A. Grüntzig

Nonoperative dilatation of coronary-artery stenosis: percutaneous transluminal coronary angioplasty.

In percutaneous transluminal coronary angioplasty, a catheter system is introduced through a systemic artery under local anesthesia to dilate a stenotic artery by controlled inflation of a distensible balloon. Over the past 18 months, we have used this technic in 50 patients. The technic was successful in 32 patients, reducing the stenosis from a mean of 84 to 34 per cent (P less than 0.001) and the coronary-pressure gradient from a mean of 58 to 19 mm Hg (P less than 0.001). Twenty-nine patients showed improvement in cardiac function during follow-up examination. Because of acute deterioration in clinical status, emergency bypass was later necessary in five patients; three showed electrocardiographic evidence of infarcts. Patients with single-vessel disease appear to be most suitable for the procedure, and a short history of pain indicates the presence of a soft (distensible) atheroma likely to respond to dilatation. We estimate that only about 10 to 15 per cent of candidates for bypass surgery have lesions suitable for this procedure. A prospective randomized trial will be necessary to evaluate its usefulness in comparison with surgical and medical management.

TREATMENT OF RENOVASCULAR HYPERTENSION WITH PERCUTANEOUS TRANSLUMINAL DILATATION OF A RENAL-ARTERY STENOSIS

Percutaneous transluminal dilatation of a left-sided renal-artery stenosis was done in a 61-year-old patient with hypertension. Shortly after dilatation blood-pressure fell to normal and renal plasma flow increased. Dilatation might be an alternative to renal vascular surgery in severe renal hypertension.

Long-term experience in percutaneous transluminal dilatation of renal artery stenosis

Percutaneous transluminal dilatation was attempted in 65 patients with renovascular hypertension. In five cases (8 percent), percutaneous transluminal dilatation could not be performed for technical reasons. In the remaining 60 patients (35 with atherosclerotic stenosis and 25 with fibromuscular dysplasia), both mean systolic and diastolic pressure fell immediately after percutaneous transluminal dilatation and remained significantly lower for a period of up to five years. Cure rates after a mean control period of 21.6 months were higher in patients with fibromuscular dysplasia (50 percent) than in those with atherosclerotic stenosis (29 percent). Improvement of blood pressure was observed in 32 percent of patients with fibromuscular dysplasia and in 48 percent of patients with atherosclerotic stenosis. Follow-up angiography in 33 cases showed occlusion of the dilated artery in two patients and recurrence of slight renal artery stenosis in nine patients. Successful redilatation could be performed in five of these cases. Furthermore, renal vein renin determinations were only of limited diagnostic or prognostic value. These results document the good long-term effect of percutaneous transluminal dilatation in patients with renal artery stenosis. Percutaneous transluminal dilatation should, therefore, be the favored procedure in patients with renovascular hypertension.

[Percutaneous dilatation of experimental coronary artery stenosis- description of a new catheter system].

A technical description of a catheter system is given for percutaneous dilatation of experimental stenosis in small ateries (e.g. left coronary artery). The system consists of two catheters: the first is positioned into the orifice of the small artery and guides the second, double-lumen-dilatation catheter into the artery. During the manipulation ischemia in the peripheral area is prevented by contineous perfusion with oxygenated blood taken from the femoral artery by a roller-pump. The catheter system was tested in canine experiments.SummaryA technical description of a catheter system is given for percutaneous dilatation of experimental stenosis in small arteries (e.g. left coronary artery). The system consists of two catheters: the first is positioned into the orifice of the small artery and guides the second, double-lumen-dilatation catheter into the artery. During the manipulation ischemia in the peripheral area is prevented by contineous perfusion with oxygenated blood taken from the femoral artery by a roller-pump. The catheter system was tested in canine experiments.ZusammenfassungEs wird die technische Beschreibung des Kathetersystems vorgelegt, mit dem es möglich ist, im Hundeexperiment kleine, schwer erreichbare Arterien (z.B. linke Coronararterie) percutan zu sondieren und Stenosen in ihrem Verlauf zu dilatieren.Das System besteht aus einem vorgeformten Führungskatheter, durch den ein dünner, doppellumiger Dilatationskatheter in die kleine Arterie vorgeschoben wird. Während der Manipulation wird eine Ischämie im peripheren Gefäßabschnitt durch die kontinuierliche Perfusion im oxygeniertem Blut verhindert. Das Blut wird einer Femoralarterie unter Verwendung einer Rollerpumpe entnommen.

The Role of the Surgeon in Percutaneous Transluminal Dilation of Coronary Stenosis

Percutaneous transluminal dilation (PTD) of coronary artery stenosis is performed by means of a balloon-tipped catheter introduced from a peripheral artery. It was attempted in 45 patients; stenosis was passed in 33 and was successfully dilated in 28 patients (62%). The method failed in 17 patients: in 6 of them an abrupt closure of a stenosed artery or a beginning infarction necessitated an emergency revascularization. There were no deaths or serious complications, but an infarction developed in 1 patient despite immediate bypass grafting. PTD was successful in 5 out of 7 patients who had recurrent angina after previous coronary bypass grafting: in 2 of them stenosis of a distal coronary artery and in 3 a stenosed bypass graft were dilated. PTD is a new method of treatment of coronary artery disease and is an addition rather than an alternative to coronary bypass grafting. The best results can be expected in patients with single-vessel disease, with a short history of angina (less than 1 year), and with narrow, noncalcified proximal stenosis. Some late complications of bypass grafting are also amenable to this method of treatment.

Möglichkeiten und Grenzen der qualitativen Venen-Diagnostik mit Doppler-Ultraschall (Ergebnisse einer Blindstudie)

SummaryThe Doppler ultrasound method is applied for the diagnosis of thrombotic occlusions and insufficient valvular function in the deep venous system of the legs. A blind study was carried out in order to demonstrate the validity of this method. — The diagnoses obtained in the course of 42 ascending and 35 pelvic phlebographies with Valsalva manoeuvre were used as reference and compared with those established on the basis of the Doppler ultrasound technique. — The agreement between ultrasonic and venographic findings from the evaluation of chronic thrombosis of the pelvic and deep femoral veins was 93%. The accuracy of the Doppler method in discerning venous valve insufficiency corresponded to 94%. The cases are presented in which the two methods yielded different results. It could be demonstrated that false positive and false negative results of the Doppler ultrasonic method were mostly due to the fact that the latter allows only functional but not morphological conclusions on the vessels investigated. It appeared that the examination with the Doppler technique must be performed carefully and each team should check the validity of the findings obtained with the Doppler method by a series of phlebographies.ZusammenfassungIn einer Blindstudie wurden die Ergebnisse von 42 anterograden und 35 retrograden Beinphlebographien der Doppler-Ultraschall-Diagnose gegenübergestellt.Für die Beurteilung der Abflußbehinderung in den tiefen Oberschenkel- und Beckenvenen aufgrund von Stenosen oder thrombotischen Verschlüssen ergab sich eine Übereinstimmung von 93%.Im Vergleich mit der Preßphlebographie konnte für die Klappeninsuffizienz eine Übereinstimmung von 94% erreicht werden.Die nicht übereinstimmenden Fälle wurden im einzelnen dargestellt. Es zeigte sich, daß die falsch positiven und falsch negativen Doppler-Entscheidungen sich zum größten Teil daraus ergaben, daß dieses Verfahren nur funktionelle, nicht aber morphologische Aussagen über das untersuchte Gefäß liefern kann.Es wurde deutlich, daß größte Sorgfalt bei der Doppler-Untersuchung erforderlich ist und daß jede Untersuchergruppe die Treffsicherheit ihrer Diagnose durch eine Reihe von Phlebographien überprüfen sollte.

Percutaneous transluminal dilatation: a new treatment of renovascular hypertension?

ZusammenfassungBei einem 61jährigen Patienten mit renovasculärer Hypertonie bei linksseitiger arteriosklerotischer Nierenarterienstenose wurde eine perkutane transluminale Dilatation der Stenose vorgenommen. Die biochemische und hämodynamische Aktivität der Nierenarterienstenose wurde durch Messung der Plasmareninaktivität im Nierenvenenblut, Bestimmung des renalen Plasmaflusses und der prä- und poststenotischen Blutdruckwerte in der Nierenarterie belegt.Kurz nach der Dilatation der Stenose normalisierte sich der Blutdruck, und es kam zu einem Anstieg des renalen Plasmaflusses. Weitere Untersuchungen werden zeigen, ob die beschriebene Methode eine Alternative zur operativen Korrektur der Nierenarterienstenose bietet.SummaryPercutaneous transluminal dilatation of a left sided renal artery stenosis was performed in a 61 year old patient with hypertension. Biochemical and hemodynamic activity of the renal artery stenosis was demonstrated by measurement of renal venous renin-activity and determination of renal plasma flow and of pre- and poststenotic blood pressure values.Shortly after the dilatation procedure hypertension disappeared and renal plasma flow increased.The described procedure might be an alternative method to renal vascular surgery.

188. Percutane transluminale Dilatation chronischer Coronarstenosen

SummarySince September 1977 67 patients with disabling angina pectoris have been treated with percutaneous transluminal coronary angioplasty (PTCA) using a double-lumen dilatation catheter. In 54 patients we were able to complete the procedure, of whom 47 (70%) were anatomically and clinically improved. In the follow-up period there were recurrences in 6 patients, of whom 3 had a second PTCA. Seven of the 54 patients needed coronary operation, 6 within 24 h, due to deterioration of symptoms. Therefore, standby of the cardiac surgeon during PTCA is mandantory. Coronary lesions most suitable for the procedure are subtotal, discrete, noncalcified and proximal stenoses in patients with a short history of angina (less than 1 year).ZusammenfassungSeit September 1977 wurden 67 Patienten mit der percutanen transluminalen Coronar-Angioplastie (PTCA) behandelt. In 54 Patienten konnte der Katheter durch die Stenose gebracht und diese dilatiert werden. In 47 (70%) wurde ein anatomischer und klinischer Primärerfolg verzeichnet. In der Kontrollperiode kam es zu 6 Rezidiven, wobei bei 3 die Dilatationsbehandlung wiederholt wurde. Sieben der 54 Patienten mußten sich einer Coronaroperation unterziehen, 6 innerhalb von 24h, weil sich die Symptome nach der Dilatation akut verschlechterten. Die Operationsbereitschaft des Herzchirurgen ist daher während der Dilatation unbedingt nötig. Für diese Therapie geeignet sind subtotale, kurzstreckige, nicht calcifizierte proximale Stenosen bei Patienten mit Ein-Gefäß-Erkrankung und kurzer Anamnese der Angina pectoris (kürzer als 1 Jahr).