Intracoronary Thrombolytic Therapy Research Articles

Clot Management in Primary Percutaneous Coronary Intervention: Fighting Your Enemy

Clot is often the enemy during primary percutaneous coronary intervention. Taking inspiration from the ancient wisdom of fighting a war, an interventionist should first look into the strength of the enemy, i.e. assess the thrombus burden, by both Thrombolysis in MI thrombus grade and angiographic features. This is to be followed by choosing the appropriate strategy: to attack – aspiration and mechanical thrombectomy; to surround – pharmacological therapy, including oral and parenteral antiplatelet therapy and intracoronary thrombolytic therapy; to avoid – stenting strategies including direct stenting and deferred stenting; to battle – stenting under a distal protection device or stenting across local obstructive thrombus; or to flee – to move from percutaneous coronary intervention to optimal antithrombotic therapy and circulatory support when flow fails to be regained. Of note, most of these strategies have not been demonstrated to be beneficial on routine use. The key remains to adopt different strategies selectively and appropriately in different scenarios.

Safety and efficacy of intracoronary thrombolytic therapy via a new infusion catheter in patients with ST-segment elevation myocardial infarction with large thrombus burden: a pilot study.

A large intracoronary thrombus burden is associated with adverse clinical results. The optimal management of this scenario remains unknown. We aimed to determine the efficacy and safety of a new rapid infusion catheter combined with low-dose intracoronary thrombolysis in patients with ST-segment elevation myocardial infarction (STEMI) with a large thrombus burden. This pilot study included 22 patients with STEMI with a large thrombus burden. A large thrombus burden was defined as a definite thrombus with the largest dimension of at least two vessel diameters [thrombolysis in myocardial infarction (TIMI) thrombus grades 4 and 5]. All patients received primary percutaneous coronary intervention guided by the presence of recurrent chest pain or clinical myocardial ischemia evidences. All patients regained myocardial perfusion immediately after the infusion catheter crossed the thrombus. Local fibrinolysis with low-dose recombinant human prourokinase was administered continuously via the infusion catheter for 30 min. Repeat coronary angiography revealed marked thrombus resolution, with an improvement in TIMI flow from 0.14 ± 0.35 at baseline to 2.82 ± 0.40. Only one patient with postlysis thrombus grades 4-5 was observed. No major bleeding events were observed. In patients with STEMI presenting with a large thrombus burden, all patients regained myocardial perfusion immediately after the infusion catheter crossed over the thrombus, and low doses of intracoronary thrombolysis could significantly reduce the thrombus burden and improve the coronary flow without major bleeding.

Administration of Intracoronary Streptokinase During Primary Percutaneous Coronary Intervention for Anterior Wall Myocardial Infarction with Definite Coronary Thrombosis

Background: The presence of intracoronary heavy thrombus burden during primary percutaneous coronary intervention (PCI) plays increases the incidence of occurrence no-reflow phenomenon. Intracoronary thrombolytic therapy during primary PCI may improve microvascular perfusion. The aim of this study was to assess the effect of using 250,000 U of intracoronary streptokinase during primary PCI in patients presenting with an acute anterior wall ST segment elevation myocardial infarction (STEMI) with a definite thrombus in the left anterior descending coronary artery (LAD) on clinical and angiographic outcomes. Methods: Prospective cohort study conducted on 100 patients managed by primary PCI within 12 hours of symptom onset. Patients were divided into a study group (n=50) that received intracoronary streptokinase during primary PCI, and a control group (n=50) that received no additional therapy. Post-procedural TIMI flow grade, myocardial blush grade (MBG), and corrected TIMI frame count were assessed. Admission and peak CK-MB and percentage of ST segment resolution were recorded. At 6-months follow-up, assessment for major adverse cardiovascular events (MACE) was performed. Results: There were no differences between both groups regarding baseline clinical characteristics, time to reperfusion, and risk factors for the development of coronary artery disease. Peak CK-MB was significantly higher in the control group (p = 0.004). In the study group, a larger proportion of patients had TIMI 3 flow at the end of the procedure 42 (84%) vs 29 (58%) – p = 0.026, and a larger proportion had MBG 2 and 3, 23 (46%) vs 17 (34%) and 24 (48%) vs 14 (28%), respectively – p = 0.001. Corrected TIMI frame count at the end of the procedure was significantly smaller in the study group 24.2 ± 4.97 vs 31.28 ± 6.7 frames (p<0.0001). Conclusion: Administration of intracoronary streptokinase during primary PCI in patients presenting with acute anterior STEMI with definite coronary thrombosis improves coronary perfusion by improving TIMI flow grade, MBG, and shortening corrected TIMI frame count.

A Study of Low-dose Intracoronary Thrombolytic Therapy in STEMI (Heart Attack) Patients.

A Study of Low-dose Intracoronary Thrombolytic Therapy in STEMI (Heart Attack) Patients.

Role of Intracoronary Fibrinolytic Therapy in Contemporary PCI Practice.

Plaque rupture or plaque erosion leads to intracoronary thrombus formation resulting in coronary artery occlusion and ST-segment elevation myocardial infarction. Early restoration of blood flow in occluded coronary artery is the mainstay of therapy and it can be achieved by either thrombolytic therapy or primary percutaneous coronary intervention (P-PCI) or a combination of these two in many different ways. It has been proved that primary PCI is better than thrombolytic therapy in establishing early and effective recanalization of infarct related artery, reducing major adverse cardiovascular events (MACE) and increasing survival. There have been tremendous advances in PCI techniques over the years with newer stents, thrombectomy devices, and adjunctive pharmacotherapy. However, intracoronary thrombus continues to be the bane of interventional cardiologists. Failure of recanalization, suboptimal results, distal embolization, no reflow and impaired myocardial perfusion are some of the unresolved difficulties, regularly seen during PCI of patients with large intracoronary thrombus burden indicating an unmet need. This review focuses on emerging evidence about the usefulness of intracoronary thrombolytic therapy as an adjunct to PCI in patients with large intracoronary thrombus burden.

The application of intracoronary thrombolytic therapy during primary percutaneous coronary intervention in elderly patients with acute ST-segment elevation myocardial infarction

Objective To evaluate the efficacy and safety of intracoronary thrombolysis during primary percutaneous coronary intervention(PCI)in elderly patients with acute ST segment elevation myocardial infarction(STEMI). Methods This prospective study was conducted at the Department of Cardiology of Shangqiu First People's Hospital.Elderly patients diagnosed with STEMI and undergoing primary PCI were consecutively recruited from September 2016 to September 2017.Of all recruited patients, 106 patients were successfully followed up and were randomly divided into a treatment group(intracoronary thrombolysis group, n=54)and a control group(intracoronary saline group, n=52). Patients in the treatment group received an injection of 10 mg recombinant prourokinase(10 ml)via a balloon catheter while patients in the control group were injected with 10 mL saline instead.The incidences of slow flow, bleeding in 3 days after operation, left ventricular ejection fraction(LVEF), left ventricular end diastolic diameter(LVEDD), and major adverse cardiovascular events(MACE)in 90 days after operation were compared between the two groups. Results Compared with the control group, the treatment group had a decreased incidence of slow flow(χ2=4.06, P 0.05). The treatment group also had an elevated incidence of LVEF(t=2.95, P 0.05). Conclusions In elderly patients with STEMI, intracoronary thrombolysis during primary PCI can reduce the incidence of slow flow during operation, and improve the function and size of left ventricle without increasing the incidence of bleeding. Key words: Myocardial infarction; Angioplasty, transluminal, percutaneous coronary; Thrombolytic therapy

TCTAP C-164 Role of Intracoronary Thrombolytic Therapy During Percutaneous Coronary Interventions

### Patient initials or identifier number SAHA ### Relevant clinical history and physical exam A 70-years-old patient with chest pain on exertion was investigated for coronary artery disease. He had diabetes mellitus and dyslipidemia. Cardiac examination was unremarkable, with a heart rate 74 bpm

Comment on "Dual Prosthetic Heart Valve Presented with Chest Pain: A Case Report of Coronary Thromboembolism".

We have recently read with great interest the case report by S. Wongrakpanich et al. describing a patient with a history of dual prosthetic heart valves and atrial fibrillation who developed coronary embolism (CE) due to inadequate anticoagulation [1]. Thanks are due to the authors for their contribution of the present report including a rare complication of prosthetic valve thrombosis (PVT). On the other hand, we want to make essential criticism regarding some major drawbacks in the management of the patient. CE is a rare cause of acute coronary syndrome (ACS) in patients with prosthetic heart valves. The majority of patients with prosthetic heart valve who were admitted with ACS had non-ST elevation ACS rather than ST segment elevation ACS [2]. The information in the literature about this complication is scarce and mainly based on case reports. There is a controversy regarding the treatment of patients with CE. In the current literature, intracoronary or intravenous thrombolytic therapy (TT), stent implantation, and embolectomy were performed as reperfusion strategies, but there is no consensus regarding the optimal treatment. In the case report presented by S. Wongrakpanich et al. a 54-year-old man with two ball-caged metallic prosthetic valves in mitral and aortic position was admitted with ACS. He had a history of left embolic stroke 15 years ago and international normalized ratio on the last admission was subtherapeutic. The authors performed emergent coronary angiography (CAG) before evaluation of the prosthetic valve with transthoracic (TTE) or transesophageal echocardiography (TEE). CAG revealed a thrombus image in the middle segment of the circumflex coronary artery which was aspirated successfully. The underlying vessel structure was normal which was consistent with a coronary embolism. So they performed TTE which revealed acceptable pressure gradients across both mechanical prostheses. First of all, the major concern regarding the management of this patient is that, even with the gradients and orifice area being within normal limits, TTE is usually uncapable of demonstrating the presence of nonobstructive thrombus on the prosthetic valves, necessitating TEE examination. Since the patient had aortic prosthesis, urgent conventional CAG without TEE examination carried a high risk of new potential thromboembolism due to catheter manipulation during CAG. Although the patient was not complicated with new thromboembolism, it would be better if they performed CAG just after TEE findings suggested that catheter intervention would be safe. Another noteworthy issue regarding the management of the patient is that, when a patient with prosthetic valve was admitted with ACS, PVT was needed to be excluded by TEE before CAG. This strategy helps the clinician to decide what to do during percutaneous interventions. If there is no PVT, you may focus on solving the coronary problem only; however if there are signs of PVT, you should find solutions for two problems. In such situations TT may be a favorable treatment strategy which aims to lyse both valvular and coronary thrombi in the absence of contraindications. The fresh nature of the embolic thrombus may play a role in the successful outcomes of TT. In our recently published case series TT was considered as an initial therapy in the management of PVT and related CE with successful outcomes for both prosthetic and coronary thrombosis [3]. Treatment modalities for PVT include heparin treatment, TT, and surgery. Guidelines lack definitive class I recommendations due to lack of randomised controlled trials and usually leave the choice of treatment to the clinician's experience. Surgery is suggested as a first line strategy in most situations of left sided PVT; however, TT has been recently used with successful outcomes [4, 5]. We have previously reported that low dose (25 mg) and slow infusion (6 hours) of tPA is very safe and associated with very high thrombolytic success in this regard [4]. As a result, we can conclude that CAG should be deferred after TEE due to risk of thromboembolism during catheter manipulation in aortic PVT patients and also in order to decide the best treatment strategy for PVT patients who were admitted with ACS. TT should be considered as an initial treatment modality in these patients. Low dose and prolonged infusion of tPA is an effective regimen which can be safely performed in the absence of contraindications.

Coronary Artery Embolism Causing Acute Myocardial Infarction in Patients with Mechanical Heart Valve Prosthesis: Which is the Optimal Treatment?

Coronary artery embolism resulting in acute myocardial infarction (AMI) is an infrequent but potentially life-threatening occurrence. To date, there is still no consensus in the literature regarding the optimal therapeutic algorithm for embolic myocardial infarction. We present our experience with three patients who had mechanical valve prosthesis and suffered from AMI due to coronary artery embolism in the setting of sub-therapeutic or interrupted anti-coagulation therapy. Those patients were treated with intracoronary thrombolysis, thrombus aspiration followed by balloon angioplasty and thrombus aspiration alone, respectively. In our case 1, the coronary angiogram demonstrated extensive thrombus within the left circumflex coronary artery and extending into the left anterior descending (LAD). We performed intracoronary thrombolytic therapy, which results in completed thrombus resolution and favourable clinical outcome. In our case 3, coronary angiography revealed massive thrombus within the middle-LAD with a TIMI grade 3 distal flow. The patient underwent a successful thrombus aspiration procedure without stent implantation. In our case 2, the coronary angiography revealed total occlusion of the middle LAD, and thrombus aspiration was initially performed because of the large thrombus burden. However, this approach was unsuccessful and so the patient was then treated with balloon angioplasty, resulting in TIMI 2 flow. Embolic myocardial infarction, although uncommon, can occur in predisposed groups such as those with prosthetic mechanical valves with sub-therapeutic anticoagulation. The treatment for this specific group of patients needs to be tailored individually.

“Rescue administration” of intracoronary thrombolytic therapy for drug-eluting stent thrombosis

Stent thrombosis is an example of device-induced, platelet-mediated arterial thrombosis with a potentially fatal adverse event that often leads to myocardial infarction and/or death. The optimal treatment of patients with drug-eluting stent thrombosis in whom mechanical thrombectomy has failed is not established. This case demonstrates the usefulness of intracoronary thrombolysis after failed mechanical thrombectomy in patients with stent thrombosis. To our knowledge, this is the first report on using intracoronary thrombolysis in this specific situation.

Herzinfarkt (NSTEMI) bei einem jungen Patienten mit Koronaraneurysma

A 28-year-old man without a significant past medical history presented to our emergency department with severe chest pain and dyspnoa. Vital signs and the rest of the physical examination were unremarkable. The electrocardiogram showed T-wave inversions and the cardiac enzymes were elevated. Angiocardiography showed an aneurysm of the right coronary artery and a thrombus formation in its distal part. Intracoronary thrombolytic therapy was attempted an oral anticoagulation was started. Further investigations did not find the cause of the aneurysmatic RCA. The patient had no further episode of chest pain. Acute coronary syndrome is a rare finding in patients under the age of 30 years. Coronary aneurysms with associated thrombus can be the cause of it.

Intracoronary thrombolytic therapy

The benefit of the routine application of aspiration thrombectomy in primary percutaneous coronary intervention (PPCI) is now well established. The optimal management of patients who have "failed" thrombectomy characterized by a large residual thrombus burden after repeated mechanical thrombectomy, however, is not known. We report a case of failed aspiration thrombectomy in a 66-year-old woman who was admitted to our institution with chest pain associated with inferior ST segment elevation. Coronary angiography showed a thrombotic occlusion of the right coronary artery. Aspiration thrombectomy did little to reduce thrombus load and so the patient was treated with intracoronary tenecteplase. Repeat coronary angiography 18 hr later revealed marked thrombus resolution with thrombolysis in myocardial infarction (TIMI) grade 3 anterograde flow and patency of the infarct-related artery was maintained at 2-month follow up. This case demonstrates the potential for intracoronary thrombolytic therapy as a treatment option for the management of patients following failed thrombectomy in PPCI.

Pharmacoinvasive therapy for acute myocardial infarction

Thrombus remains the bane of interventional cardiology. The use of thrombus extraction devices and distal protection devices has been controversial. Pharmacological modulation using intracoronary (IC) thrombolytic therapy during percutaneous coronary intervention (PCI) is also not an established choice although intravenous thrombolytic therapy is widely accepted and applied treatment of choice for acute ST-elevation myocardial infarction (STEMI). This case report shows successful management of a patient of STEMI using a combination of IC thrombolytic therapy, thrombectomy device, and PCI.

Time dependence of myocardial preservation after thrombolysis. Consequences for indication and procedure

To examine whether the limitation in infarct size after effective thrombolytic therapy is time-dependent the relationship between left ventricular wall motion in the infarct region and the time interval between onset of symptoms and intracoronary streptokinase infusion was investigated. The relationship was significant: When intracoronary thrombolytic therapy was begun within 2 hours, wall motion was almost always within normal limits, whereas the probability of wall motion improvement fell to less than 50%, when treatment was begun later. As a further step a lysis procedure was examined which took account of these findings: the intravenous bolus injection of urokinase. Approximately one hour after bolus injection coronary patency could be demonstrated angiographically in 60% of the infarct patients. A clinically relevant limitation of the infarct size was found in those patients in whom lysis therapy could be begun within 2 hours. On the basis of these findings, a thrombolytic therapy seems to be indicated in all patients with acute myocardial infarction when lysis treatment can be begun within 2 hours. The intravenous urokinase therapy, by virtue of its simplicity, is an alternative to intravenous streptokinase therapy.

Persistent and proximal migration of a large coronary thrombus during percutaneous coronary intervention in the setting of acute Q-wave myocardial infarction

We describe a patient with an acute inferior myocardial infarction. Patient was taken to the cardiac catheterization laboratory for primary angioplasty. Angiography revealed 100% occluded proximal right coronary artery (RCA). After initial balloon angioplasty of the occluded RCA, a very large mobile thrombus was seen in the proximal RCA. Despite multiple stenting, suctioning through the guide catheter lumen, and intracoronary thrombolytic therapy, the thrombus persisted and migrated proximally after each stenting. However, patient did well despite of persistent large thrombus burden in the proximal RCA on aggressive antithrombotic treatment.

Preexisting Antibodies to Platelet Factor 4-Heparin Complexes in Patients with Acute Coronary Syndrome Who Have No History of Heparin Exposure

Preexisting heparin-induced thrombocytopenia (HIT) antibodies are detected in some patients who have not previously been exposed to any kind of heparin. However, the role of preexisting HIT antibodies in acute coronary syndrome (ACS) is still unknown. This study was carried out to clarify the role of preexisting HIT antibodies in patients with ACS. Forty patients with ACS who had not been exposed to any kind of heparin via the venous or subcutaneous route or heparin-coated materials and had undergone percutaneous coronary intervention (PCI) under heparin anticoagulation within 6 h from the onset of ACS were chosen from the medical records in the cardiac emergency department. As a control of the ACS patients, 51 patients with angina pectoris who underwent elective PCI under heparin anticoagulation were chosen in the same manner as the ACS patients. Preexisting HIT antibodies were detected by ELISA in 6 patients. Two of the 6 patients developed HIT and 1 patient experienced thrombosis requiring intracoronary thrombolytic therapy. Thrombotic complications during and immediately after PCI in the very early stage after heparin administration were found in 4 of 6 patients with preexisting HIT antibodies. The frequency of preexisting HIT antibodies in ACS patients was significantly increased in comparison with that in non-ACS patients. The odds ratio of the risk of thrombotic complication between ACS and non-ACS patients was estimated at 8.82 (95% CI: 1.3–63). Also, preexisting HIT antibodies in ACS patients significantly increased the risk of thrombotic complications compared with ACS without preexisting HIT antibodies. In conclusion, ACS patients with positive HIT antibodies have an increased risk of thrombotic complications during PCI performed under anticoagulation with heparin.

Safety of adjunctive intracoronary thrombolytic therapy during complex percutaneous coronary intervention: Initial experience with intracoronary tenecteplase

Intracoronary thrombus is associated with increased risk of in-laboratory vessel closure, recurrent myocardial infarction (MI), urgent vessel revascularization, and death. There is a lack of consensus on what represents the ideal treatment for patients with thrombotic complications during percutaneous coronary intervention (PCI), but the development of newer thrombolytic agents with increased fibrin specificity and longer half-life provides a potentially useful treatment option. In this study, the safety and efficacy of intracoronary tenecteplase (TNK) was evaluated in 34 patients (22 with acute ST elevation MI, 4 with rescue PCI, 6 with non-ST elevation MI, and 2 during elective PCI) who developed no-reflow, distal embolization, or visible intracoronary thrombus during PCI. The mean age was 57 years, 76% were Caucasian, and there were 14 women and 20 men. Cardiogenic shock was present in seven (21%) patients at baseline. All patients were being treated with aspirin and either unfractionated heparin (33 patients) or bivalrudin. Glycoprotein IIb/IIIa inhibitors were used in 76% of patients. Intracoronary TNK was used at a mean dose of 10.2 +/- 5.2 mg (median, 10 mg; range, 5-25 mg). There was one TIMI major bleeding event and three TIMI minor bleeding events. The mean hematocrit measured the morning following PCI was 35.5% +/- 4.9% in patients receiving TNK and 36.5% +/- 4.4% in a randomly selected sample of 150 consecutive patients undergoing PCI (P = 0.25). In conjunction with mechanical intervention, TNK was successful at dissolving angiographic thrombus and/or improving flow in 91% of patients. In conclusion, intracoronary TNK is safe and well tolerated in patients who develop thrombotic complications during complex PCI.

Development and Pathophysiological Basis of Thrombolytic Therapy in Acute Myocardial Infarction: Part IV

Acute and day 10 to 14 recanalization rates with intracoronary thrombolytic and/or spasmolytic therapy were determined in the First Mt. Sinai‐N.Y.U. Reperfusion Trial (1984). Recanalization of total occlusion was accelerated by intracoronary streptokinase, the first proven potentially beneficial effect of thrombolytic therapy. Intravenous administration of thrombolytic agents, including t‐PA, was less effective in accelerating recanalization than intracoronary streptokinase as assessed by 90‐minute rates of TIMI‐III flow. In clinical practice the greater ease of intravenous administration outweighed this disadvantage, but intracoronary administration was uniquely suited to analyze the pathophysiological principles of reperfusion therapy. The first randomized trial (n = 533) to establish the benefits of early reperfusion, the Netherlands Randomized Trial, achieved infarct vessel patency in 85% of patients within 200 minutes of symptom onset by administering intracoronary streptokinase alone or following a rapid intravenous infusion of streptokinase. Ejection fraction improved significantly and mortality at 28 days was reduced (6% vs 12%). The ISIS‐2 Trial (1988) showed mortality reduction with intravenous thrombolytic therapy up to 24 hours after infarct onset, but did not explain the benefit of late reperfusion. In the Second Mt. Sinai‐N.Y.U. Reperfusion Trial (1989; n = 393), intracoronary streptokinase administered 4 to 14 hours after infarct onset increased thallium uptake. Streptokinase improved ejection fraction in patients with collateralized total occlusion but not in those with noncollateralized total occlusion. Preintervention antegrade flow was associated with ejection fraction improvement regardless of treatment assignment. We concluded that thrombolytic therapy after &gt; 4 hours of infarction salvages myocardium in patients with collateralized total coronary artery occlusion. Total coronary occlusion was associated with collateral flow in 33% at acute angiography, but in 90% at day 10 to 14 angiography, indicating a second phase of collateral growth. An angioplasty model was developed to assess appearance and disappearance of collateral flow immediately after controlled coronary occlusion and reflow in humans. Using this model we demonstrated limitation of ischemia by collateral recruitment prospectively.

Development and Pathophysiological Basis of Thrombolytic Therapy in Acute Myocardial Infarction: Part III, 1981–1985 Registries of Intracoronary Thrombolytic Therapy and Experimental Reperfusion Studies

The angiographic results of intracoronary thrombolysis were correlated with various outcome parameters in three registries. The West German Registry (n = 232) showed that mortality and improvement of left ventricular function were related to recanalization and prevention of reocclusion. This registry became the core database for the Food and Drug Administration (FDA) approval of thrombolytic agents for myocardial infarction in 1982. The European Registry (n = 414) analyzed changes in left ventricular ejection fraction further. A continuous model suggested that the functional benefit of reperfusion decreases rapidly and in a nonlinear fashion with delays in treatment during the first 3 hours. Reperfusion after &gt; 6 hours was still associated with a significant benefit, which appeared to be related to collateral flow to the infarct zone. Myocardial salvage in experimental reperfusion studies and the reperfusion injury controversy are reviewed. In experimental studies performed by our group, it was found that thrombolytic agents did not exacerbate myocardial hemorrhage or increase infarct size. The Goettingen Registry (n = 152) demonstrated that reperfusion resulted in a steeper slope of the regression line between infarct size determined by ventriculography and cumulative serial creatine kinase release. Furthermore, reperfusion was associated with transient loss of R waves and transient development of Q waves. The implications of these findings regarding the reperfusion injury controversy and assessment of infarct size are discussed. Other analyses of the Goettingen data found that flow patterns to the infarct zone at preintervention angiography correlated with the duration of angina pectoris, incidence of antianginal therapy, and baseline ejection fraction. Assessment of the reliability of the admission ECG showed that half of the patients with infarction due to occlusion of the circumflex artery lacked diagnostic changes. The Goettingen Registery followed the first group of 70 patients ever treated with intracoronary thrombolytic therapy for 3 years. Mortality was low by the standards of the time. Reperfusion was associated with sustained improvement of left ventricular function and often dramatic clinical stabilization not seen before.

Risk factors of stroke after percutaneous transluminal coronary angioplasty.

Objective: to determine possible risk factors of a stroke after percutaneous transluminal coronary angioplasty (PTCA). Design: this is a retrospective evaluation of a consecutive group of 4088 patients undergoing PTCA between 1988 and 1995. We have studied the incidence, clinical characteristics, risk factors, and outcome. Results: seven patients, six males and one female (0.17%) developed a stroke after this procedure. In comparison with the control group, the stroke group did not differ regarding age or gender. The existence of a stroke (six located in the brain, and one in the spinal cord), represented 1.24% of all complications (P < 0.001), and 5% of all deaths (P < 0.01) of PTCA. Three patients developed TIA, two patients developed hemorrhagic strokes (in which they received previous thrombolytic therapy), and the other two patients suffered from an ischemic stroke. The statistically significant risk factors of a stroke after PTCA included: intracoronary thrombolytic therapy (P < 0.01), hypercholesterolemia (P < 0.001) and a prior PTCA (P < 0.05). Conclusions: although these procedural complications are infrequent, they are usually serious and important risk factors which could be identified prior to the procedure. These risk factors would allow identification of patients who are prone to a stroke after PTCA. Intracranial hemorrhage occurred only after thrombolytic therapy, and the factors related to hemorrhagic strokes were probably different from those predisposed to ischemic strokes and TIA. Copyright 1998 Lippincott Williams & Wilkins