Harold E. Aldridge

Aspirin and dipyridamole in the prevention of restenosis after percutaneous transluminal coronary angioplasty.

To examine the role of antiplatelet therapy in the prevention of arterial restenosis after percutaneous transluminal coronary angioplasty (PTCA), we conducted a randomized, double-blind, placebo-controlled study in 376 patients. The active treatment consisted of an oral aspirin-dipyridamole combination (330 mg-75 mg) given three times daily, beginning 24 hours before PTCA. Eight hours before PTCA, the oral dipyridamole was replaced with intravenous dipyridamole at a dosage of 10 mg per hour for 24 hours, and oral aspirin was continued. Sixteen hours after PTCA, the initial combination was reinstituted. Treatment was continued in patients with a successfully dilated vessel until follow-up angiography four to seven months after PTCA--or earlier, if symptoms dictated. Of 249 patients who underwent follow-up angiography, 37.7 percent of patients receiving the active drug had restenosis in at least one segment, as compared with 38.6 percent of patients taking placebo (P not significant). The number of stenotic segments was virtually the same in the two groups. Among the 376 randomized patients, there were 16 periprocedural Q-wave myocardial infarctions--13 in the placebo group and 3 in the active-drug group (6.9 percent vs. 1.6 percent, P = 0.0113). Although the use of this antiplatelet regimen before and after PTCA did not reduce the six-month rate of restenosis after successful coronary angioplasty, it markedly reduced the incidence of transmural myocardial infarction during or soon after PTCA. Thus, the short-term use of antiplatelet agents in relation to PTCA can be recommended.

Percutaneous coronary laser balloon angioplasty: Initial results of a multicenter experience

A multicenter clinical trial was initiated to test the potential safety and short-term efficacy of a percutaneous coronary application of laser balloon angioplasty, which has been shown experimentally to alleviate the common causes (dissection, recoil, thrombus) of suboptimal luminal results of conventional balloon angioplasty. Fifty-five patients, the majority (62%) of whom had relatively high risk lesions, were treated in 10 centers with a laser balloon that was identical in size (3 x 20 mm) to a balloon used for conventional balloon angioplasty performed on the same lesion immediately before laser balloon angioplasty. One or more neodymium:yttrium aluminum garnet (Nd:YAG) (1,060 nm) laser doses of 250 to 450 J were each delivered over a 20 s duration per exposure. Immediately and 1 day after laser balloon angioplasty no significant adverse effects on the arterial lumen were noted in any patient. By computerized image analysis of cineangiograms initial conventional balloon angioplasty failed to achieve a minimal luminal diameter greater than 1.5 mm in 14 patients (25%), including 3 patients with acute closure. However, after subsequent laser balloon angioplasty, minimal luminal diameter exceeded this value in all patients including this subgroup. Overall, minimal luminal diameter increased from 1.74 +/- 0.46 mm after conventional balloon angioplasty to 2.32 +/- 0.31 mm after laser balloon angioplasty (p less than 0.001) with no change found on 1 day and 1 month follow-up angiograms. Thus, laser balloon angioplasty is a safe, effective procedure for improving luminal dimensions after conventional balloon angioplasty.

Acute coronary artery occlusion during percutaneous transluminal coronary angioplasty treated by redilation of the occluded segment

Acute occlusion of a coronary artery during percutaneous coronary angioplasty usually results in unremitting ischemia requiring emergency surgical intervention. Seven patients are described, in whom complete occlusion occurred during coronary angioplasty as a result of coronary artery dissection. Despite this, it was possible to reintroduce the balloon catheter immediately and redilate the vessel with abrupt reversal of clinical and electrocardiographic manifestations of ischemia. Six patients had no subsequent evidence of myocardial infarction. The seventh had a slight elevation of serum creatine kinase and transient electrocardiographic changes. All patients were discharged from the hospital without further intervention. Four patients had elective coronary artery bypass surgery (greater than 4 weeks after angioplasty) and three have remained asymptomatic or in improved condition since the coronary angioplasty. It is concluded that sudden occlusion of a coronary artery during coronary angioplasty can be safely treated by redilation in the acute stage.

Improved diagnosis in coronary cinearteriography with routine use of 110° oblique views and cranial and caudal angulations

Abstract Conventionally mounted X-ray systems for coronary cinearteriography limit angulation of the X-ray beam to the transverse plane of the patient, and use of the motorized cradle restricts rotation to 60° to 70°. These limitations of available projections seriously hamper adequate examination of the coronary arteries. With use of the Siemens Cardoskop-U, which was designed to overcome this problem, the coronary arteries of 100 consecutive patients were examined with standard oblique projections, and in addition with cranial and caudal angulated oblique and 110° oblique projections. These arteriograms were independently examined by two expert observers. In approximately 20 percent of patients the additional views unmasked lesions that would otherwise have been missed. In a further 34 percent the diagnosis was significantly improved because the full extent of a lesion was revealed, overlap of branches was avoided or the degree of an eccentric stenosis was upgraded. In 4 of 12 patients with apparently normal arteriograms in standard projections, lesions were unmasked by the additional views.

Complications associated with the guide wire in percutaneous transluminal coronary angioplasty

This report describes three cases of unraveling of the platinum coil of the guide wire during percutaneous transluminal coronary angioplasty. In one case the wire ruptured and required surgical removal. The exact cause of this phenomenon is not known, but wire entrapment may be a factor. This is more likely to occur with tortuous vessels. Precautions to avoid uncoiling and rupture of guide wires during coronary angioplasty are discussed.

PARTIAL ANOMALOUS PULMONARY VENOUS DRAINAGE WITH INTACT INTERATRIAL SEPTUM ASSOCIATED WITH CONGENITAL MITRAL STENOSIS.

A case of partial anomalous pulmonary venous drainage with intact interatrial septum associated with mitral stenosis is reported. The roentgenogram showed plethora confined to the anomalously draining lung tissue, i.e., right upper amd middle lobes, and when the patient developed pulmonary edema, rales were confined to normally draining lung tissue, i.e., left lung and right lower lobe.The pulmonary capillary “wedge” pressures recorded from the normally draining lung tissue reflected the left atrial hypertension, while “wedge” pressures recorded from anomalously draining lung tissue were much lower and reflected the right atrial pressure. Left heart catheterization confirmed the presence of mitral stenosis. Autopsy examination revealed congenital mitral and aortic stenosis, anomalous venous drainage from the right upper and middle lobes and an intact interatrial septum. The differential pulmonary plethora, the differential pulmonary edema, and the differential pulmonary capillary wedge pressures suggested the correct diagnosis during life.