Percutaneous Transluminal Coronary Angioplasty Attempt Research Articles

Real-time assessment of acute myocardial ischaemia by an intra-thoracic 6-lead ECG: evaluation of a new diagnostic option in the implantable defibrillator†

In the presence of coronary artery disease, implantable cardioverter-defibrillators (ICD) are used effectively for treating life-threatening tachyarrhythmias. Continuous monitoring of myocardial ischaemia would provide a new diagnostic option in future ICD generations. In 22 selected patients undergoing coronary angioplasty, percutaneous transluminal coronary angioplasty (PTCA), three electrodes, similar to those used in the ICD, were inserted aiming to create six intra-thoracic ECG (IT-ECG) leads according to Einthoven and Goldberger. In total, 27 PTCA were conducted. The diagnostic efficacy for ischaemia assessment was compared with the surface ECG. The IT-ECG proved to be more sensitive than conventional ECG in early and overall ischaemia assessment. At 30 s of coronary artery occlusion, ischaemic ST-segment alterations (> or =0.25 mV) were present in the IT-ECG 2.3 times more often (23 vs. 10/27 PTCA attempts, P<0.01) and at 90 s 1.4 times more often compared with conventional ECG leads (18 vs. 26/27, P<0.05). Intra-thoracic Einthoven 2 (SVC+RVA vs. ICD-housing) and Goldberger 3 (SVC+ICD-housing vs. RVA) had the highest sensitivity (88/85%). Using > or =4 IT-ECG, ischaemia monitoring was independent of severity and site of origin. IT-ECG signals showed double ST-T signal amplitude (4.19+/-0.6 vs. 2.15+/-0.3 mV, ratio: 1.95, P<0.01) at a QRS/ST amplitude ratio similar in the two ECG techniques. This study provides strong evidence that the ICD-based IT 6-lead ECG would provide a new and efficient means of assessing a patient's daily ischaemic burden.

Sustained benefit of stenting chronic coronary occlusion: long-term clinical follow-up of the Stenting in Chronic Coronary Occlusion (SICCO) study

Objectives. This study assessed the long-term clinical outcome of stenting chronic occlusions.Background. In the Stenting in Chronic Coronary Occlusion (SICCO) study, patients were randomized to additional stent implantation (n = 58) or not (n = 59) after successful recanalization and dilation of a chronic coronary occlusion. Palmaz-Schatz stents were used with full anticoagulation. The previously published 6-month angiographic follow-up results showed reduction of the restenosis rate from 74% to 32%.Methods. The primary end point was the occurrence of major adverse cardiac events (cardiac death, lesion-related acute myocardial infarction, repeat lesion-related revascularization or angiographic documentation of reocclusion).Results. Late clinical follow-up was obtained in all patients at 33 ± 6 months. Major adverse cardiac events occurred in 14 patients (24.1%) in the stent group compared with 35 patients (59.3%) in the percutaneous transluminal coronary angioplasty (PTCA) group (odds ratio 0.22, 95% confidence interval 0.10 to 0.49, p = 0.0002). Target vessel revascularization (including failed PTCA attempts) was performed in 24% of the stent group and in 53% of the PTCA group (p = 0.002). There were no events in the stent group after 8 months, whereas events continued to occur in the PTCA group. By multivariate analysis, allocation to the PTCA group, left anterior descending coronary artery lesion and lesion length were significantly related to the development of major adverse cardiac events.Conclusions. These data demonstrate the long-term safety and clinical benefit of stenting recanalized chronic occlusions. There is a continued risk of late clinical events related to nonstented lesions. Implantation of an intracoronary stent should therefore be considered after successful opening of a chronic coronary occlusion.

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

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

Outcome after prolonged balloon inflations of >20 minutes for initially unsuccessful percutaneous transluminal coronary angioplasty

Prolonged balloon inflation with or without autoperfusion techniques is a common initial approach to major dissection or abrupt occlusion after percutaneous transluminal coronary angioplasty (PTCA). To assess such a strategy in the setting of unsuccessful angioplasty, 40 patients who underwent prolonged balloon inflations of >20 minutes between January and July of 1991 after initially unsuccessful angioplasty were studied. These patients (median age 59 years) underwent PTCA for progressive or unstable angina (16 [40%]), symptomatic or asymptomatic residual stenosis after myocardial infarction (10 [25%]), acute myocardial infarction (3 [8%]), stable angina (3 [8%]), reinfarction (2 [5%]), and other indications (6 [15%]). The significant stenoses were primarily in the proximal and midportions of the right coronary (53%), left anterior descending (30%) and left circumflex (17%) coronary arteries. Before prolonged balloon inflation, the longest single inflation was 11 ± 6 minutes and the total time of all inflations was 17 ± 8 minutes (mean ± standard deviation). Stenosis was reduced from 91 ± 9 to 68 ± 16% before prolonged inflation. After prolonged balloon inflation of 30 ± 9 minutes, the residual stenosis was 47 ± 21% (p = 0.0001 vs value before prolonged inflation). Furthermore, improvements in the appearance of filling defects or dissections, or both, occurred in 19 patients (48%). Procedural success was obtained in 32 of 40 patients (80%). Coronary bypass grafting was performed in 8 patients (20%): 4 after unsuccessful PTCA (3 emergently) and 4 electively after initially successful PTCA. Although 5 patients had creatine kinase-MB elevations >20 IU/liter after the procedure, only 1 sustained a Q-wave myocardial infarction. There were no deaths in the hospital. In summary, prolonged balloon inflations of >20 minutes are successful in 80% of patients in whom initial extensive PTCA attempts were not. Prolonged inflations may thus be desirable before consideration of bypass grafting or stenting.

The role of coronary angioplasty in the management of unstable angina pectoris

Using percutaneous transluminal coronary angioplasty (PTCA) as primary therapy for unstable angina is quite common. Unstable angina appears to be the indication for the procedure in approximately one third of all PTCA attempts. Considering the unstable nature of the placque in this type of angina, and the increased risk of abrupt occlusion due to frequent intraluminal thrombus, the generally reported rate of success, approximately 85%, is highly respectable. The evidence supporting a period of pretreatment with aspirin and heparin is strong. Less certain is the value of concomitantly administering plasminogen activators. Pending data should produce important further guidelines for effective therapy. Major trials, some using fibrinolytics as well as taking an overall aggressive, interventional approach (like that taken by UNSA, TIMI-III, and others), are reaching the recruitment-completion and promulgation stages.

Balloon dilatation of symptomatic subacute intimal dissection presenting as restenosis

Repeat percutaneous transluminal coronary angioplasty (PTCA) for subacute intimal dissections that produce symptoms after a period of 1 month or more is reluctantly performed for fear of extension and abrupt closure. Patients were identified with demonstrated intimal dissections (intimal contrast staining or frank intimal flap) at the time of initial PTCA who returned a mean of 17.5 weeks (range 9 to 50) later with recurrent chest pain. Repeat angiography revealed luminal compromise due to dissection rather than restenosis in 22 patients. Of these, 17 underwent repeat PTCA. Elective bypass surgery without attempted PTCA was chosen in the other 5 patients because of extensive intimal dissections (>2 balloon lengths) or involvement of critical branches. In the group of 17 patients who had repeat PTCA, 10 (group 1) had a frank intimal flap without persistent contrast staining after the initial PTCA, white 7 (group 2) had both persistent staining and a flap. Successful PTCA was performed in 13 of these 17 patients (76%). There were 2 abrupt closures and 2 unsatisfactory luminal openings. One of these patients required urgent coronary bypass surgery. All 10 group 1 patients had successful repeat procedures versus only 3 of 7 group 2 patients (p = 0.01). The 3 patients with the greatest degree of luminal compromise immediately after the initial PTCA had failed repeat PTCA attempts. These results suggest that repeat PTCA for subacute intimal dissections presenting as restenosis can be successfully performed in selected patients, and that the presence of contrast staining and the degree of luminal compromise by the dissection may be predictive of outcome.

Will emergency coronary bypass grafting after failed elective percutaneous transluminal coronary angioplasty prevent myocardial infarction?

An emergency aorto-coronary bypass grafting operation was performed within 12 hours after the development of acute myocardial ischemia due to partial or complete vascular occlusion in 34 of 950 (3.6%) patients who had received elective percutaneous transluminal coronary angioplasty (PTCA). Of the 34 patients, three (= 8.8%) died postoperatively in irreversible cardiogenic shock. Half of the surviving patients developed a Q-wave infarction after the operation, whereas the other half remained without transmural infarct. With comparable clinical data and times of operation up to placement of the aorto-coronary bypass vessel, an adequate residual perfusion must still have been present in the cases with non Q-wave infarction. Since in many cases a myocardial necrosis is unavoidable despite relatively early operative revascularization, the decisive role will be played by the remaining perfusion of the vessel concerned and any collaterals. It follows that treatment of an early PTCA complication, occurring in the catheter laboratory, ought to be the earliest possible aorto-coronary bypass operation unless available cardiological methods can reliably assure reperfusion. Treatment of a PTCA complication occurring later, however, e.g. after hours in the intensive-care unit, should be a repeat PTCA attempt: surgery at this stage will not prevent the transmural infarction but will increase risk of lethal complications.

Percutaneous transluminal coronary angioplasty in patients with prior coronary artery bypass grafting: Long-term results

In 83 patients with previous coronary artery bypass grafting, 92 percutaneous transluminal coronary angioplasty attempts were done, 33 in a venous bypass graft (success rate 97%) and 59 in a native coronary artery (success rate 86.4%). There were no procedural-related deaths and two myocardial infarctions. Forty-six percent of the patients with successful angioplasty after previous bypass grafting remain symptom free after 5 years versus 79% of the patients without previous bypass grafting (p less than 0.001). Long-term success rates for native vessel angioplasty as compared with bypass graft angioplasty are similar. Patients with a short interval between the recurrence of angina after bypass grafting and the angioplasty attempt have a better chance of long-term success. Repeat angiography indicates that a restenosis occurs after angioplasty of a venous graft in 31% and in the native system in 28.6% and that signs of progression of coronary artery disease elsewhere are present in 30%. Of the 83 patients, 11 had reoperation eventually. We conclude that percutaneous transluminal coronary angioplasty after coronary bypass grafting gives less satisfactory results than a primary procedure, that angioplasty provides symptomatic relief in a smaller number of patients than in those with primary angioplasty, but that symptomatic relief is often sufficient to further postpone or prevent bypass grafting and can be achieved with low mortality and low complication rates.

Primary angiographic success rates of percutaneous transluminal coronary angioplasty

Three distinct periods in catheter design have been identified since the advent of percutaneous transluminal coronary angioplasty (PTCA) in 1977. In the first period PTCA was performed using a double-lumen balloon catheter that had a fixed, flexible guidewire at the tip. In the second period, an independent, steerable guidewire and the steerable catheter system were used. In the third period, low-profile catheters were introduced. A total of 2,969 patients who had single-vessel PTCA of a native coronary artery was separated into groups according to the period during which PTCA was performed. Introduction of the steerable catheter system was accompanied by improvement in primary success rate in PTCA attempts on the right coronary artery (78% vs 88%, p < 0.005). Introduction of the low-profile catheter was accompanied by improved primary success in PTCA attempts on the left anterior descending coronary artery (LAD) (90% vs 94%, p < 0.005). The percentage of PTCA attempts on the LAD decreased over the 3 periods (70% to 60% to 56%), while the percentage of attempts on the left circumflex artery increased (7% to 12% to 16%). Before steerable and low-profile catheters were used, there were significant differences in ability to reach and cross stenoses among the 3 major coronary arteries. These differences no longer exist. These results indicate that technical improvements and operator experience have made stenoses in all 3 major coronary arteries equally accessible to dilatation catheters and that primary success rates and reasons for failure in these arteries are now similar.