Percutaneous Coronary Angioplasty Procedures Research Articles

P51 HYBRYD TREATMENT FOR CORONARY ARTERY DISEASE CONCOMITANT WITH MINIMALLY INVASIVE CARDIAC VALVE SURGERY

Abstract Cardiac valvular surgery concomitant with coronary artery bypass grafting has a higher mortality than isolated valve surgery. Therefore, a hybrid approach that combines the benefits of the low risk of percutaneous coronary angioplasty (PCI) with those of minimally invasive valve surgery, should be considered. At present, data on hybrid valve/PCI procedures are limited to clinical cases and small cases, in which the PCI procedure is usually followed by surgery after about 3 weeks. We report our experience in which valve surgery was first performed with a minimally invasive approach (minithoracotomy or ministernotomy), then followed by coronary revascularization with PCI, to reduce the risks of post–surgical bleeding due to anti–aggregating therapy, in a non–randomized but consecutive case. Between July 2019 and June 2021, 22 patients were treated. Median of the days between surgery and PCI was 8, median of total hospitalization was 13 days. In 6 patients the surgical approach was a ministernotomy, in 16 was performed a right minithoracotomy. In 14 (64%) patients PCI was performed on single coronary vessel, in 5 (22.5%) on 2 coronary vessels and in 3 (13.5%) on 3 coronary vessels. There were no reinterventions for postoperative bleeding. One patient presented gastro–intestinal bleeding from a colon polyp. No patients died during hospitalization, nor at the follow–up performed by telephone every 6 months. No patients required valve reintervention or coronary artery bypass during hospitalization or follow–up. One patient underwent a new PCI procedure at 7 months. In conclusion, the hybrid approach consisting of minimally invasive valve surgery followed by PCI may offer an alternative to the standard but more complex operation of coronary artery bypass grafting plus valve surgery through complete sternotomy.

Modified Radial Technique

In 1948, Radner described the first radial approach for the cardiovascular study. Subsequently, in 1989, L. Campeau described the radial technique to perform a coronary angiography, and in 1993 F. Kiemeneij used it for a percutaneous coronary angioplasty procedure, emerging the trans radial access as an attractive alternative to the femoral access. New advances in interventionism have made the radial approach an easily accessible technique, without major complications and with greater comfort for the patient. It certainly requires a greater learning curve than the femoral one; however, its advantages over femoral access have been demonstrated. Of the complications the most frequent is the spasm that leads to failure in 38% of the procedures and produces dissections, ruptures, avulsion, etc; despite the use of spasmolytic agents or prior anatomic evaluation. Therefore, we have shown that the technique can be modified simply with the placement of a 25cm hydrophilic introducer that avoids crossing through the forearm segment. With which all kinds of complications are avoided, generating greater comfort in the patient and technically favoring the procedures.

Investigation of dose to patients in conventional cardiac intervention

Objective To investigate patient doses undergoing routine interventional cardiology procedures in China. Methods A retrospective analysis was performed on 238 adult patients who achieved one of interventional procedures including coronary angiography (CAG), percutaneous coronary angioplasty (PTCA) and radiofrequency catheter ablation (RF). According to intervention operations, all cases were divided into three groups: CAG (77), PTCA (95) and RF (66). Data of four special metrics, peak skin dose (PSD), dose-area product (DAP), cumulative dose (CD), and fluoroscopy time (FT), these parameters were measured and collected for these procedures. Frequencies of high-dose cases (PSD>2 Gy and PSD>3 Gy) were specifically recorded. Third quartile of DAP distribution was used to establish dose reference level (DRL) and then DRL values in this study were compared with ones reported in literatures. Wallis Kruskal rank-sum test was used to compare radiation dose of patients undergoing different intervention procedures. The total correlation among CD, DAP and PSD was analyzed by Spearman method. Results For patients undergoing CAG,PTCA and RF procedure, the median PSDs were 0.24, 1.05 and 0.62 Gy, respectively.The median DAPs were 34.99, 94.53 and 36.33 Gy·cm2, respectively.The median CDs were 0.39, 1.27 and 0.36 Gy, respectively.The median FTs were 4.50, 15.31 and 13.40 min, respectively. The difference among procedures was statistically significant (χ2=105.083, 92.032, 115.509, 100.883, respectively, P 2 Gy, including 14 patients undergoing PTCA and 8 patients undergoing RF. There were 1.6% (22/238) patients with PSD>3 Gy, including 1 patients undergoing PTCA and 3 patients undergoing RF. The DRL for PTCA in this study is 133 Gy·cm2 and higher than that in literatures. The DRL for CAG in this study is 46 Gy·cm2 and slight lower than that in literatures. The DRL for RF in this study is 49 Gy·cm2. Conclusion Data from this study are in the range of most reported values for CAG and RF procedure, while higher than that obtained in some literatures for PTCA. Key words: Heart; Radiology, interventional; Radiation dose; Comparative study

Rheolytic Thrombectomy during Percutaneous Coronary Intervention Improves Long‐Term Outcome in High‐Risk Patients with Acute Myocardial Infarction

Aim of the present study was to compare the immediate and long-term effects of AngioJet rheolytic thrombectomy performed in the setting of a percutaneous coronary angioplasty (PTCA) with those of conventional PTCA in patients with acute myocardial infarction (AMI) and angiographic evidence of high intracoronary thrombus burden. Plaque rupture, with subsequent exposure to the flowing bloodstream of high thrombotic materials often leads to intravascular thrombosis, representing the main pathophysiological event of acute coronary syndromes. PTCA is the first-choice treatment for these patients in hospitals with cardiac catheterization facilities. However, distal embolization of thrombotic material, fibrin, and other fragments from atherosclerotic plaques might lead to procedural failure. Immediate and 1-year follow-up results of a group of 30 consecutive patients, presenting with AMI and angiographic evidence of high thrombus burden, who underwent rheolytic thrombectomy and PTCA were compared with those of 30 consecutive patients with similar clinical presentation, risk profile, and angiographic picture, and treated with standard PTCA procedure. After the procedure, angiographic analysis showed a higher incidence of final thrombolysis in myocardial infarction (TIMI) flow grade 3 in the AngioJet group (93.3% vs 83.3%, P = 0.034). In addition, mean corrected TIMI frame count (cTFC) was significantly lower in the AngioJet group (22.4 vs 32.4, P = 0,0004). At 1-year follow-up, patients treated with AngioJet showed a significantly lower incidence of death (3.33% vs 13.33%,P < 0.001), major adverse cardiac events (MACE: 10% vs 30%, P = 0.026), and need of revascularization (6.67% vs 20%, P = 0.013). Data of the present study highlight that AngioJet thrombectomy in selected AMI patients at high risk for distal thrombotic embolization results not only in immediately improved angiographic results as compared to conventional PTCA but, indeed, seems to be associated with a significantly better long-term clinical outcome.

Seguimiento clínico al año de angioplastias coronarias exitosas en pacientes no seleccionados

Re-stenosis after percutaneous coronary angioplasty (PTCA) is related to clinical and angiographic features. To describe the clinical and angiographic characteristic of our patients with coronary cardiopathy subjected to PTCA and the predictor factors for re-stenosis. We gathered the clinical and angiographic characteristics of all patients who underwent a successful PTCA of a native coronary artery. All patients had a clinical assessment one year after the procedure. Patients were classified in Group 1, if they did not have angina or coronary events after the angioplasty or Group 2, if they had angina or a coronary event after the procedure. Only Group 2 patients were subjected to a coronary angiogram. We collected 383 PTCA procedures. Follow up information was obtained in 92.2%. Three hundred forty two patients (89.3%) were assessed one year the procedure. Nine patients (2.3%) died of a cardiovascular cause. Ninety patients (26.3%) were classified in Group 2. In 65 patients, angiographic re-stenosis was demonstrated (19%). Re-stenosis occurred in 36 and 13% of patients with an without Diabetes Mellitus, respectively (p <0.01). The other clinical predictor variables were a history of myocardial infarction (p =0.007), obesity (p =0.041) and hypercholesterolemia (p =0.050). None of the angiographic characteristics predicted restenosis. Stents were protective factors against restenosis (15.6% in stented lesions vs 25.4% in nonstented; p =0.01). Re-stenosis after angioplasty occurred in 19% of our patients with angina or coronary events. The clinical variables associated with a higher risk of re-stenosis were diabetes (the main risk factor), previous myocardial infarction, obesity and hypercholesterolemia. Angiographic variables were not associated with re-stenosis. The use of stents decreases the incidence of re-stenosis in all groups).

Smoking cessation reduces mortality after coronary artery bypass surgery: a 20-year follow-up study

OBJECTIVESThe goal of this study was to determine the influence of smoking cessation on mortality after coronary artery bypass graft surgery (CABG), which has still not been established clearly.BACKGROUNDCigarette smoking is one of the known major risk factors of coronary artery disease.METHODSOne thousand and forty-one patients underwent CABG between 1971 and 1980. The preoperative and postoperative smoking habits of 985 patients (95%) could be retrieved and were analyzed in a multivariate Cox analysis.RESULTSThe median follow-up was 20 years (range 13 to 26 years). Smoking status before surgery did not entail an increased risk of mortality: patients who had smoked before surgery and those who had not smoked in the year before surgery had a similar probability of survival. However, smoking cessation after surgery was an important independent predictor of a lower risk of death and coronary reintervention during the 20-year follow-up when compared with patients who continued smoking. In analyses adjusted for baseline characteristics, the persistent smokers had a greater relative risk (RR) of death from all causes (RR 1.68 [95% confidence interval 1.33 to 2.13]) and cardiac death (RR 1.75 [1.30 to 2.37]) as compared with patients who stopped smoking for at least one year after surgery. The estimated benefit of survival for the quitters increased from 3% at five years to 14% at 15 years. The quitters were less likely to undergo repeat CABG or a percutaneous coronary angioplasty procedure (RR 1.41 [1.02 to 1.94]).CONCLUSIONSPatients who continued to smoke after CABG had a greater risk of death than patients who stopped smoking. They also underwent repeat revascularization procedures more frequently. Cessation of smoking is therefore strongly recommended after CABG. Clinicians are encouraged to start or to continue smoking-cessation programs in order to help smokers to quit smoking, especially after CABG.

Quantitative Doppler tissue imaging for assessment of regional myocardial velocities during transient ischemia and reperfusion

Doppler tissue imaging (DTI) is a new noninvasive imaging modality that directly interrogates myocardial velocity with high temporal and spatial resolution. This study was designed to test the hypothesis that quantitative DTI provides unique information regarding regional myocardial systolic and diastolic function during acute ischemic events. Myocardial velocities were quantified during the acute ischemic and reperfusion phases of 13 elective percutaneous coronary angioplasty procedures in 12 patients. In myocardium subtended by angioplasty vessels, peak velocities decreased during occlusive balloon inflation (from 21.2 ± 9.8 to −0.6 ± 4.0 mm/sec in systole [ p < 0.001] and from 21.7 ± 9.2 to −0.6 ± 3.9 mm/sec in diastole [ p < 0.001]). During early reperfusion, velocities exceeded those observed at baseline ( p = 0.003). In regions remote from the treated artery, peak myocardial velocities increased in the absence of significant stenosis but remained unchanged or decreased in the presence of significant stenosis of the associated vessel. We conclude that (1) myocardial velocities rapidly decrease during acute ischemia and show a rebound increase after reperfusion, and (2) in regions remote from ischemia, velocities display distinct patterns on the basis of the presence or absence of obstructive coronary disease in the associated vessel. Quantitative DTI is a useful tool for the assessment of myocardial velocity and may provide new insights into myocardial systolic and diastolic function.

Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty. A 10-year experience.

Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.

Acute complications of percutaneous transluminal coronary angioplasty for total occlusion

The incidence of major complications after percutaneous coronary angioplasty (PTCA) of a totally occluded artery was assessed retrospectively. A total of 1649 PTCA procedures were analyzed. After exclusion of procedures for acute myocardial infarction or total occlusion that resulted from restenosis, 90 patients were selected. Forty-four patients (49%) had stable angina and 46 (51%) had unstable angina. The estimated duration of occlusion was 87 ± 78 days in patients with stable angina, as compared with 10 ± 8 days in patients with unstable angina (p < 0.001). Abrupt vessel closure during PTCA occurred only in patients with unstable angina (0% versus 17%, p < 0.05). The major complication rate was 2.5% in the stable angina group, and 20% in unstable angina group (p < 0.01). This rate was also significantly higher than the complication rate of 8% observed in 442 procedures that were performed during the same period in patients with the unstable angina and nonocclusive stenosis (p < 0.01). Patients with unstable angina who undergo PTCA of a totally occluded artery represent a subset at high risk for major complications.

Extracorporeal membrane oxygenation for percutaneous coronary angioplasty in high risk patients.

Improvements in percutaneous coronary angioplasty (PTCA) have broadened the scope of this therapy to higher risk patients. The authors used an extracorporeal membrane oxygenator (ECMO) system during seven PTCA procedures to provide rapid, safe, cardiopulmonary support for high-risk patients. Six patients underwent femoral cutdown and placement of arteriovenous cannulae before PTCA; one patient was cannulated percutaneously. In two patients, no ECMO support was used, whereas two of the remaining five patients were maintained on low flow (1.5 L/min) during the procedure and three patients were maintained with higher flows (average 3.0 L/min). All patients were removed from cardiopulmonary support with satisfactory hemodynamics and maintained on i.v. heparin for 12-48 hours. In six patients groin hematomas developed, in four deep venous thrombosis developed, and in one patient arterial occlusion after percutaneous cannulation developed. One patient died of retroperitoneal hemorrhage unrelated to the ECMO cannulation site. Six patients survived. This system can be rapidly deployed while providing satisfactory cardiopulmonary support.