Djavad T. Arani

Short- and long-term mortality for patients undergoing primary angioplasty for acute myocardial infarction

OBJECTIVES The goal of this study was to learn more about the risk factors and short- and long-term outcomes for primary angioplasty. BACKGROUND Primary angioplasty (direct angioplasty without antecedent thrombolytic therapy) has been an effective alternative to thrombolytic therapy for patients with acute myocardial infarction (AMI). However, most reported studies have been compromised by small sample sizes and short observation times. METHODS New Yorks coronary angioplasty registry was used to identify New York patients undergoing angioplasty within 6 h of AMI between January 1, 1993 and December 31, 1996. Statistical models were used to identify significant risk factors for in-patient and long-term survival and to estimate long-term survival for all patients as well as various subsets of patients undergoing primary angioplasty. RESULTS The in-hospital mortality rate for all primary angioplasty patients was 5.81%. When patients in preprocedural shock (who had a mortality rate of 45%) were excluded, the in-hospital mortality rate dropped to 2.60%. Mortality rates for all primary angioplasty patients at one year, two years and three years were 9.3%, 11.3% and 12.6%, respectively. Patients treated with stent placement did not have significantly lower risk-adjusted in-patient or two-year mortality rates. CONCLUSIONS Primary angioplasty is a highly effective option for AMI.

A Comparison of Short- and Long-Term Outcomes for Balloon Angioplasty and Coronary Stent Placement

OBJECTIVES We sought to compare patient outcomes for coronary stent placement and balloon angioplasty. BACKGROUND Since 1994, the number of patients treated only with balloon angioplasty has decreased nationally, whereas the use of coronary stents as an alternative has grown tremendously. The objectives of this study were to compare short- and long-term survival and subsequent revascularization rates for patients undergoing single-vessel balloon angioplasty and coronary stent placement. METHODS New Yorks Coronary Angioplasty Registry was used to identify New York patients undergoing either balloon angioplasty or stent placement between July 1, 1994, and December 31, 1996. Statistical models were used to compare risk-adjusted short- and long-term survival and subsequent coronary artery bypass graft surgery (CABG) and percutaneous coronary interventions (PCIs). RESULTS No significant differences were found in adjusted in-patient mortality, but patients who had balloon angioplasty were, on average, 1.36 times more likely to have died at any time during the two-year period after the index procedure (p = 0.003). The adjusted in-patient CABG rate was significantly higher for balloon angioplasty (2.72% vs. 1.66%, p<0.0001), and the adjusted two-year CABG rate was also significantly higher for balloon angioplasty (10.81% vs. 7.25%, p<0.001). The adjusted two-year rate for subsequent PCIs was also significantly higher for balloon angioplasty (19.6% vs. 14.3%, p<0.0001). Although measures were taken to eliminate or minimize the effect of selection bias, it should be noted that patients with stents were healthier at hospital admission than patients who had balloon angioplasty. CONCLUSIONS Stent placement is associated with significantly lower risk-adjusted long-term mortality, CABG and subsequent PCI rates, as compared with balloon angioplasty.

The Half-Axial Projection A New Look at the Proximal Left Coronary Artery

The half-axial view is a dividend of large film selective coronary arteriography. The half-axial projection is obtained by combining caudal tilt of the overhead tube with rotation of the patient into the right posterior oblique position. Thus, the main left coronary artery and the proximal portions of its primary and secondary branches are maximally displayed because the X-ray beam is nearly perpendicular to these vessels and overlap is minimized. The half-axial view adds less than two minutes to the procedure and in nearly half of our patients adds significantly to the arteriographic assessment of the left coronary artery.

Avulsion of the Left Internal Mammary Artery After Minimally Invasive Coronary Bypass

Minimally invasive direct coronary artery bypass grafting is a relatively new procedure. An unusual complication occurred in a patient after a period of heavy lifting, namely, avulsion of the left internal mammary artery graft. He presented with a clinical picture of myocardial infarction and shock. Diagnostic work-up and surgical management are described.

Coronary artery fistulas emptying into left heart chambers.

We present three cases of coronary artery fistulas entering into the left heart chambers. Coronary arteriography in one showed aneurysmal dilatation of the main left coronary artery and a fistulous communication with a large left atrium. Exploration during repair revealed an anomalous branch of the left circumflex emptying into the left atrium. In the second case the proximal left circumflex gave rise to a branch supplying a hemangioma which emptied into the left atrium. Coronary arteriograms of the third patient showed an enlarged left anterior descending artery with an anomalous branch emptying into the left ventricle. Shunt flow was estimated with hydrogen as a tracer in the last two cases and was two thirds and one third of the left coronary inflow, respectively. Review of the literature shows 32 previously reported cases of a fistula draining into the left side of the heart.

Lordotic right posterior oblique projection of the left coronary artery: a speical view for special anatomy.

The lordotic right posterior oblique projection of the left coronary artery is obtained by combining cranial angulation of the X-ray beam with rotation of the patient into the right posterior oblique position. This projection is helpful for separation of the main left coronary artery and the proximal portions of the left anterior descending and circumflex divisions, especially in patients in whom the left anterior descending artery is directed cephalad early in its course. The obtaining of an image from the lordotic right posterior oblique projection adds less than two minutes to the procedure and improves arteriographic assessment of the left coronary artery.

Renal carbuncle: Simulation of tumor response to epinephrine

A case of renal carbuncle with unusual angiographic findings is presented. The abscess showed abnormal vessels on selective angiogrpahy which were enhanced after intra-arterial epinephrine. New foci of abnormal vessels were also seen on the postepinephrine angiogram.

Safety and effectiveness of the arani curve guiding catheters in Palmaz-Schatz stenting of right coronary artery stenosis

The purpose of this study was to evaluate the safety and efficacy of Arani curve guiding catheters in Palmaz-Schatz stenting of right coronary artery (RCA) stenosis. A total of 15 stents was implanted in 13 right coronary arteries. For stenting of the RCA with marked superior orientation and shepherds crook configuration of the proximal segment, a catheter with a 75 degrees primary curve was used. A catheter with a 90 degrees primary curve was usually the best choice for stenting of the RCA with slight superior, horizontal, or interior orientation of the proximal segment. These catheters provided excellent support in 12 of 13 cases (93%) and resulted in successful stent deployment in these patients. There was one dissection which occurred distal to the stent following poststent balloon dilatation, and which required emergency coronary artery bypass graft surgery. There were no complications attributed to these guiding catheters. An extraordinary formation of pseudostenosis occurred in one patient. We conclude that Arani curve guiding catheters provide strong support and are safe and effective in stenting of RCA stenosis.