Percutaneous Transluminal Coronary Artery Angioplasty Research Articles

Long term course over 10 years after balloon dilatation in stable and unstable angina pectoris

To assess the cardiac status of patients ten years after percutaneous transluminal coronary artery angioplasty (PTCA). Data of 534 patients (436 men, 98 women; mean age 53.2 +/- 8 years) in whom a PTCA had been performed between 1983 and 1986 were analysed, based on a questionnaire answered 121 +/- 11 months after the initial procedure. At the time of PTCA 184 patients (35%) had unstable angina, 350 (65%) stable angina. 116 patients (63%) with unstable angina and 164 (47%) with stable angina had at least one cardiac event after the initial PTCA (repeat PTCA, bypass operation, myocardial infarction, death). None of these events occurred in 68 patients (37%) with unstable or in 186 (53%) with stable angina (P < 0.001). After 10 years 196 of the 302 surviving patients with stable angina (65%) and 104 of the 153 surviving patients with unstable angina (68%) were symptom-free. Ten-year follow-up after PTCA has shown that cardiac events are significantly more frequent in patients who had had unstable angina than in those with stable angina. This difference already develops in the first year post-PTCA, with no increase later. Symptoms are lastingly improved after 10 years in both groups of patients.

Endovascular Reconstruction of Complex Arterial Obstructions in the Mesenteric Arcade with “Kissing Stents”: Technical Note

This report describes a technique for advanced endoluminal reconstruction of complex bifurcational arterial obstructions located within the mesenteric arcade deploying applications from percutaneous transluminal coronary artery angioplasty. A patient was treated for persistent mesenteric ischemia during prolonged recovery after initial small bowel resection due to acute mesenteric ischemia. Following endovascular reconstruction of a complex arterial obstruction within the mesenteric arcade, ischemic symptoms subsided quickly and the patient recovered well. According to the literature, this seems to be the first case where such distal reconstruction of the mesenteric arcade has successfully been achieved percutaneously.

Health-related quality of life of coronary artery bypass grafting and percutaneous transluminal coronary artery angioplasty patients: 1-year follow-up

The aim of the study was to compare the health-related quality of life (HRQoL) of patients undergoing coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) before the interventions and 6 and 12 months afterward, and to compare their HRQoL also with that of the general population. The sample (n = 615) consisted of consecutive coronary artery disease patients treated with elective CABG (n=432) or PTCA (n=183). The baseline data before the treatments were collected by structured interview, the follow-up data mainly by mailed self-administered questionnaires. HRQoL was measured by the 15D. For comparisons, the groups were standardized for differences in socioeconomic and clinical characteristics with a regression analysis. At baseline, the average 15D scores of the patient groups were 0.752 (95 percent confidence interval [CI], 0.743-0.761) in CABG and 0.730 (95 percent CI, 0.716-0.744) in PTCA. After standardization, the difference between the groups was statistically significant but not clinically important. These scores were significantly worse (statistically and clinically) than the score of 0.883 (95 percent CI, 0.871-0.879) in the general population sample matched with the gender and age distribution of the patients. By 6 months, the CABG and PTCA patients had experienced a statistically significant and clinically important improvement to 0.858 (95 percent CI, 0.844-0.872) and 0.824 (95 percent CI, 0.806-0.842), respectively. No significant change took place in either group from 6 to 12 months. Both CABG and PTCA produces an approximately similar, clinically important improvement in HRQoL in 1-year follow-up.

Results after transplantation using donor hearts with preexisting coronary artery disease

ObjectiveCardiac allografts with coronary artery disease may permit a selective expansion of the donor pool. Twenty-two recipients who received donor hearts with mild to moderate coronary artery disease on angiography were reviewed. All donor organs had preserved left ventricle function on echocardiogram. MethodsThe procedure was explained to the patients in detail. All survivors have at least 1 year of follow-up. If the coronary arteries of the donor heart were significantly occluded, then the implanting surgeon performed coronary revascularization. Donors were allocated to patients facing imminent death (group I, n = 4) or to those who would otherwise not have been transplanted (group II, n = 18). Median recipient age was 57 years old for group I and 68 years old for group II. Median follow-up was 25 months for group I and 44 for group II. ResultsOutcome was evaluated using survival and freedom from graft coronary disease as end points. In group I, 3 of the 4 hearts required revascularization. In group II, 10 of the 18 required revascularization. The majority of the revascularizations were recipient saphenous vein grafts (84.6%) to the donor left anterior descending artery (50%). The 1-month and 2-year actual survivals for group I are 75% and 50% and 87.5% and 81.3 for group II. One patient in group I who was in extremis and 3 in group II died at less than 90 days. Group II early deaths had donor risk factor combinations of coronary artery disease, left ventricular hypertrophy, and long distance. Freedom from new graft coronary artery disease was 100% at 2 years in group I and 87.5% in group II. ConclusionsSelective use of donor hearts with coronary artery disease is acceptable. Early deaths are related to recipient factors as well as associated donor risk factors. Donor hearts with mild or moderate coronary artery disease and preserved function on echocardiogram can be used but may require revascularization with recipient conduit and/or percutaneous transluminal coronary artery angioplasty. Coronary disease in donor hearts requires grading and does not categorically preclude use, particularly in risk-matched recipients.

Why Are Some Individuals Resistant to the Cardioprotective Effects of Aspirin?

It has been slightly more than 100 years since the synthesis, development, and commercialization of acetylsalicylic acid, the most widely consumed drug in the world. It is estimated that 35 000 kg are consumed daily in the United States and 6000 kg in the UK.1 Who would have ever thought that this widely consumed drug would achieve significant uses other than as an analgesic, antipyretic, and anti-inflammatory. The first report of a possible antithrombotic effect of aspirin appeared in 1953 in the Mississippi Valley Medical Journal .2 Dr Craven noticed that the patients who took Aspergum had a tendency to bleed more easily. He concluded that aspirin must be thinning the blood and because thrombosis of the coronary arteries led to myocardial infarction, if his patients took aspirin, they might be less prone to experiencing a myocardial infarction. See p 1650 These prescient observations were succeeded by the discovery by numerous investigators that aspirin could significantly decrease platelet function. In 1971, the mechanism by which aspirin inhibited platelet function began to unfold when Smith and Willis3 demonstrated that aspirin inhibited platelet prostaglandin synthesis. It was subsequently shown that aspirin irreversibly acetylated serine-529 close to the active site of the fatty acid cyclooxygenase (COX).4 In the case of the anucleate platelet, the enzyme is rendered inactive for its lifetime. Samuelsson and co-workers5 demonstrated that thromboxane A2 along with prostaglandin H2 were the arachidonic acid metabolites responsible for activation of the platelet. Thromboxane A2 is also a very effective vasoconstrictor and mitogenic substance. After the discovery of thromboxane A2, numerous studies followed that investigated its potential role in thrombotic cardiovascular diseases. Platelet thromboxane A2 synthesis is increased in acute myocardial infarction, unstable angina, thrombolysis therapy, percutaneous transluminal coronary artery angioplasty, and …

State of percutaneous transluminal coronary artery angioplasty and effectiveness of low-density lipoprotein apheresis.

We have recognized percutaneous transluminal coronary artery angioplasty (PTCA) as an important procedure for achieving myocardial revascularization. PTCA has been performed for stable and unstable angina, acute myocardial infarction, and silent myocardial ischemia. Among many new devices, the coronary stent is the most important advancement in PTCA. Frequent stent use is due to the introduction of antiplatelet therapy to prevent stent thrombosis. One serious problem is that PTCA, even with stent use, often causes chronic restenosis. This problem has not been solved, however, despite various strategies. Aggressive lipid-lowering therapy is one of the most important therapies for coronary heart disease. The findings in aggressive lipid-lowering therapy show us its importance. We report that low-density lipoprotein (LDL) apheresis, when performed immediately before and after PTCA, can prevent restenosis of coronary artery lesions. Lipid-lowering therapy should be applied more aggressively with medicine and/or with LDL apheresis for patients who have undergone PTCA.

Choice of revascularization strategy for patients with coronary artery disease.

SURGICAL CORONARY ARTERY BYpass grafting (CABG) was first performed in 1967 and percutaneous transluminal coronary artery angioplasty (PTCA) in 1977. Initially the 2 revascularization methods appeared complementary: the less invasive PTCA seemed suited for patients with limited lesions, and CABG for those with diffuse disease. The Duke University group, in a large prospective study, first established that PTCA achieved the greatest survival benefit in patients with a singlevessel disease other than proximal left anterior descending (LAD) artery stenosis, and CABG in those with multivessel disease or proximal LAD artery stenosis. Patients with 2-vessel disease or an isolated proximal LAD artery stenosis had similar results with either therapy. However, individual clinical variables, such as the characteristics of the stenosis, the patient’s ventricular function, and associated comorbidities, are often factored into the final decision about the method of revascularization. In the 1990s, a number of randomized trials attempted to refine the indications for PTCA vs CABG in patients who could concurrently be approached by both methods.

Endovascular brachytherapy--treatment planning and radiation protection.

The risk of restenosis, main late effect limiting the success of percutaneous transluminal coronary artery angioplasty, can be reduced significantly by vascular radiotherapy, subsequent to PTCA. This discovery lead to the development of new irradiation techniques. Endovascular brachytherapy is the choice in treatment of coronary artery stenosis. Successful irradiation, however, requires precise treatment planning. This review addresses the physical possibilities and problems of intravascular brachytherapy planning, and the radiobiologically based definition of the target volume and of structures at risk. Recommendations for dose specification, recording and reporting are given. The criteria for selecting a vascular radiotherapy technique are discussed as well as the possibilities of dosimetric treatment planning and quality assurance based on precise plastic scintillator dosimetry and intravascular ultrasound. Radiation protection and safety must be reconsidered prior to the usage of therapeutic radiation sources in the catheter laboratory and for the decision about emergency plans. Finally, the design of clinical trials, the role of medical physicists, and the future of irradiation treatment of stenosis is discussed.

ARCADIA: A System for the Integration of Angiocardiographic Data and Images by an Object-Oriented DBMS

Use of data base techniques to store medical records has been going on for more than 40 years. Some aspects still remain unresolved, e.g., the management of textual data and image data within a single system. Object-orientation techniques applied to a database management system (DBMS) allow the definition of suitable data structures (e.g., to store digital images): some facilities allow the use of predefined structures when defining new ones. Currently available object-oriented DBMS, however, still need improvements both in the schema update and in the query facilities. This paper describes a prototype of a medical record that includes some multimedia features, managing both textual and image data. The prototype here described considers data from the medical records of patients subjected to percutaneous transluminal coronary artery angioplasty. We developed it on a Sun workstation with a Unix operating system and ONTOS as an object-oriented DBMS.

Health-Related Quality of Life Among Patients Undergoing Percutaneous Transluminal Coronary Angioplasty

A randomized clinical trial was recently conducted to investigate whether a new antiplatelet agent could prevent restenosis in patients who had undergone percutaneous transluminal coronary artery angioplasty (PTCA). Approximately 1,200 patients were enrolled at 13 separate clinical sites. To assess the impact of this intervention on health-related quality of life, a patient questionnaire for telephone administration was developed. This questionnaire focused attention on several specific dimensions likely to be important in this patient population: physical well-being, perceived health, emotional well-being, home management, work, recreation, and social and sexual functioning. This paper describes the instrument that was used in this trial and reports on its psychometric [corrected] properties based on completed interviews with approximately 500 patients at study entry and 1 month after PTCA.

Septic complications after cardiac catheterization and percutaneous transluminal coronary angioplasty

Septic complications after cardiac catheterization and percutaneous transluminal coronary artery angioplasty are distinctly uncommon. However, we have recently treated nine patients with sepsis and life-threatening complications after cardiac catheterization alone or after catheterization and subsequent percutaneous transluminal coronary angioplasty. The common denominator in all patients was either repeat puncturing of the ipsilateral femoral artery or leaving the femoral artery sheath in for 1 to 5 days after the procedure. Two patients died as a direct result of their septic complications. One death occurred in a patient in whom bacterial endocarditis with congestive heart failure developed, and the other patient had a large retroperitoneal hematoma that became secondarily infected. Infected aneurysms that were successfully treated developed in three patients. Our study suggests that colonization of the needle tract by skin flora predisposes to septic complications if repeat arterial punctures are required or if a femoral artery sheath is left in place for more than 24 hours. Patients in whom sepsis develops after these procedures should be initially treated with antibiotics effective against gram-positive organisms. CT scanning or angiography should be considered for patients with persistent sepsis, septic emboli, and abdominal or flank pain. Infected aneurysms require resection or ligation because of the propensity of these aneurysms to rupture.

Power injection of contrast media during percutaneous transluminal coronary artery angioplasty

Visualization of the coronary arteries during all phases of percutaneous transluminal coronary angioplasty using hand-held contrast media injection devices is suboptimal. Power injection of contrast media for diagnostic coronary cineangiography has been performed in over 18,000 cases without power injector complication. Here we report our experience with 294 patients using power injection for visualization during all phases of PTCA. It provides optimal visualization of the coronary arteries and has not been associated with complications. It is a safe and efficient system with reduction in both the time and radiation exposure required to perform PTCA and allows determination of the adequacy of the result without unnecessary recrossing of the area of dilatation.

Morphologic correlates of coronary angiographic patterns at the site of percutaneous transluminal coronary angioplasty.

Over the last 10 years considerable interest has been paid in the angiographic recognition of successful percutaneous transluminal coronary artery angioplasty (PTCA), complication of the technique, and angiographic predictors of restenosis. This report summarizes various angiographic patterns visualized at the site of angioplasty and correlates these patterns with morphologic findings. Of 66 patients undergoing PTCA for chronic or unstable angina pectoris, 76 PTCA sites were available for analysis. The two most common angiographic patterns at the angioplasty site (intimal flap = 43%, intraluminal haziness = 38%) correlated morphologically with intimal-medial splits with localized dissections (79%). Shallow, superficial intimal lesions, laminated thrombus, and adventitial tears accounted for the remaining morphologic changes. Eight PTCA sites without morphologic injury corresponded to smooth wall changes and spasm at angiography.

Transient alterations of the QRS complex and ST segment during percutaneous transluminal balloon angioplasty of the left anterior descending coronary artery

Using continuous 3-lead electrocardiographic (ECG) recordings in 19 patients undergoing elective percutaneous transluminal coronary artery angioplasty (PTCA) of the left anterior descending (LAD) artery, this study described the dynamic changes of the ST segment and the R- and S-wave amplitudes that occur during transient myocardial ischemia. The waveforms from lead V 2 were quantified at 10-second intervals during the length of the balloon inflation that produced the greatest extent of ST-segment deviation. The simultaneous changes that occurred in leads a VF and V 5 were also observed, but not quantified. Measurements of R- and S-wave amplitudes were performed during maximal ischemia from both the PR- and the J-ST-segment baselines to determine which of these most nearly maintained its control position during ischemia. The results indicate that the R-wave amplitude is best determined from the PR-segment baseline (p = 0.0007), while the S wave is best determined from the J-ST-segment baseline (p = 0.03). However, only a portion of the QRS changes observed during PTCA could be accounted for by the baseline shift. There were additional QRS changes during ischemia in 11 of the patients (58%) suggestive of conduction disturbances in 3 endocardial sites: left septal, right septal and left anterosuperior. It is hypothesized that these changes may represent ischemia-induced delay in conduction (“periischemic block”) previously thought to occur only with myocardial infarction.

Sequential thallium-201 myocardial perfusion studies after successful percutaneous transluminal coronary artery angioplasty: delayed resolution of exercise-induced scintigraphic abnormalities.

To characterize the sequential changes of myocardial perfusion scintigraphy in patients with coronary artery disease (CAD) after complete revascularization, 43 patients underwent exercise thallium-201 (201Tl) myocardial perfusion scintigraphy before and at 9 +/- 5 days, 3.3 +/- 0.6, and 6.8 +/- 1.2 months after percutaneous transluminal coronary angioplasty (PTCA). Only patients with single-vessel CAD, without previous myocardial infarction, and without evidence of restenosis at 6 to 9 months after PTCA were included. Perfusion scans were analyzed blindly with the use of a new quantitative method to define regional myocardial perfusion in the topographic distribution of each coronary artery, which was shown to be reproducible (r = .94 or higher and SEE of 7% or less, between repeated measures by one and two operators). At 4 to 18 days after PTCA, the mean treadmill walking time increased by 123 +/- 42 sec, mean exercise-induced ST segment depression decreased by 0.6 +/- 0.3 mm, group maximal heart rate increased by 20 +/- 9 beats/min, and group systolic blood pressure at peak exercise increased by 24 +/- 10 mm Hg, compared with pre-PTCA values (p less than .001). However, no group differences were noted in these variables between the three post-PTCA stages. Myocardial perfusion in the distribution of the affected (dilated) coronary artery, on the other hand, improved progressively. In the 45 degree left anterior oblique view for instance, myocardial perfusion increased at 9 days after PTCA (from 68 +/- 24% before PTCA to 91 +/- 9%, p less than .001) and at 3.3 months after PTCA (101 +/- 8%, p less than .05 vs 9 days after PTCA), but no further significant changes were seen at 6.8 months after PTCA (102 +/- 8%). Similar changes were noted in the other two views. No relationship between minor complications during PTCA and delayed improvement on the 201Tl was observed. Myocardial ischemia was diagnosed in 12 of the 43 scans recorded a few days after PTCA, but in none recorded at later stages. We conclude that 201Tl scans after PTCA often show delayed improvement and therefore, an abnormal myocardial perfusion scan soon after PTCA does not necessarily reflect residual coronary stenosis or recurrence.

Oculomotor Nuclear Complex Infarction

We describe a patient with an isolated mesencephalic dorsal tegmental infarct affecting the oculomotor nuclear complex and medial longitudinal fasciculus, documented by high-resolution computed tomography, after undergoing percutaneous transluminal coronary artery angioplasty. Clinically, the patient exhibited bilateral ptosis, bilateral internuclear ophthalmoplegia, transient convergence retractory nystagmus, and minimal somnolence. We believe the combined clinical and radiological findings favor the presence of a caudal, dorsal, and paramedian embolic infarct in the territory of the paramedian branches of the mesencephalic artery as the most likely mechanism for these exceptional findings and correlate them with Warwick's scheme of the oculomotor subnuclei.