Reocclusion In Patients Research Articles

A mathematical prognosis modelling of reocclusions in patients with occlusive-stenotic diseases of the main arteries of the infrarenal aorta

Annotation. Obliterating atherosclerosis the lower extremities vessels often leads to permanent disability and mortality in some cases. Despite the improvement of methods and techniques of endovascular and open operations, nowadays there is still a significant frequency of amputations due to progression of atheroscleroses and various intra- and postoperative complications, such as shunt thrombosis or thrombosis of zone of reconstruction. Therefore, the aim was to research the factors influencing the occurrence of reocclusion after surgery and to develop predictive modeling of the risk of their occurrence with the help of logistic mathematical regression. 100 patients with occlusive-stenotic lesions of the main arteries of the infrarenal aorta by atherosclerotic origin were examined. 50 patients (general group) revealed reocclusion occurred in the early postoperative period, and 50 patients (comparison group) have no reocclusion. The factors influencing the occurrence of reocclusion have been identified, and mathematical prognostic modeling of reocclusions based on logistic regression has been created. It was found that the risk of reocclusion increases significantly with increasing duration of the lesion (b=0.5214, p=0.005), in the presence of complex anatomical conditions (b=3.5080, p=0.034), in the presence of two or more multistory occlusions (b=9.0073, p=0.002), in the presence of technical errors in the intervention process (b=8.0802, p=0.004).

Mechanical Thrombectomy for Large Vessel Occlusions in Cocaine Associated Acute Ischemic Stroke: Small Case Series and Review of the Literature

IntroductionCocaine through multifactorial pathogenetic mechanisms causes small and large vessel occlusions (LVO) leading to acute ischemic stroke. The optimal treatment for cocaine related LVO remains unknown. Mechanical thrombectomy (MT) poses a unique challenge, and successful MT are not widely reported. Material and MethodsWe report three patients with no other risk factors and a common history of cocaine metabolites found on presentation drug screen who underwent MT for MCA occlusions with subsequent failed recanalization or vessel re-occlusion due to persistent thrombosis and severe vasospasm.Two patients initially had good revascularization but then developed severe vasospasm and reoccluded, and the remaining patient had persistent severe distal vasospasm. Rescue therapy either with balloon angioplasty with stent placement or intraarterial vasodilator was used in all patients and was ineffective. All patient had large hemispheric strokes and developed malignant cerebral edema requiring hemicraniectomy in two of them. We also did literature review and summarized previously reported cases of cocaine associated vasospasm in MT and other endovascular procedures. ConclusionIn this case series, cocaine induced vasospasm contributed to unsuccessful recanalization and reocclusion in patients undergoing MT with poor outcomes. Further studies are needed to ascertain strategies for improved outcomes in patients with LVO related to cocaine use.

Rationale and design for the study Apixaban versus ClopidoGRel on a background of aspirin in patient undergoing InfraPoPliteal angioplasty for critical limb ischemia: AGRIPPA trial

New antithrombotic strategies that reduce primary thrombosis and restenosis might improve vascular outcomes in patients with peripheral artery disease (PAD) undergoing arterial angioplasty. The study objective is to evaluate the potential benefit of apixaban plus aspirin compared with standard of care dual antiplatelet therapy (DAPT) in reducing thrombotic restenosis and artery re-occlusion in patients undergoing endovascular infrapopliteal revascularization. This multicenter, parallel-group, prospective, randomized, open-label, blinded-endpoint adjudication, proof-of-concept, exploratory trial aims to randomize 200 patients 72 hours after successful infrapopliteal angioplasty for critical limb ischemia (CLI). Patients will be randomly assigned in a 1:1 ratio to receive oral apixaban (2.5 mg twice daily) plus aspirin (100 mg once daily) for 12 months or clopidogrel (75 mg daily) for at least 3 months on a background of aspirin (100 mg once daily) for 12 months. The primary endpoint is the composite of target lesion revascularization (TLR), major amputation, or restenosis/occlusion (RAS) in addition to major adverse cardiovascular events - MACE (myocardial infarction, stroke or cardiovascular death) at 12 months. The primary safety endpoint is the composite of major bleeding or clinically relevant non-major bleeding at 12 months. This study will evaluate the efficacy and safety of apixaban 2.5 mg twice daily plus aspirin compared with DAPT (clopidogrel plus aspirin) in patients with CLI undergoing endovascular infrapopliteal revascularization and might prove the concept of an alternative antithrombotic regimen for these patients to be tested in a future large randomized clinical trial.

Antiplatelet and anticoagulant for prevention of reocclusion in patients with atrial fibrillation undergoing endovascular treatment for low extremity ischemia

The purpose of this study is to report the efficacy of the mono antiplatelet plus anticoagulation therapy for prevention of reocclusion in patients with atrial fibrillation (AF) undergoing endovascular treatment for lower extremity ischemia. From March 2014 to July 2016, 32 (21 males; range, 68-84 years) patients were submitted to endovascular therapy for low extremity ischemia with AF and all were treated with endovascular treatments to correct underlying lesions. Then 20 patients receive aspirin plus rivaroxaban post-operation and 12 patients receive aspirin plus warfarin to prevent reocclusion. Complete reconstruction of occluded femopopliteal arteries with unimpeded blood flow to legs were successfully obtained in all 32 patients; 12 (37.5%) patients had acute ischemia, 17 (53.1%) patients had chronic ischemia, 3 (9.4%) patients had acute on chronic ischemia. Endovascular treatments including percutaneous transluminal angioplasty (PTA) and stenting were performed to correct residual lesions after the thrombolytic/thrombectomy procedure or to correct native lesions for chronic patients. All 32 patients showed significant improvements in symptoms and 4 patients improved completely. The mean ankle-brachial index (ABI) had risen from 0.43±0.21 preoperatively to 0.81±0.16 postoperatively (P<0.01), and the primary patency rates were 88.9% at 12 months, and 81.5% at 24 months. No episodes of major bleeding and only one patient showed positive fecal occult blood tests during the follow-up. The mono antiplatelet plus anticoagulation therapy offers a safe and effective alternative for prevention of reocclusion in patients with AF undergoing endovascular treatment for lower extremity ischemic.

Risk Factors for Hospitalization Among Post-ERCP Patients Presenting With Stent Occlusion

Introduction: ERCP with stent placement is an effective treatment modality for relieving biliary obstruction, but stent occlusion (SO) is one of the most common complications after ERCP. However, not all patients with SO require hospitalization. This study examined the risk factors for hospitalization and stent re-occlusion in patients with initial episode of post-ERCP SO. Methods: Medical records of patients who had ERCP with bile duct stent placement, between 2009 and 2014 at our institution were reviewed. Of these, patients with SO were included. Clinical, procedural and demographic data were obtained from electronic medical records for two groups: those who were hospitalized for SO and those not hospitalized for SO. Lab values and demographic values between hospitalized and non-hospitalized patients were compared using chi-square test and Mann-Whitney U test. Univariate and multivariate analysis were performed. Results: A total of 196 patients had SO post-ERCP. Average age of cohort was 63±13.4 years and 117 (59.7%) were males. Fifty-one (26.0%) were hospitalized for SO and 58 (29.6%) had re-occlusion of stent after second ERCP. Positive blood cultures, leukocytosis, anemia, and elevated liver function tests were associated with risk of hospitalization post SO (Table 1). On multivariate analysis, positive blood cultures were associated with hospitalization (OR=3.46 [1.23 - 9.74]; p=0.019). Using a metal stent (OR=4.59 [1.72 - 12.24]; p=0.002), or performing sphincteroplasty (OR=2.83 [1.29 - 6.22]; p=0.009), conferred higher risk of hospitalization for SO (Table 2a). Also, undergoing ERCP for the indication of stricture (OR=2.29 [1.2 - 4.37; p=0.012) increased risk of re-occlusion (Table 2b).Table: Table. Comparison of labs at the time of stent occlusion between patients hospitalized for stent occlusion and those not hospitalizedTable: Table. Risk of hospitalization for SOTable: Table. Risk of stent re-occlusionConclusion: Positive blood cultures, usage of metal stent and sphincteroplasty were associated with increased risk of hospitalization for SO. ERCP for biliary stricture was associated with increased risk of stent re-occlusion.

Efectividad y seguridad de la alteplasa frente a la tenecteplasa en la fibrinólisis del síndrome coronario agudo con elevación de ST

Introduction The importance of early administration of fibrinolytic therapy in ST elevated myocardial infarction (STEMI), with the aim of reducing mortality, is universally accepted and endorsed by many publications. Our objective was to determine whether the fibrinolytic reperfusion with tenecteplase (TNK) was less effective than that obtained with alteplase (rt-PA), and also to analyse the safety of both agents. Methodology A retrospective observational study was conducted on patients admitted to our ICU between 2005-2008 due to an STEMI, and treated with one of these two thrombolytic agents. Clinical and angiographic criteria data were used to evaluate the effectiveness of fibrinolysis, bleeding complications and the intra-ICU mortality rate. Results Of the 453 patients who met the inclusion criteria, 286 were treated with TNK and 167 with rt-PA. Both groups were homogeneous and no difference was found between them regarding the effectiveness parameters (pain management, myoglobin ratio or ST depression). Artery re-occlusion in patients who already met the criteria for effective fibrinolysis was higher in the TNK group (22.5% vs. 11.6%, P=.04). In the 346 patients who underwent coronary angiography within 72 h (203 in the group treated with TNK and 143 in the group treated with rt-PA), closed arteries were open (TIMI 3) in 28.4% and 53.9% respectively ( P=.001). There were no significant differences in bleeding complications between both groups, however less bleeding was observed with TNK. There were no differences in mortality rate between both groups. Conclusions Both drugs showed a similar rate of reperfusion, although there was a smaller percentage of re-occlusions with rt-PA. The complication rate did not differ in both groups, although TNK seemed to be less harmful, especially at the expense of extracranial bleeding.

Lipoproteins and the Development of Restenosis After Stent Implantation in the Superficial Femoral Artery in Patients with Peripheral Artery Disease

High levels of apolipoprotein B (apo B) are a risk factor for the development of major vascular events. We evaluated the association between plasma lipoproteins and the development of superficial femoral artery (SFA) in-stent restenosis and reocclusion in patients with peripheral artery disease. We included 139 patients with SFA stenting. Plasma lipoproteins were measured after stent implantation. Stent restenosis was assessed with duplex scan after 3, 6, and 12months. A stenosis grade was considered relevant if >50%. Seventy-two patients experienced recurrence of their atherosclerotic disease, meaning restenosis of >50% within 1year of follow-up. Ten of these patients had a stent occlusion. In the patients who experienced recurrence, the mean apo B level was 105.8 versus 94.9mg/dl in patients without recurrence (P<0.05). Patients without recurrence had higher high-density lipoprotein cholesterol levels than patients with recurrence (39.7 vs. 34.7mg/dl, P<0.05). Comparing patients with a stent occlusion (n=10) and those with a restenosis of 75-99% (n=28), the patients with a stent occlusion had higher levels of plasma cholesterol (234.1 vs. 185.9mg/dl, P<0.05), apo B (135.3 vs. 99.8mg/dl, P<0.05), low-density lipoprotein cholesterol (160.3 vs. 113.6mg/dl, P<0.05), and low-density lipoprotein apo B (115.5 vs. 82.4mg/dl, P<0.001) than the patients with restenosis of 75-99% (n=28). Changes in the lipid profile could be one reason for the development of restenosis and for the development of reocclusion after SFA stenting.

Subacute Recanalization and Reocclusion in Patients with Acute Ischemic Stroke Following Endovascular Treatment

To determine the rate of subacute recanalization and reocclusion and its effect on clinical outcomes among patients with ischemic stroke treated with endovascular treatment. Subacute recanalization and reocclusion occurring hours after completion of the intravenous or intra-arterial thrombolysis for acute ischemic stroke has been reported in anecdotal cases. We performed cerebral angiography at 24 h to determine the status of occlusion after endovascular treatment (compared with immediate post-procedure angiogram) in a series of patients with ischemic stroke treated with endovascular treatment. Clinical and radiological evaluations were performed before and 24 h, and prior to discharge or 1-3 months after treatment. We performed multivariate analysis to evaluate the effect of subacute recanalization on clinical outcome graded using modified Rankin scale (mRS). Favorable outcome was defined by mRS of 0-2. A total of 56 patients (mean age 66 +/- 14 years; 22 were men) were analyzed. Subacute recanalization was observed in 16 (29%) patients and consisted of additional recanalization in 8 patients with early recanalization. Subacute recanalization was associated with a trend toward a higher rate of favorable outcome (Wald chi-square 3.3, P = 0.19) after adjusting for other covariates. Subacute recanalization was not associated with either neurological deterioration or symptomatic intracranial hemorrhage. Subacute reocclusion was observed in 5 (9%) patients. Subacute reocclusion was associated with a trend toward higher rate of neurological deterioration within 24 h (Wald chi-square 2.1, P = 0.15) after adjusting for other covariates. We found that new or additional recanalization occurs in one-fourth of the patients within 24 h of endovascular treatment and is not associated with any adverse consequences. Subacute reocclusion occurs infrequently after endovascular treatment.

A strategy of using enoxaparin as adjunctive antithrombin therapy reduces death and recurrent myocardial infarction in patients who achieve early ST-segment resolution after fibrinolytic therapy: the ExTRACT-TIMI 25 ECG study

To determine the relationship between a strategy of enoxaparin (ENOX), early ST-segment resolution (STRes), and clinical outcomes on patients with ST-segment elevation myocardial infarction (STEMI) after fibrinolysis. Baseline and 180 min ECGs were analysed in 3208 of the 20 479 patients in the ExTRACT-TIMI 25 trial, which randomifzed patients with STEMI to ENOX vs. unfractionated heparin (UFH) as adjunctive therapy. STRes was defined as complete (70%), partial (30-70%), or none (<30%). There was no evidence for a difference in STRes between the groups assigned to the ENOX or UFH (median 69.4 vs. 67.2%; P = 0.13). Among patients with complete STRes (n = 1100), ENOX significantly reduced death or non-fatal recurrent MI at 30 days when compared with UFH (4.4 vs. 9.9%; OR(adj) 0.39; P < 0.001), whereas there was no difference in patients with only partial or no STRes [14.2 vs. 12.5%; OR(adj) 1.0; P = 0.98 (n = 368) and 16.2 vs. 15.9%; OR(adj) 1.0; P = 0.97 (n = 830), P for interaction = 0.008]. When compared with UFH, a strategy of ENOX significantly reduces death or non-fatal recurrent MI in patients who achieved complete STRes, but not in patients with less STRes. These data suggest that a strategy of ENOX improves outcomes by preventing re-occlusion in patients achieving initial successful reperfusion after fibrinolytic therapy rather than by facilitating initial reperfusion.

Antiplatelet Agents in Cardiovascular and Cerebrovascular Diseases

Aspirin has become a widely accepted platelet function inhibitor and is used to prevent arterial occlusions in coronary cerebral and peripheral vascular disease. The results of clinical studies with aspirin in the area of peripheral arterial occlusive disease are critically reviewed. Two thienopyridine compounds, ticlopidine and clopidogrel, have been effectively used in the prevention of myocardial infarction and stroke in several clinical trials, especially in the recently published CAPRIE-trial. Potent new platelet function inhibitors recently were developed. Intravenous treatment with abciximab, a new platelet membrane glycoprotein IIb/IIIa-inhibitor, effectively prevented coronary reocclusions in patients with high-risk coronary events. A series of promising new oral IIb/IIIa- inhibitors have been developed and may become effective drugs in the prevention of reocclusions in patients with periph eral vascular disease and in coronary or cerebral vascular dis ease. Key Words: Antiplatelet agents—Aspirin—Peripheral arterial disease—Ticlopidine—Clopidogrel—GPIIb/IIIa inhibitor.

Systems for measuring and tracking electrophysiologic distributions.

Electrocardiographic mapping has played an important role in the study and analysis of cardiac electrophysiologic phenomena. The first systems used for experimental or clinical studies were expensive, cumbersome, and limited in their ability to sample the complex electrophysiologic events associated with cardiac function and disease. New insights into the mechanisms of arrhythmias and the need for timely detection and characterization of changing cardiac states have made it essential that new tools be available to measure the spatial characteristics and dynamics of electrophysiologic events. For example, observation of the distribution and dynamics of ventricular repolarization is critical to predicting arrhythmia prone states, detecting reperfusion or reocclusion in patients undergoing post myocardial infarction therapy or angioplasty, or to accurately detect acute infarction in patients presenting with chest pain. Technology now permits affordable, flexible systems for making the critical observations. The authors present an example of such a system and its applications in this article.

HBW 023 (recombinant hirudin) for the acceleration of thrombolysis and prevention of coronary reocclusion in acute myocardial infarction

To define an optimal dose of hirudin that would improve early coronary artery Thrombolysis in Myocardial Infarction grade 3 (TIMI 3) patency and prevent reocclusions in patients with acute myocardial infarction treated with front-loaded recombinant tissue-type plasminogen activator (rt-PA). Recombinant hirudin (HBW 023) was tested in a sequential dose-escalating study as adjunct to front-loaded rt-PA in 143 patients with acute myocardial infarction. The sequential model was assigned two 'decision boundaries': it triggered an increase in dosage if the 60-min TIMI 3 flow rate in a dosage group was statistically not consistent with a target patency rate of 75%, or if the deterioration in coronary blood flow (of at least one TIMI grade, from TIMI 2 or 3, from one angiography to the next) exceeded 5%. The decision boundary for TIMI 3 flow grade at 60 min was crossed when 18 patients were treated with 0.1/0.06 mg/kg (bolus/infusion per hour over 48 h) r-hirudin (dosage group I), 42 patients treated with 0.2/0.1 mg/kg (dosage group II), and 83 patients with 0.4/0.15 mg/kg (dosage group III). TIMI 3 flow at 60 min was 50%, 58%, and 63% in dosage groups I-III, respectively (P = 0.15). Early, complete, and sustained patency (TIMI 3 flow at 60 min, 90 min and 48 h) were 44%, 55% and 64% (P = 0.07). Reocclusion between 90-min and 48-h angiograms or reinfarction occurred in 0 to 15, two of 36, and one of 72 patients, respectively (P = 0.5). Four patients (2.8%) died in hospital and 14 patients suffered a major bleeding event, but no intracranial bleeding was encountered. With increasing doses of hirudin, there was a trend towards greater early and complete patency, but no clear dose--response relationship was observed. A borderline significant effect was observed with respect to early, complete, and sustained patencies. In all groups, reocclusions or reinfarctions were rare. Neither clinical nor laboratory data predicted the imbalance in haemorrhagic events observed in a subsequent, prematurely terminated, phase III trial with hirudin and rt-PA.

MR imaging signal-intensity abnormalities after placement of arterial endoprostheses.

Our objectives were to describe changes in T2-weighted MR images of patients who had undergone implantation of an endoluminal stent-graft and determine the rate of early reocclusion in patients with abnormal MR findings. Twenty-nine patients with 26 occlusions (average length, 8.7 +/- 5.6 cm) and three dissections of the superficial femoral artery were treated with 45 endoluminal stent-grafts. T2-weighted gradient-echo and T2-weighted turbo spin-echo MR images were obtained for all patients at 48 hr and at 4 weeks after stent-graft placement. We reviewed the MR imaging studies to assess the extent and severity of tissue alteration at the site of stent-graft implantation. Technical success rate of stent-graft placement was 100%. Three signal-intensity patterns were seen on MR images obtained at 48 hr: normal signal intensity (n = 8), subtle perivascular signal-intensity abnormalities at the site of stent-graft implantation (n = 11), and extensive signal-intensity abnormalities from the adductor canal to the subcutis (n = 10). Twenty of 21 patients with abnormal signal intensity on MR images had fevers and pain at the implantation site. Clinical signs of deep vein thrombosis, a diagnosis excluded on the basis of phlebography, were seen in the 10 patients with extensive signal-intensity abnormalities. In two of these 10 patients, the superficial femoral artery reoccluded within 4 weeks of implantation. MR images obtained at 4 weeks showed no signal-intensity abnormalities in any of the 29 patients. MR findings of perivascular signal-intensity abnormalities after implantation of endoluminal stent-grafts are associated with clinical complications such as local pain and fever. Care should be taken to avoid confusing the clinical signs of the postimplantation syndrome at 48 hr with deep vein thrombosis.

Prothrombin activation by thrombolytic agents

Previous studies showed an early increase of fibrinopeptide A and thrombin-anti-thrombin III complex (TAT) plasma levels during thrombolytic therapy. This might be caused not only by liberation of preformed thrombin from the thrombus or reperfused tissue, but also by activation of prothrombin. In 11 patients with acute myocardial infarction treated with 1.5 million U streptokinase (SK) over 30 min, and in 6 patients with deep vein thrombosis receiving standard dose urokinase (UK) infusion, TAT and the prothrombin fragment F1+2 increased significantly 3h after commencing thrombolytic therapy, and decreased again thereafter. In vitro, TAT and F1+2 levels increased in anticoagulated normal plasma after incubation with SK, UK or tissue-type plasminogen activator (t-PA). By incubation of purified prothrombin with SK+plasminogen (PLG), UK, UK+PLG, t-PA, t-PA+PLG, or plasmin, F1+2 immunoreactivity was generated. Also the generation of thrombin-like activity from purified prothrombin could be demonstrated by means of a chromogenic substrate assay with inhibition of non-specific cleavage by purified plasminogen activator inhibitor type 2 (PAI-2) or α 2-antiplasmin (APL). These results demonstrate an activation of prothrombin associated with stimulation of fibrinolysis. Further studies should clarify the clinical significance of this phenomenon, and whether it could have implications for optimizing the concomitant anticoagulation in order to prevent reocclusion in patients undergoing thrombolysis.

Angiographically assessed coronary arterial patency and reocclusion in patients with acute myocardial infarction treated with anistreplase: Results of the anistreplase reocclusion multicenter study (ARMS)

In this open multicenter study, 156 patients with acute myocardial infarction received 30 U of anistreplase intravenously over 5 minutes within 4 hours of the onset of chest pain. The patency of the infarct-related vessel was determined by coronary angiography 90 minutes after anistreplase treatment, and also 24 hours after treatment, in patients with a patent infarct-related vessel at 90 minutes, to assess the reocclusion rate. The investigators categorized the infarct-related vessel as patent or occluded, and 2 independent cardiologists graded the infarct-related vessel according to the Thrombolysis in Myocardial Infarction (TIMI) perfusion criteria. At the 90-minute assessment, 106 of 145 evaluable patients (73%) had patent infarct-related vessels, and 39 of 145 (27%) had occluded infarct-related vessels. Of the 139 independently assessed patients, 98 (71%) had TIMI grades 2 or 3 and 41 (29%) had TIMI grades 0 or 1. At the 24-hour assessment, 98 of 102 patients (96%) had a patent infarct-related vessel, and reocclusion had occurred in 4 of 102 patients (4%). Of the 94 independently assessed patients 90 (96%) had TIMI grades 2 or 3, and 4 (4%) had TIMI grades 0 or 1. The reliability of noninvasive parameters as indicators of achieved patency of the infarct-related vessel was estimated by means of correlation with patency assessed by coronary angiography. A significant correlation of 0.62 was found. The patency rate of 71 to 73% after use of anistreplase in patients with acute myocardial infarction corresponds with findings in earlier studies. The low reocclusion rate of 4% after use of anistreplase probably reflects the prolonged action of anistreplase.

Fibrin monomer protects thrombin from inactivation by heparin-antithrombin III: implications for heparin efficacy.

Fibrin II monomer has a dramatic inhibitory effect on the rate of heparin-catalyzed inactivation of human alpha-thrombin by antithrombin III. At 6 microM fibrin II monomer, equivalent to the concentration of fibrinogen in plasma, the second-order rate constant was reduced by a factor of 308--from 2.05 x 10(8) M-1.s-1 to 6.65 x 10(5) M-1.s-1. Fibrin II monomer minimally affected the uncatalyzed rate of thrombin inactivation showing a reduction in the second-order rate constant by a factor of only 1.6. Fibrinogen and the product of plasmin degradation of fibrinogen, fragment E, at 6 microM concentrations also decreased the second-order rate constant for heparin-catalyzed thrombin inactivation, but by factors of only 2.7 and 1.9, respectively. On the basis of these observations it is proposed that protection of thrombin from inactivation by heparin-antithrombin III by fibrin II monomer can explain the limited efficacy of heparin in preventing coronary reocclusion in patients treated with tissue plasminogen activator and other fibrinolytic agents.

Indications for and Risks of Early Bypass Surgery in Patients with Acute Infarct

Aortocoronary bypass surgery as the primary means of restoring orthograde coronary blood flow is indicated only in a limited number of patients. However, as an adjunct to thrombolytic therapy, there seems to be a place for early bypass surgery in order to improve the result of thrombolysis by increasing the coronary flow when there is a residual tight stenosis, and in order to prevent reinfarction due to reocclusion in patients with significant salvage of myocardium. Salvage of myocardium is assessed by serial intracoronary thallium-201 scintigraphy at the time of thrombolysis and relates well with the change of ventricular function. Since February 1980 39 patients have been operated upon within 24 h and 16 patients between day 1 and day 7 after thrombolysis. Though the haemodynamic data and the requirement of inotropic support did not reveal any statistically supported differences among the groups, there was a higher morbidity in the patients operated upon within 24 h. These patients required a longer time on the ventilator and spent a significantly longer time in the intensive care unit. Though there were major changes in the coagulation profiles, due to administration of both heparin and streptokinase among the patients operated upon early, there were only two bleeding complications, and as an average no more blood loss was observed through the chest tubes during the first 24 h postoperatively. It is concluded that bypass surgery can be done safely and effectively even early after thrombolysis without risk of haemodynamic deterioration or increased risk of bleeding.