Initial Percutaneous Transluminal Coronary Angioplasty Research Articles

Late Coronary Ostial Stent Fracture and Embolism Causing an Acute Thrombotic Occlusion of the Carotid Artery With Cerebral Infarction

A 56-year-old woman presented 30 minutes after onset of a right arm paresis. The cardiovascular risk factors included high cholesterol levels and heavy smoking, leading to a posterior myocardial infarction 6 years earlier, with stenting of a subtotal right coronary artery (RCA) ostial stenosis (3×13 mm bare metal stent). A symptomatic 70% RCA ostial restenosis, 9 months after initial percutaneous transluminal coronary angioplasty, led to the deployment of a 3×18 mm Cypher stent (Cordis, Warren, New Jersey) within the former RCA stent, postdilated (3.5×10 mm and 4.0×20 mm balloon, 25 bar) with a satisfactory result, the proximal end of the drug eluting stent (DES) protruding into the aorta (Figure 1A).The carotid arteries were known to be free of stenotic lesions. After the admission in the neurology department, a computed tomography examination revealed a significant reduction in the perfusion of the right brain hemisphere without cerebral infarction, the subsequent computed tomography-angiography showed a thrombotic occlusion of the extracranial right internal carotid artery, with a patent intracranial segment (Figure 1B). The cause of the occlusion was not recognized. An ultrasound examination confirmed the presence of recent thrombotic material occluding the carotid artery. Because of the recent onset of the symptoms and lack of cerebral infarction, we decided that immediate surgery was the best course of action. The patient underwent a standard carotid artery thrombectomy under general …

Wirkung hoher und niedriger Dosen Acetylsalicylsäure auf die Re-Stenosierungsrate nach primär erfolgreicher koronarer Angioplastie

A comparison was made in 79 patients (63 men, 16 women: mean age 52 +/- 9 years) of the effect of high and low doses of aspirin on restenosis rate during the first six months after originally successful percutaneous transluminal coronary angioplasty (PTCA), 39 patients (group 1) received 1000 mg aspirin daily, while 40 (group 2) received 100 mg daily. All patients took 1000 mg aspirin as loading dose on the day before PTCA, and additionally calcium antagonists and slow-release nitrates in the post-PTCA period. Both groups were comparable with respect of localization of the dilated coronary artery stenosis and the morphological changes after dilatation. Intimal lesions after PTCA were demonstrated in 9 patients of group 1 and 10 of group 2. Within six months clinically significant restenosis had occurred in 8 patients of group 1 and 7 of group 2. 33 patients in group 2 and 31 in group 1 were free of symptoms and had no ischaemic reaction on the exercise ECG six months after the initial successful PTCA. These results demonstrate that high aspirin dosage does not reduce the restenosis rate more than low dosage.

Late Results After PTCA for Coronary Stenosis After the Arterial Switch Procedure for Transposition of the Great Arteries

The arterial switch operation has become the surgical approach of choice for d-transposition of the great arteries, but there is an increased awareness of adverse sequelae in some survivors. Long-term patency and normal function of the translocated coronary arteries must be achieved. It is reported that dependent of the prior coronary status, 3% to 11% of all survivors have proximal coronary stenosis or complete occlusion develop after arterial switch operations. However, treatment of these stenoses is still a matter of debate. Late results after percutaneous transluminal coronary angioplasty (PTCA) for coronary stenosis after the arterial switch operation for d-transposition of the great arteries are reported. Seven children after arterial switch operation for d-transposition of the great arteries who had subsequently undergone PTCA for coronary stenosis were angiographically re-evaluated 3 to 15 months after the initial PTCA and again after 3 to 5 years. All children survived the initial PTCA procedure. There were no late deaths. The degree of stenosis before PTCA ranged from 74% to 97%; immediately after PTCA from 5% to 10%; at 3 to 15 months after PTCA from zero to 6%; and at 3 to 5 years after PTCA from zero to 3%. Three to 5 years after PTCA all children showed normal development of the treated coronary artery. Primary PTCA of stenotic proximal coronary arteries after the arterial switch procedure for d-transposition of the great arteries seems to be an effective treatment with excellent long-term results.

Coronary artery bypass grafting (CABG) after initially successful percutaneous transluminal coronary angioplasty (PTCA): a review of 17 years experience.

Patients who undergo successful percutaneous transluminal coronary angioplasty (PTCA) may subsequently require operative myocardial revascularization. This review examines whether prior successful PTCA alters outcomes following subsequent coronary artery bypass grafting (CABG). The costs of interventional cardiology procedures and definitive surgery were also examined. From January 1981 through December 1997, 361 patients underwent CABG following initially successful PTCA (interval group). This group was compared with 11,909 patients who underwent CABG as the primary intervention for coronary artery disease (control group). The average time interval to CABG following initial PTCA was 13.7 months. The post-CABG myocardial infarction rate was 4% for patients in the interval group and 3% for patients in the control group. The 30-day mortality was similar for both patient groups (2%). For the interval group, the average cost of total interventional management was 24,220 dollars per patient. This included average costs of 13,873 dollars for CABG and 10,347 dollars for all preoperative interventional cardiology procedures. There is little doubt that PTCA procedures may provide successful myocardial revascularization. However, these procedures often need to be repeated over time and may serve only to delay coronary surgery, at substantial financial and personal cost.

Predictors of Restenosis after Coronary Angioplasty. A Study on Demographic and Metabolic Variables

Objective - The major concern about percutaneous transluminal coronary angioplasty (PTCA) is the high incidence of restenosis. Methods - Demographic, clinical and biochemical data were recorded 2 weeks prior to PTCA in 388 patients fulfilling the criteria for initial stenosis, successful PTCA, and angiographic follow-up after 6 months. Restenosis was evaluated by quantitative coronary angiography. Results - Variables predictive of restenosis in univariate analysis were diabetes mellitus, male gender, and the levels of high density lipoprotein (HDL) cholesterol, apolipoprotein A1 (Apo A1) and thio-barbituric acid-reactive substances (TBARS). In trend analysis through quartiles TBARS and fasting glucose levels were significantly associated with restenosis (p = 0.016 and 0.044, respectively), whereas the negative predictivity of Apo A1 and HDL-cholesterol were of borderline significance. In multivariate analysis male gender and diabetes mellitus showed predictivity of significance, and a negative predictivity was also apparent for HDL-cholesterol. Conclusion - We conclude that diabetes mellitus, male gender, and low HDL-cholesterol are predictors of restenosis 6 months after PTCA. In addition, TBARS may be a marker for the development of restenosis after PTCA.

Outcome 14 to 18 years after percutaneous transluminal coronary angioplasty

Outcome 14 to 18 years after percutaneous transluminal coronary angioplasty

Quality of life after coronary revascularization in the United States and Canada

Cardiac procedures are performed less frequently in Canada than in the United States (US), yet rates of cardiac death and myocardial infarction are similar. We therefore sought to compare long-term symptoms and quality of life in Canadian and American patients undergoing initial coronary revascularization. The 161 patients enrolled in the Bypass Angioplasty Revascularization Investigation at the Montreal Heart Institute were compared with 934 patients enrolled at 7 US sites. Patients’ outcomes were documented for 5 years after random assignment to percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery. Functional status was assessed using the Duke Activity Status Index. Canadian patients were significantly younger and had more angina at study entry. Death and nonfatal myocardial infarction were not significantly different between Canadian and US patients after adjustment for baseline risk. Canadian patients had significantly greater improvements in functional status at 1-year follow-up (Duke Activity Status Index score + 13.5 vs + 6.0, p = 0.002), but this difference progressively narrowed over 5 years. Angina was equally prevalent in Canadian and US patients at 1 year (16% vs 19%), but significantly more prevalent in Canadian patients at 5 years (36% vs 16%, p = 0.001). Repeat revascularization procedures were performed less often over 5 years among Canadian patients (26% vs 34%, p = 0.08), especially coronary artery bypass graft surgery after initial percutaneous transluminal coronary angioplasty (18% vs 32%, p = 0.03). These results suggest more anginal symptoms are required in Canada before coronary revascularization, but as a result Canadians receive greater improvements in quality of life after the procedure.

Relationship of extent of revascularization with angina at one year in the bypass angioplasty revascularization investigation (BARI)

OBJECTIVESTo determine the relative degree of revascularization obtained with bypass surgery versus angioplasty in a randomized trial of patients with multivessel disease requiring revascularization (Bypass Angioplasty Revascularization Investigation [BARI]), one-year catheterization was performed in 15% of patients.BACKGROUNDComplete revascularization has been correlated with improved outcome after coronary artery bypass grafting (CABG) but not with percutaneous transluminal coronary angioplasty (PTCA). Relative degrees of revascularization after PTCA and surgery have not been previously compared and correlated with symptoms.METHODSConsecutive patients at four BARI centers consented to recatheterization one year after revascularization. Myocardial jeopardy index (MJI), the percentage of myocardium jeopardized by ≥50% stenoses, was compared and correlated with angina status.RESULTSAngiography was completed in 270 of 362 consecutive patients (75%) after initial CABG (n = 135) or PTCA (n = 135). Coronary artery bypass grafting patients had 3 ± 0.9 distal anastomoses and PTCA patients had 2.4 ± 1.1 lesions attempted at initial revascularization. At one year, 20.5% of CABG patients had ≥1 totally occluded graft and 86.9% of vein graft, and 91.6% of internal mammary artery distal anastomotic sites had <50% stenosis. One year jeopardy index in surgery patients was 14.1 ± 11%, 46.6 ± 20.3% improved from baseline. Initial PTCA was successful in 86.9% of lesions and repeat revascularization was performed in 48.4% of PTCA patients by one year. Myocardial jeopardy index one year after PTCA was 25.5 ± 22.8%, an improvement of 33.8 ± 26.1% (p < 0.01 for greater improvement with CABG than PTCA). At one year, 29.6% of PTCA patients had angina versus 11.9% of surgery patients, p = 0.004. One-year myocardial jeopardy was predictive of angina (odds ratio 1.28 for the presence of angina per every 10% increment in myocardial jeopardy, p = 0.002). Randomization to PTCA rather than CABG also predicted angina (odds ratio 2.19, p = 0.03).CONCLUSIONSIn this one-year angiographic substudy of BARI, CABG provided more complete revascularization than PTCA, and CABG likewise improved angina to a greater extent than PTCA.

Clinical correlates of the initial and long-term cost of coronary bypass surgery and coronary angioplasty

Background Medical costs vary substantially among patients. Understanding the baseline factors that predict subsequent cost may allow better selection of therapy for individual patients. Understanding the postprocedure events that increase cost should help to improve efficiency and effectiveness of coronary revascularization. Methods Data on 4-year costs were collected from patients randomly assigned to coronary angioplasty or bypass surgery as part of the BARI (Bypass Angioplasty Revascularization Investigation) trial. Regression models first examined factors known at the time of randomization that prospectively predicted initial procedure cost and long-term cost. Subsequent models tested the value of postrandomization events as explanatory variables for cost. Results The independent baseline predictors of higher initial percutaneous transluminal coronary angioplasty cost included 3-vessel disease (+12%) and acute presentations (+22%), whereas the independent predictors of higher initial coronary artery bypass grafting cost included the number of comorbid conditions (+5% per condition) and female sex (+7%). The independent baseline predictors of 4-year cost included heart failure (+26%), diabetes (+22%), comorbidity (+10%), and angioplasty assignment in patients with 2-vessel disease (–15%). Postrandomization models showed higher initial and long-term costs were strongly correlated with the number of repeat revascularization procedures (+30% to +128%) and the occurrence of clinical complications (+8% to +131%). Conclusions Two-vessel disease identifies patients likely to have lower costs after angioplasty, whereas heart failure, comorbid conditions, and diabetes identify patients likely to accrue higher costs after either angioplasty or bypass surgery. Long-term costs can be potentially reduced by interventions that decrease procedural complications or reduce the need for repeat revascularization. (Am Heart J 1999;138:376-83.)

Incidence and predictors of target vessel revascularization following percutaneous transluminal coronary angioplasty: a report from the national heart, lung, and blood institute percutaneous transluminal coronary angioplasty registry

We sought to determine the rate of target vessel revascularization (TVR) after percutaneous transluminal coronary angioplasty (PTCA) and to determine factors that predispose to its occurrence. The 10-year outcome of 2,262 patients in the National Heart, Lung, and Blood Institute PTCA Registry was analyzed to determine the incidence and characterize predictors of TVR. TVR was performed in 30.4% of patients. Male gender (relative risk [RR] 1.26; p <0.05), diabetes (RR 1.57; p <0.001), multiple discrete lesions (RR 1.38, p <0.01), diffuse lesions (RR 1.27; p <0.05), and calcium at the lesion site (RR 1.25; p <0.05) were predictors for TVR. TVR was performed early (≤1 year) in 18.3% and late (>1 year) in 12.2%. Age ≥65 years (RR 1.24; p <0.05), congestive heart failure (RR 1.70; p <0.05), acute coronary insufficiency (RR 1.28; p <0.05), and left anterior descending lesion location (RR 1.34, p <0.01) were significant predictors of early versus late TVR by multivariate analysis. Coronary artery bypass grafting (CABG) rather than PTCA was the TVR procedure in 21% of patients undergoing early TVR and 58% of those undergoing late TVR. Significant independent predictors of CABG as the TVR procedure were multivessel disease (RR 1.97; p <0.001), presence of collateral vessels (RR 1.81; p <0.05), diffuse (RR 1.89; p <0.01), or occluded (RR 1.82; p <0.05) target lesions, and a greater residual stenosis after the initial PTCA (RR 1.19; p <0.001). Age ≥65 years (RR 0.65; p <0.05) conferred a lower risk for CABG.

Predictors for restenosis after angioplasty of chronic coronary occlusions

Background: The Stenting In Chronic Coronary Occlusion (SICCO) study assessed the effects of additional intracoronary stenting (Palmaz–Schatz) after successful percutaneous transluminal coronary angioplasty (PTCA) of chronic coronary occlusions and showed a significant reduction of restenosis in stented patients. Methods: Univariate and logistic regression analyses were used to assess clinical, angiographic and procedure related predictors for restenosis (>50% diameter stenosis at follow-up) and Major Adverse Clinical Events (MACE=cardiac death, lesion-related acute myocardial infarction, repeat lesion-related angioplasty, bypass surgery involving the treated segment or angiographic documentation of reocclusion in non-revascularized patients) in the 114 SICCO patients with an angiographic end-point and 300 days clinical follow-up. Results: By 6 months the restenosis rate was 53%, and after 300 days MACE had occurred in 39%. Both the rates of restenosis and MACE was significantly reduced by stenting. The restenosis rate was improved by stenting also in patients with a `stentlike' result after the initial PTCA. In the multivariate model the risk of restenosis was increased by a history of unstable angina, a long lesion and a non-tapering occlusion stump. LAD location was associated with a threefold increased risk of MACE. Conclusion: Stent implantation should always be considered in successfully opened chronic occlusions.

A comparison of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty in patients on hemodialysis

The hospital records of 22 patients on hemodialysis undergoing coronary artery bypass grafting, and 19 others undergoing percutaneous transluminal coronary angioplasty were reviewed to compare the outcomes of these procedures in this population. Evidence of previous myocardial infarction or triple vessel or left main coronary artery disease was more common in patients undergoing coronary artery bypass graft than those undergoing percutaneous transluminal coronary angioplasty. Perioperative mortality and complication rates following coronary artery bypass graft (4.5% and 41%, respectively) were similar to those following percutaneous transluminal coronary angioplasty (5.3% and 42%). Cardiac event-free rates at 18 months by life-table analysis following coronary artery bypass graft and percutaneous transluminal coronary angioplasty were 87±16% and 40±14%, respectively. Survival at 18 months were 67±17% following coronary artery bypass graft and 69±14% following percutaneous transluminal coronary angioplasty. Cardiac events were observed to occur in three patients undergoing coronary artery bypass graft at a median of 10 months, and in nine patients following percutaneous transluminal coronary angioplasty at a median of 6 months. One patient required percutaneous transluminal coronary angioplasty after the initial coronary artery bypass graft. Seven patients required repeat percutaneous transluminal coronary angioplasty, and two patients underwent coronary artery bypass graft after initial percutaneous transluminal coronary angioplasty. Although these conclusions are limited by the retrospective nature of the study, it is concluded that coronary artery bypass graft can be performed with morbidity and mortality equivalent to percutaneous transluminal coronary angioplasty, and provides better cardiac event-free rates than percutaneous transluminal coronary angioplasty in patients on hemodialysis. Percutaneous transluminal angioplasty does not appear to be justified in this population because of its unacceptably high restenosis and cardiac event rates.

Cost-effectiveness analysis of abciximab: a Canadian hospital perspective.

To assess the cost-effectiveness of abciximab therapy versus traditional practice in high-risk patients receiving percutaneous transluminal coronary angioplasty (PTCA) from a Canadian hospital perspective. A predictive decision analytic model using published clinical and economic evaluations, as well as costs of medical care in Canada. High-risk PTCA patients as defined by the Evaluation of c7E3 for Prevention of Ischemic Complications trial and the c7E3 Fab Antiplatelet Therapy in Unstable Refractory Angina trial. Two treatment strategies were compared: (1) abciximab 0.25 mg/kg intravenous bolus 10 minutes prior to PTCA followed by abciximab 10 micrograms/min intravenous infusion for 12 hours after the procedure, and (2) no abciximab adjunctive therapy at the time of PTCA. Both treatment strategies were combined with intravenous heparin up to 100 units/kg bolus pre-PTCA followed by bolus doses for 1 hour after PTCA per the protocol. Cumulative outcomes were considered up to 6 months after initial PTCA. At 6 months, 29% of the patients in the abciximab treatment arm compared with 33% in the no abciximab arm achieved one of the primary events. The most common adverse event experienced was major bleeding at 4% in the abciximab treatment arm versus 1.6% in the no abciximab arm. The average cost per patient for each strategy was $3261 Can ($1 Can = $0.686 US) (abciximab arm) versus $2073 Can (no abciximab arm), resulting in an incremental cost-effectiveness ratio of $29,700 Can per event-free patient. In univariate sensitivity analyses, the only controllable factor that changed the results of the cost-effectiveness outcome was the cost of abciximab. Although the use of abciximab as an adjunct to PTCA results in a reduction in event rates in high-risk patients compared with traditional treatment, there is an increased cost associated with this strategy.

Conservative management of patients with acute myocardial infarction and spontaneous acute patency of the infarct-related artery

The role of systematic emergency percutaneous transluminal coronary angioplasty (PTCA) in patients with spontaneous reperfusion during myocardial infarction is debated. We retrospectively examined the inhospital outcome of 47 consecutive patients with myocardial infarction <6 hours and angiographically proven spontaneous patency of the infarct artery managed without initial PTCA. There was one death (2.1%) and no incidence of reinfarction. Predischarge angiography showed regression of the culprit coronary lesion to <50% stenosis in 23% of the patients, therefore obviating the need for PTCA. However, 17% of the patients had acute recurrent ischemia, requiring emergency intervention in 10.6%. Comparison with matched patients in whom Thrombolysis in Myocardial Infarction grade 3 patency was achieved by thrombolysis or by primary PTCA showed that patients with spontaneous patency tended to have smaller infarctions, as judged from a lower peak creatine kinase level (1132 ± 1002, 2051 ± 1536, and 2715 ± 2146 IU, respectively; p = 0.001) and a higher left ventricular ejection fraction (56.4%, 47.9%, and 48.7% respectively; p = 0.02). In conclusion, these patients have an excellent inhospital outcome, with evidence of less myocardial damage than in patients in whom reperfusion therapy was required to achieve TIMI 3 patency. Initial conservative treatment appears safe.

Fate of Collateral Vessels After Successful Coronary Angioplasty in Patients With Effort Angina

Objectives. The purpose of the present study was to evaluate whether severe restenosis after percutaneous transluminal coronary angioplasty (PTCA) promotes collateral development and whether successful dilation regresses collateral vessels.Background. It is well known that in the presence of severe coronary stenosis, native collateral arterioles mature to small coronary arteries with several layers of smooth muscle cells. However, it remains unclear whether well developed collateral vessels regress after removal of coronary stenosis.Methods. The study group comprised 41 patients who underwent elective PTCA for effort angina due to single-vessel disease, followed by repeat PTCA to treat restenosis. We classified the patients into three groups depending on the change in baseline Thrombolysis in Myocardial Infarction (TIMI) flow grade of the ischemia-related artery at initial and repeat PTCA, and we compared the extent of ST segment elevation at 1 min of the first balloon inflation between the two procedures. The average interval from initial to repeat PTCA was 125 days.Results. The three patient groups comprised group A, 12 patients with decreased flow grade because of severe coronary restenosis; group B, 12 patients with increased flow grade who had severe initial stenosis and relatively mild restenosis; and group C, 17 patients with unchanged flow grade. In the presence of comparable rate-pressure products at initial and repeat PTCA, patients in group A had significantly greater ST segment elevation (p < 0.01) at initial than at repeat PTCA (mean ± SD 0.42 ± 0.31 vs. 0.13 ± 0.22 mV). In group B, ST segment elevation was significantly less at initial than at repeat PTCA (0.13 ± 0.25 vs. 0.19 ± 0.17 mV, p < 0.05), and in group C, it was comparable at the two procedures (0.37 ± 0.32 vs. 0.35 ± 0.33 mV, p = 0.50).Conclusions. These findings indicate that severe restenosis after PTCA promotes collateral development and that successful dilation regresses collateral vessels during a relatively short period of time.(J Am Coll Cardiol 1997;29:544–8)

Endovascular β-irradiation after percutaneous transluminal coronary balloon angioplasty

Purpose : Intraluminal β-irradiation has been shown to markedly decrease fibrointimal proliferation after arterial injury in experimental models. With the aim of reducing the incidence of restenosis after percutaneous transluminal coronary angioplasty (PTCA), we undertook a pilot clinical evaluation to assess both the technical feasibility and the clinical safety of this treatment after balloon coronary angioplasty. Methods and Material : Between June 21 and November 15, 1995, 15 patients (6 women and 9 men, aged 72 ± 5 years) underwent intracoronary β-irradiation immediately after a conventional PTCA procedure. Both the PTCA and irradiation procedure were done in a conventional catheterization laboratory, using an endoluminally centered pure metallic 90Y source, a newly developed technique of intracoronary β-irradiation. This was done after documenting the ability of the system to generate reproducible dose delivery to the arterial wall. Results : Both the PTCA and the irradiation procedure were technically feasible in all attempted cases, and a dose of 18 Gy was delivered with a local exposure time of 391 ± 206 s (range 153–768). In four patients, the intervention was completed by intraarterial stent implantation because of dissection induced by the initial PTCA. No inhospital hospital complications occurred, and serial creatine kinase measurements remained within the normal range in all cases. Conclusion : Our early experience thus suggests that reliable and reproducible dose delivery can be achieved, and that coronary endoluminally centered β-brachytherapy is both feasible and safe on a short-term basis in the clinical setting. Whether this novel mode of therapy will favorably influence post-PTCA restenosis in patients, as it does in experimental models, must await long-term angiographic follow-up of the present series as well as further clinical study.

Hostility Predicts Restenosis After Percutaneous Transluminal Coronary Angioplasty

To investigate the "toxic" total (potential for) hostility component of the type A behavior pattern (assessed by means of the structured interview) as it relates to prediction of restenosis after percutaneous transluminal coronary angioplasty (PTCA). Patients with single vessel or multivessel coronary artery disease in whom PTCA had been scheduled or done were administered the structured interview by one trained interviewer prospectively or retrospectively (blinded to angiographic endpoints). A total of 41 patients underwent 53 initial balloon dilations on native arteries by 1 of 5 participating cardiologists. Inclusion criteria for this study were a successful initial PTCA and post-PTCA recatheterization if a patient complained of ischemic symptoms possibly related to restenosis. Of the 41 patients, 15 (36.6%) had restenoses at a total of 18 previous angioplasty sites. Patients with high total (potential for) hostility ratings were almost 2.5 times more likely to have restenosis than those with low total (potential for) hostility scores (95% confidence interval = 1.03 to 5.32). Logistic regression revealed that total (potential for) hostility scores predicted post-PTCA restenosis overall as well as when adjusted for gender and race. Total (potential for) hostility scores were also positively associated with the number of arteries restenosed (P = 0.01). This is the first report of type A total (potential for) hostility behavior conferring an increased risk for restenosis after PTCA. Its modification may be effective in reducing recurrent cardiac events. A coronary-prone behavior modification program for patients with persistent, same-site restenosis after PTCA has been initiated.

CABG after successful PTCA: A case-control study

We sought characteristics predictive of the need for operative revascularization subsequent to a successful coronary angioplasty. Through June 1993, 128 patients who had successful percutaneous transluminal coronary angioplasty (PTCA) between January 1982 and March 1989 required subsequent coronary artery bypass grafting (CABG) at our hospital. These cases were matched with 128 controls who had a successful PTCA but did not require subsequent CABG. Controls were matched to cases by the date of their initial PTCA. Before initial PTCA there were no differences between the cases and controls in terms of age, sex, prior myocardial infarction, ejection fraction, duration of anginal symptoms, hypertension, hyperlipidemia, family history, or obesity (all not significant). A greater number of cases had diabetes (35 versus 18; p = 0.009). Angiography before initial PTCA revealed that cases had a greater mean number of total lesions (4.1 versus 3.3; p = 0.002) and a higher incidence of left anterior descending and circumflex artery stenoses of 70% or greater (98 versus 75 and 57 versus 34, respectively; p = 0.006). The mean number of lesions successfully dilated was greater in cases (2.4 versus 1.7; p = 0.0001). Cases had CABG at a mean interval of 16.7 +/- 23 months. There were 17 late deaths among cases and 9 among the controls at a mean of 38.6 +/- 30 months. The survival probability at 5 years was 94.5% for controls and 87.9% for cases (p = 0.048). Initial revascularization by PTCA is followed by CABG at a brief interval in a subset of patients who have markers of more severe disease than do patients who do not require early CABG.(ABSTRACT TRUNCATED AT 250 WORDS)

Utility of various clinical, noninvasive, and invasive procedures for determining the causes of recurrence of myocardial ischemia or infarction ≥1 year after percutaneous transluminal coronary angioplasty

In patients with recurrent symptoms ≥1 year after successful percutaneous transluminal coronary angioplasty (PTCA), the decision of whether to proceed directly with coronary angiography or to evaluate the patient noninvasively can be difficult. To determine which demographic, historical, clinical, and laboratory factors are useful in helping to make this decision, 76 consecutive patients who presented >1 year (768 ± 309 days) after successful PTCA with resolution of symptoms were studied. The initial PTCA successfully treated all stenoses (except chronically occluded vessels) in all major vessels and segments. The patient group was predominantly men (68%), with a mean age of 64 ± 10 years. A prior myocardial infarction was present in 39 patients (51%), and there was a mean or 2.8 risk factors per patient. In patients who presented with recurrent symptoms, the Canadian Cardiovascular Society functional class was 2.0 ± 0.9; 2 patients presented with acute infarctions, 57 were admitted to the hospital with unstable angina, and 17 had stable angina. New electrocardiographic changes at rest were found in 19 of 74 patients (26%) with recurrent angina. A thallium stress test was performed in 40 patients (53%), with a sensitivity of 77% and a specificity of 36% for the presence of a significant stenosis. No nonangiographic variable was predictive of angiographic findings. At angiography, the number of coronary arteries with ≥50% diameter narrowing was 1.4 ± 1.0. Forty-two patients had stenosis at a new site, 7 had restenosis, and 27 had no new stenoses. Thus, differentiation between restenosis, disease progression, and quiescence is only accomplished by coronary angiography, since neither clinical nor noninvasive parameters are predictive of changes in coronary anatomy.

Angiographic follow-up after successful percutaneous coronary angioplasty for chronic total coronary occlusion: Experience in 110 consecutive patients

Percutaneous transluminal coronary angioplasty (PTCA) was performed in 110 consecutive patients (111 vessels) with chronically occluded coronary arteries and was successful in 69 patients (69 vessels). Successful initial PTCA was related to the extent of coronary artery disease, the morphology of the proximal surface of the occlusion site, and the clinical duration of occlusion. Repeat angiography was performed for 62 patients, with successful initial PTCA and demonstrated restenosis in 34 (55%) patients, of whom 11 had total occlusion. Repeat PTCA was performed in 30 patients and was successful in 80%. Follow-up angiography after repeat PTCA was carried out in all patients who underwent successful second PTCA, and, it demonstrated re-restenosis in 7 (29%) patients. In this study, among 111 total occlusions, 28 vessels undergoing successful initial PTCA and 17 undergoing successful repeat PTCA were free from restenosis or re-restenosis at the time of follow-up angiography.