Geoffrey O. Hartzler

Multicenter investigation of coronary stenting to treat acute or threatened closure after percutaneous transluminal coronary angioplasty : clinical and angiographic outcomes

OBJECTIVESnThis study reports on the initial experience with the Gianturco-Roubin flexible coronary stent. The immediate and 6-month efficacy of the device and the incidence of the complications of death, myocardial infarction, emergency coronary artery bypass surgery and recurrent ischemic events are presented.nnnBACKGROUNDnAbrupt or threatened vessel closure after coronary angioplasty is associated with increased risk of myocardial infarction, emergency coronary artery bypass graft surgery and in-hospital death. When dissection or prolapse of dilated plaque into the lumen is unresponsive to additional or prolonged balloon catheter inflation, coronary stenting offers a nonsurgical mechanical means to rapidly restore stable vessel geometry and adequate coronary blood flow.nnnMETHODSnFrom September 1988 through June 1991, 518 patients underwent attempted coronary stenting with the 20-mm long Gianturco-Roubin coronary stent for acute or threatened vessel closure after angioplasty. In 494 patients, one or more stents were deployed. Thirty-two percent of patients received stents for acute closure and 69% for threatened closure.nnnRESULTSnSuccessful deployment was achieved in 95.4% of patients. Overall, stenting resulted in an immediate angiographic improvement in the diameter stenosis from 63 +/- 25% before stenting to 15 +/- 14% after stenting. Emergency coronary artery bypass graft surgery was required in 4.3% (21 of 493 patients). The incidence of in-hospital myocardial infarction (Q wave and non-Q wave) was 5.5% (27 of 493 patients). At 6 months, myocardial infarction was infrequent, occurring in 1.6% (8 of 493 patients). The incidence of in-hospital death was 2.2% (11 of 493 patients). Late death occurred in 7 patients (1.4%) and 34 patients (6.9%) required later bypass graft surgery. Complications included blood loss, primarily from the arterial access site, and subacute thrombosis of the stented vessel in 43 patients (8.7%).nnnCONCLUSIONSnThe early multicenter experience suggests that this stent is a useful adjunct to coronary angioplasty to prevent or minimize complications associated with flow-limiting coronary artery dissections previously correctable only by surgery. Although this study was not randomized, it demonstrated a high technical success rate and encouraging results with respect to the low incidence of emergency coronary artery bypass graft surgery and myocardial infarction.

Percutaneous transluminal coronary angioplasty with and without thrombolytic therapy for treatment of acute myocardial infarction

Successful percutaneous transluminal coronary angioplasty (PTCA) was performed during evolving acute myocardial infarction (AMI) in 41 patients. Catheterization was performed within 1 hour of presentation, from 1 to 12 hours (mean 3.3) following symptom onset. In 17 of 29 patients with a totally occluded coronary artery, successful thrombolytic therapy was followed by PTCA of a residual high-grade atheromatous stenosis. Successful PTCA without prior thrombolytic therapy was employed in 11 of 12 subtotal coronary stenoses producing acute infarction syndromes and in two patients having critical coronary stenoses not immediately responsible for AMI. Three patients experienced early in-hospital reocclusion with reinfarction. One death occurred in a patient presenting with cardiogenic shock. All remaining patients had prompt pain relief, subsequent stable clinical courses, and no clinical or late angiographic evidence of coronary reocclusion. Dramatic improvement of regional and global left ventricular function was evident in 22 of 27 patients undergoing late left ventricular angiography. At follow-up, 94% of patients remained free of angina although three required repeat dilatation of recurrent stenoses. We concluded that PTCA may be performed with or without thrombolytic therapy in selected patients with AMI and may reduce the likelihood of late reocclusion following successful thrombolytic therapy.

Predictors of in-hospital and 6-month outcome after acute myocardial infarction in the reperfusion era: The primary angioplasty in myocardial infarction (PAMI) trial

OBJECTIVESnThis study examined the predictors of in-hospital and 6-month outcome after different reperfusion strategies in acute myocardial infarction.nnnBACKGROUNDnThrombolytic therapy and primary angioplasty are both widely applied as reperfusion modalities in patients with myocardial infarction. Although it is accepted that restoration of early patency of the infarct-related artery can reduce mortality and salvage myocardium, the optimal reperfusion strategy remains controversial, and the predictors of outcome in the reperfusion era have been incompletely characterized.nnnMETHODSnAt 12 centers, 395 patients presenting within 12 h of onset of acute transmural myocardial infarction were prospectively randomized to receive tissue-type plasminogen activator (t-PA) or undergo primary angioplasty without antecedent thrombolysis. Sixteen clinical variables were examined with univariate and multiple logistic regression analysis to identify the predictors of clinical outcome.nnnRESULTSnBy univariate analysis, in-hospital mortality was increased in the elderly, women, patients with diabetes and in patients treated with t-PA as opposed to angioplasty. Only advanced age and treatment by t-PA versus angioplasty independently correlated with increased in-hospital mortality (6.5% vs. 2.6%, respectively, p = 0.039 by multiple logistic regression analysis). Similarly, the only variables independently related to in-hospital death or nonfatal reinfarction were advanced age and treatment by t-PA versus angioplasty (12.0% vs. 5.1%, p = 0.02). The reduction in in-hospital death or reinfarction with angioplasty versus t-PA was particularly marked in patients > or = 65 years of age (8.6% vs. 20.0%, p = 0.048). Furthermore, primary management with angioplasty versus t-PA was the most powerful multivariate correlate of freedom from recurrent ischemic events (10.3% vs. 28.0%, p = 0.0001). The independent beneficial effect of angioplasty on freedom from death or reinfarction was maintained at 6-month follow-up (8.2% vs. 17.0%, p = 0.02).nnnCONCLUSIONSnIn the reperfusion era, the two most powerful determinants of freedom from death, reinfarction and recurrent ischemia after myocardial infarction are young age and treatment by primary angioplasty.

Left main coronary angioplasty: Early and late results of 127 acute and elective procedures

The results of 127 left main (LM) coronary angioplasties were reviewed to assess short- and long-term effectiveness. Three major subgroups were considered: (1) elective protected (defined as the presence of a patent bypass graft to the left coronary circulation) patients (n = 84); (2) elective unprotected patients (n = 33); and (3) acute patients, in whom LM coronary angioplasty was performed in the setting of an acute myocardial infarction (n = 10). Successful LM dilation was achieved in 94% of elective patients and 90% of acute patients. Procedural mortality was 4.3% in elective patients (2.4 and 9.1% in protected and unprotected patients, respectively, p = 0.14) and 50% in the acute subgroup. Long-term follow-up data, available for 98% of patients, revealed actuarial 3-year survival rates of 90 and 36% in elective protected and unprotected subgroups, respectively (p less than 0.0005). In the acute subgroup, 3 patients (30%) were alive at the time of follow-up; all had undergone coronary artery bypass surgery. Thus, although elective angioplasty of an unprotected LM coronary artery is technically feasible, the long-term prognosis of such patients is very poor. LM angioplasty in this subgroup should be reserved for patients in whom surgical revascularization is not an option. In contrast, elective angioplasty of a protected LM coronary artery can be accomplished safely with good long-term results. LM coronary angioplasty for acute myocardial infarction can be effective as a salvage procedure; however, adjunctive coronary bypass surgery is important for long-term survival.

Short- and long-term outcome of percutaneous transluminal coronary angioplasty in chronic dialysis patients.

Accelerated atherosclerosis occurs in chronic renal failure. The role of percutaneous transluminal coronary angioplasty (PTCA) in chronic renal failure patients requiring dialysis has not been characterized. We studied 17 chronic dialysis patients requiring PTCA over a 6-year period. Their mean age was 60 years, four were diabetic, eight had severe hypertension, and seven had unstable angina. Angiographic success was achieved in 47 of 49 (96%) stenoses attempted, including multivessel PTCA in 12 patients. There was one procedural death, two non-Q wave myocardial infarctions following PTCA, and one additional in-hospital noncardiac death. The 15 survivors were asymptomatic on discharge (mean stay 11 days), but recurrent angina developed within 6 months in 12 patients. Angiography in 11 of these 12 patients demonstrated restenosis of 26 of 32 (81%) dilated sites. Repeat PTCA in six patients was followed by return of angina in four patients with restenosis in 11 of 12 sites. Bypass surgery was ultimately performed in four patients with long-term angina relief. During follow-up (mean 20 months), seven patients died (five from chronic renal failure, two cardiac deaths). Thus although PTCA in chronic dialysis patients is technically feasible and provides relief of angina, aggressive restenosis limits the long-term benefit. Coronary bypass surgery may be the preferred therapy for this unique patient group.

“High-risk” percutaneous transluminal coronary angioplasty

Of 6,500 percutaneous transluminal coronary angioplasty procedures performed between June 1980 and June 1987, 3,501 (1,604 single lesion and 1,897 multiple lesion) were performed in low-risk patients with a procedure-related mortality of 0.2 to 0.3%. In comparison, several clinical variables were identified that increased procedural risk by up to 50-fold. These factors include left main dilatation (n = 103, mortality 3.9%), left main equivalent dilatation (n = 77, mortality 2.6%), ejection fraction less than or equal to 40% (n = 664, mortality 2.7%), age greater than or equal to 70 years (n = 1,038, mortality 1.4%), dilatation of all 3 vessels (n = 305, mortality 1.3%), combined diagnostic catheterization and angioplasty for unstable angina (n = 193, mortality 1.5%), and percutaneous transluminal coronary angioplasty for acute myocardial infarction (n = 446, mortality 8.5%). Important considerations in the selection and management of these high-risk patients are discussed.

Retained percutaneous transluminal coronary angioplasty equipment components and their management

Of 5,400 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures, 12 patients had complications resulting in retention of 1 or more PTCA equipment components. Eight patients had guidewire fragments retained within the coronary circulation, including one with a second wire segment within the abdominal aorta. A gold band catheter marker was retained within a coronary artery in 1 patient. Four of 5 extraction procedures in these patients were successful, including retrieval of a wire segment totally contained within the distal circumflex coronary artery. Bioptomes were used to retrieve guidewire segments from the abdominal aorta in 4 patients and a knotted guiding catheter from another. At late follow-up, 5 patients with wire segment retained for an extended time within the coronary circulation had no sequelae attributable to the PTCA component debris. We conclude that many fractured intracoronary wires with proximal portion extending into the ascending aorta can be extracted. Guidewire segments retained for a long time totally within the coronary circulation may be benign, particularly when entrapped within total coronary occlusions. Bioptomes can be used effectively to remove wire segments within the abdominal aorta and to assist in the removal of kinked guide catheters.

Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery.

OBJECTIVESnWe attempted to determine the relative risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG).nnnBACKGROUNDnDue to an expanding population of patients with surgically treated coronary artery disease and the natural progression of atherosclerosis, an increasing number of patients with previous CABG require repeat revascularization procedures. Although there are randomized comparative data for CABG versus medical therapy and, more recently, versus PTCA, these studies have excluded patients with previous CABG.nnnMETHODSnWe retrospectively analyzed data from 632 patients with previous CABG who required either elective re-CABG (n = 164) or PTCA (n = 468) at a single center during 1987 through 1988. The PTCA and re-CABG groups were similar with respect to gender (83% vs. 85% male), age > 70 years (21% vs. 23%), mean left ventricular ejection fraction (46% vs. 48%), presence of class III or IV angina (70% vs. 63%) and three-vessel coronary artery disease (77% vs. 74%).nnnRESULTSnComplete revascularization was achieved in 38% of patients with PTCA and 92% of those with re-CABG (p < 0.0001). The in-hospital complication rates were significantly lower in the PTCA group: death (0.3% vs. 7.3%, p < 0.0001) and Q wave myocardial infarction (MI) (0.9% vs. 6.1%, p < 0.0001). Actuarial survival was equivalent at 1 year (PTCA 95% vs. re-CABG 91%) and 6 years (PTCA 74% vs. re-CABG 73%) of follow-up (p = 0.32). Both procedures resulted in equivalent event-free survival (freedom from dealth or Q wave MI) and relief of angina; however, the need for repeat percutaneous or surgical revascularization, or both, by 6 years was significantly higher in the PTCA group (PTCA 64% vs. re-CABG 8%, p < 0.0001). Multivariate analysis identified age > 70 years, left ventricular ejection fraction < 40%, unstable angina, number of diseased vessels and diabetes mellitus as independent correlates of mortality for the entire group.nnnCONCLUSIONSnIn this nonrandomized series of patients with previous CABG requiring revascularization, an initial stategy of either PTCA or re-CABG resulted in equivalent overall survival, event-free survival and relief of angina. PTCA offers lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and a greater need for subsequent revascularization procedures.

Lovastatin plus probucol for prevention of restenosis after percutaneous transluminal coronary angioplasty

Combination lovastatin and probucol reduced total cholesterol (27%) and low-density lipoprotein levels (30%), but did not prevent restenosis or clinical events during the first 6 months after percutaneous transluminal coronary angioplasty.

The spectrum of symptomatic coronary air embolism during balloon angioplasty : Causes, consequences, and management

PTCA is a widely used method of myocardial revascularization. Although complications of this procedure have been characterized, air emboli to the coronary vasculature have rarely been reported and their appropriate management is uncertain. We report six cases of symptomatic coronary air emboli occurring during PTCA. The possible mechanisms of the introduction of air during PTCA include incomplete aspiration of guiding catheters, balloon rupture, insinuation of air with balloon catheter introduction or withdrawal; structural failures of the equipment, and constant negative suction of selfventing catheters left outside the body. Symptomatic responses range from mild angina to full cardiac arrest and tend to resolve spontaneously in 5 to 10 minutes. Treatment is aimed at supporting the patient for this brief period, and consists of 100% inspired oxygen, analgesics, arrhythmic therapy if needed, and pressor and balloon pump support as required. Greater awareness of the causes, prevention, and therapy of coronary air emboli will lead to the safer practice of PTCA.