CPP. The increase in ICP in these patients correlates well with changes seen in animal models and is probably related to increased cerebral blood flow. A careful, titrated infusion of papaverine, with constant reference to the patient's ICP, blood pressure, and pulse rate, minimizes the transient increase in ICP while maintaining adequate blood pressure and CPP. Failure to monitor these parameters during the infusion, with appropriate modification of the rate of titration, could potentially produce an uncontrolled change in ICP or CPP.

Coronary stenting for acute coronary dissection after coronary angioplasty: Implications of residual dissection

Objectives. The aim of this study was to assess the implications of residual coronary dissections after stenting.Background. Coronary stenting is currently used in selected patients with coronary dissection after angioplasty. However, in some patients the total length of the dissection may not be completely covered with the device.Methods. Forty-two consecutive patients (mean [±SD] age 58 ± 11 years; 39 men, 3 women) undergoing stenting for a major coronary dissection after angioplasty were studied.Results. Thirty (67%) coronary dissections were small (≤15 mm), and 29 (64%) were occlusive (Thrombolysis in Myocardial Infarction [TIMI] flow grade ≤2). In 3 patients, coronary stenting was unable to open large occlusive dissections, but a good angiographic result was obtained in 39 patients (93%). After stenting, 22 of these patients (56%) had no visible residual dissections, and 13 (33%) had small and 4 (10%) had large residual dissections. These residual dissections were stable and did not compromise coronary flow. In a repeat angiogram (24 h later) the stent was patent in all 39 patients. However, two patients experienced a subacute stent occlusion. Of the remaining 37 patients, 36 (97%) had a late angiogram after stenting. Quantitative angiography revealed a reduction in minimal lumen diameter at the stent site (2.6 ± 0.4 vs. 2 ± 0.7 mm, p < 0.05) and a trend toward improvement in vessel diameter at the site of the previous residual dissection (1.7 ± 0.6 vs. 1.9 ± 0.5 mm, p < 0.1). The angiographic image of residual dissection disappeared in all patients. These factors provided a rather smooth angiographic appearance at follow-up. The four patients with large residual dissections after stenting did not have restenosis and were asymptomatic at last visit.Conclusions. Coronary stenting is effective in the management of acute coronary dissections after angioplasty. In this setting, small residual dissections are frequently seen but have a good outcome and disappear at follow-up. Large residual dissections may have a good outcome if coronary flow is not impaired and no residual stenosis is visualized.

Clinical and angiographic outcomes after coronary artery stenting for acute or threatened closure after percutaneous transluminal coronary angioplasty. Initial results with a balloon-expandable, stainless steel design.

Acute occlusion after balloon coronary angioplasty is associated with an increased risk of angina, emergency coronary artery bypass grafting (CABG), myocardial infarction (MI), and death. Stents offer a way of restoring patency and avoiding these complications. One hundred sixteen patients underwent attempted stent placement for imminent or total acute closure after PTCA. In 103 patients (110 stents, 105 procedures) the stent was successfully deployed (89%). Angiographic success (final diameter stenosis of < 50%) was achieved in 94 placements (85%). Seventy-one phase 2 procedures (CABG optional, n = 96; phase 1, CABG required, n = 9) were angiographically successful without complications of death, Q-wave myocardial infarction, or CABG (clinical success 74%). Stent placement was associated with resolution of ST-segment deviation and angina in 84% of patients. Five deaths and 5 Q-wave MIs occurred during hospitalization. Two deaths were related to pulmonary insufficiency from chronic lung disease and one patient died after rescue stent placement for left main coronary artery occlusion during routine angiography. Another patient died after CABG was followed by right ventricular MI. The last death occurred in an elderly patient who suffered a stroke while on intravenous heparin. During hospitalization nine patients developed reocclusion after stent placement (8.6% of procedures) and six had repeat PTCA. CABG was performed after 29 stent procedures (28%). The first nine patients underwent CABG as a mandate of the phase 1 protocol. In addition, nine patients had CABG after stenting with a good angiographic result but with a large amount of myocardium at risk. Clinical follow-up was obtained in all patients at a median of 14 months (range, 2 to 43). There were three late deaths (3%), two Q-wave myocardial infarctions (2%), 16 repeat PTCAs (16%), and 15 CABG procedures (15%). Angiographic restenosis (percent diameter > or = 50%) using caliper measurements was found in 30 of 57 patients (53%) at a median of 4 months (93% of patients eligible). A total of 41 procedures were successful and unaccompanied by death, emergency or elective coronary artery bypass grafting, or angiographic restenosis in follow-up. Restenosis and/or clinical events (death, MI, CABG, repeat PTCA) were associated with non-Q MI, hypertension, diabetes, left circumflex coronary artery stenting, saphenous vein graft stenting, smaller caliber artery stenting, higher balloon to artery ratios, and shorter inflation times. Coronary artery stenting for acute closure after PTCA relieves myocardial ischemia and provides an alternate means of treatment. This series includes early learning curve experience; 70% (67 of 96) of patients were spared emergency coronary artery bypass graft surgery when this adverse outcome occurred. Certain clinical and angiographic subsets are at increased risk for restenosis and future cardiac events.

Treatment of experimental carotid aneurysms by endoprosthesis implantation: Preliminary report

Four experimental aneurysms were treated by implantation of an endoprosthetic stent. The aneurysms were surgically created by grafting a venous pouch on the carotid artery of mongrel dogs. Aneurysm patency was assessed angiographically. Under systemic heparinization and via a transfemoral approach, the stent measuring 20 mm in length and 5 mm in diameter, was implanted in the lumen of the parent artery at the level of the aneurysmal neck. Good angiographic results were obtained immediately following implantation, showing exclusion of the aneurysm from the circulation. Patency of the parent vessel was preserved in all the experimental aneurysms treated. In one case an angiogram performed 30 days later showed the same findings with excellent tolerance of the device. The technique of endovascular treatment of experimental aneurysms by stent implantation appears feasible and safe in vivo. Further investigations are still necessary before clinical applications.

Total arterial myocardial revascularization

The superiority of the internal thoracic artery (ITA) compared with venous conduits in terms of late graft patency is nowadays well documented. The inferior epigastric artery (IEA) was recently proposed as an alternative conduit for coronary artery surgery with good early clinical and angiographic results. To improve the benefits from myocardial revascularization, we expanded the use of these arterial conduits. From June 1988 to December 1991, 615 patients underwent coronary surgery in our institute. In 138 of them (22.4%) we performed total arterial myocardial revascularization placing 2 or more coronary anastomoses. An average of 2.37 anastomoses per patient were placed with the maximum number of 6 in one case. Only one patient died of cardiac related causes (0.72%). Perioperative morbidity included myocardial infarction and sternal dehiscence in 5 patients each (3.6%). No stroke or reoperation for bleeding occurred. No rectus muscle necrosis was recorded. Accurate preoperative planning of graft placement allows for the performance of as many as 6 distal anastomoses using bilateral ITA and single IEA grafts only, thus completely revascularizing most of the hearts with three-vessel disease. In our series this procedure was not reflected in an increase in the perioperative morbidity. We choose an elective total arterial revascularization in younger (under 65 years) patients who, while showing a lower incidence of complications in our study, are likely to derive the highest benefits from the good durability of ITA and hopefully IEA grafts.

Coronary angioplasty in patients with prior coronary artery bypass grafting

We studied the clinical and angiographic outcome of patients with prior coronary arterial bypass grafting who underwent percutaneous transluminal coronary angioplasty at the Royal Infirmary of Edinburgh. Over a 4 year period, 47 patients with prior bypass surgery underwent angioplasty of 23 stenotic graft sites and 37 stenotic sites of native vessels. The procedure was performed a mean of 31.3 months after surgery for recurrence of symptoms refractory to maximal medical treatment. Satisfactory angiographic results were achieved in 42 patients (58 stenotic grafts or native vessels). At a median follow up period of 18 months, 20 patients were symptomatically improved, but 22 patients experienced recurrence of symptoms a mean of 4.7 months after angioplasty, despite a good initial angiographic result. Overall, 4 patients had a repeat bypass grafting and 9 patients had a repeat angioplasty. Angioplasty can be used as an alternative to a repeat operation in patients with prior bypass grafting who experience recurrence of symptoms. Initial success rates are high and complication rates low. Restenosis or development of new lesions in the native circulation, and/or in the grafts, remain significant problems. Patients with a long asymptomatic interval (> 6 months) between the bypass operation and recurrence of symptoms are more likely to have better long-term results after successful angioplasty, perhaps because of slower progression of atherosclerotic heart disease.

Five years of angiographic and clinical follow-up after successful percutaneous transluminal coronary angioplasty.

The first 67 consecutive patients (77 lesions) who underwent successful coronary angioplasty (PTCA) at our hospital were clinically followed with serial exercise testing over a 5-year (4 to 7) observation period. Two sequential angiographic controls were performed 6.9 +/- 4.6 (64 patients) and 49.5 +/- 21.6 (42 patients) months after PTCA. The 5-year risk of cardiac death was 8%, of myocardial infarction 2%, or coronary artery bypass grafting 16% and of repeat PTCA 8%. At 5 years, 67% of the patients remain asymptomatic. Restenosis greater than or equal to 70% diameter was observed within the first year after PTCA in 30% of the patients. Progression of coronary artery disease (CAD) was observed in 13 patients (20%). In the first angiographic control, CAD progression was 4% (3/77) in dilated and 3% (3/115) in non-dilated arteries (ns). In the second angiographic control, it was 7% (3/45) and 10% (8/81), respectively (ns). Thus good clinical and angiographic results are still observed after 5 years. Restenosis is an early, self-limited, time-restricted phenomenon that occurs in 30% of patients. Angioplasty does not appear to accelerate CAD progression.

The epicardial electrogram: a quantitative assessment during balloon angioplasty incorporating monophasic action potential recordings.

An electrogram was recorded from the angioplasty catheter guide wire when coronary blood flow was interrupted in 20 patients undergoing percutaneous transluminal coronary angioplasty. Monophasic action potentials were recorded from the right ventricular septum together with the routine electrocardiogram. The patients were studied during angioplasty for lesions in the left anterior descending (12), circumflex (3), and right coronary arteries (6). ST elevation in the electrogram recorded in the left anterior descending and circumflex systems was usually more obvious than that in the electrocardiogram. Signals obtained from the right coronary artery were of very low amplitude and registered only minimal ST changes. The ST elevation developed in the electrogram during insertion of the catheter before inflation of the balloon in 11 of the 15 patients undergoing angioplasty of the left system. In eight of the patients showing pre-inflation ST elevation the ST shift lessened after successive inflations. Monophasic action potential recordings were obtained during 45 balloon inflations in 19 patients. In those patients undergoing angioplasty for lesions of the circumflex coronary artery the monophasic action potential showed no change during balloon inflation. In patients undergoing angioplasty for the right coronary artery the mean normalised duration at 60 seconds' occlusion was 99.6 (1.5)% of control. Of a total of 25 occlusions in the patients undergoing angioplasty for the left anterior descending coronary artery 19 showed shortening of less than 5%, five showed shortening between 5 and 10%, and one showed a shortening of 16.4% in the monophasic action potential. The QT interval was satisfactorily measured in the electrogram during 36 balloon inflations, and in 24 of these it was also measured in the electrocardiogram. QT changes in the electrogram tended to be the opposite of those in the electrocardiogram. When changes in RR interval were minimal (less than 20 ms) during the balloon inflation 14 of 17 electrograms showed QT prolongation but only one of 12 electrocardiograms showed prolongation. Conversely one of 17 electrograms showed shortening compared with eight of 12 electrocardiograms. There was angiographic evidence of the development of collaterals in six of 15 patients undergoing angioplasty of the left system. ST segment elevation in both the electrogram and electrocardiogram was less pronounced in these patients than in those without evidence of the development of collaterals. ST segment changes recorded from the angioplasty guide wire provide a more sensitive index of ischaemia than the surface 12 lead electrocardiogram, and fall in ST segments on balloon deflation is a prognostic index of a good angiographic result in the left anterior descending and circumflex arteries, but not in the right coronary artery.

Factors predictive of early angiographic and functional success following percutaneous transluminal coronary angioplasty.

Baseline variables in 300 coronary angioplasty procedures were analysed to identify factors predictive of a successful outcome. Separate multivariate analyses distinguished between predictors of primary angiographic success and functional success as determined by the results of predischarge treadmill stress electrocardiography. Three independent predictors of primary angiographic success were identified: number of balloon inflations per procedure, initial stenosis, and operator experience. Of these, the number of balloon inflations per procedure and operator experience were also predictive of functional success, reflecting the dependence of a good functional result on a successful procedure. Other independent predictors of functional success were the severity of the residual stenosis and single vessel coronary artery disease suggesting that adequacy of revascularization is an important determinant of the functional result. These data illustrate the interaction between clinical, angiographic and functional variables in determining the success of PTCA. A good angiographic result may not translate into a good functional result if revascularization is incomplete.