Irving Franco

Percutaneous transluminal angioplasty of saphenous vein graft stenosis: long-term follow-up

Percutaneous transluminal angioplasty was used to treat 101 patients with saphenous vein bypass graft stenosis at a mean of 50.1 months (range 2 to 196) after coronary artery bypass surgery. The patients presented between March 1981 and April 1987. A total of 107 saphenous vein grafts were dilated at 117 sites. The primary success rate was 91.8%. The incidence of cardiac complications was 7.1%. There were no cardiac complications in 53 patients with grafts implanted less than 36 months before angioplasty (Group 1). The 48 patients with grafts implanted for greater than 36 months (Group 2) had a 12.5% incidence rate of myocardial infarction, a 4% incidence rate of emergent bypass surgery and a 4% incidence rate of death for an overall cardiac complication rate of 14.9% (p less than 0.01). Follow-up was obtained at a mean of 16.8 +/- 13.9 months (range 1 to 54) in 87 patients (97% of successful cases). Repeat coronary angiography was performed in 49 patients and revealed restenosis in 30 patients (61.2%), with no difference in recurrence rates for proximal, mid or distal graft sites. Clinical recurrence (defined as recurrence of symptoms, myocardial infarction, repeat angioplasty, surgery or death) was 33.1% for Group 1 patients and 64.1% for Group 2 patients (p less than 0.01). The complication and recurrence rates of saphenous vein graft angiography are significantly higher when performed for late (greater than 36 months) vein graft failure. All therapeutic options should be carefully examined before proceeding with angioplasty for saphenous vein graft stenosis in this type of patient.

Frequency, management and follow-up of patients with acute coronary occlusions after percutaneous transluminal coronary angioplasty

Angiograms from 1,500 consecutive patients undergoing percutaneous transluminal coronary angioplasty (PTCA) at the Cleveland Clinic were reviewed to determine the frequency of acute coronary occlusion after successful PTCA. Thirty-two patients (2%) had acute coronary occlusions. Of these, 27 (84%) presented within 6 hours. Compared with control group, only the presence of eccentric lesions (72% vs 24%) and intimal tears (78% vs 34%) was more predominant in the group with acute occlusion. Redilation was attempted in 31 patients and was successful in 27 (87%). Nine of these patients eventually required coronary bypass surgery and 18 were discharged and followed for 11 to 34 months (mean 18). Thus, redilation is a safe and effective approach to manage patients in whom coronary occlusion develops after PTCA.

Relation of clinical presentation, stenosis morphology, and operator technique to the procedural results of rotational atherectomy and rotational atherectomy-facilitated angioplasty.

BackgroundRotational atherectomy using the Rotablator has recently become available to treat coronary stenoses. This study was performed to determine the relation of patient characteristics, stenosis morphology, and operator technique procedural outcome to gain insight into which patients might be best treated with this device. Methods and ResultsFour hundred stenoses from 316 patients randomly selected from the initial Rotablator experience at three major referral institutions were analyzed. Angiographic data were assessed at a central angiographic laboratory using standardized morphological criteria and caliper measurement. Patients were somewhat more elderly than most percutaneous transluminal coronary angioplasty (PTCA)-treated groups (mean age, 64±11 years), 74% were men, and the lesions treated were often complex (modified American College of Cardiology/American Heart Association lesion type A, 24%; Bi, 40%; B2, 30%; and C, 6%). Elective adjunctive PTCA was used for 82% of stenoses treated. Procedural success was achieved in 89.8% of stenoses (93.5% if results with creatine kinase two to three times normal are not counted as failures), and major ischemic complications (death, 0.3%; non-Q-wave myocardial infarction, 5.7%; Q-wave myocardial infarction, 2.2%; or emergency bypass surgery, 0.9%) occurred in 8.9% of patients. Complications were due to epicardial coronary obstruction in 3.8% of patients and to delayed coronary runoff (“slow reflow”) in 5.1% of patients. Procedural failure was correlated independently with outflow obstruction (success rate, 64%; odds ratio for failure, 5.4; multivariate P = .002), lesion irregularity (76%; odds ratio, 3.3; P = .003), stenosis bend .600 (73%; odds ratio, 3.7; P = .03), and female sex (84%; odds ratio, 2.4; P = .03). Ischemic complications were correlated independently with lesion length (≥50% narrowing) ≥4 mm (complication rate, 12%; odds ratio, 3.6; multivariate P = .005), right coronary artery stenosis (13%; odds ratio, 2.4; P = .02), stenosis bend ≥60° (27%; odds ratio, 6.1; P = .03), and female sex (13%; odds ratio, 3.0; P = .04). Slow reflow was correlated with total burring duration (odds ratio, 1.005/s; multivariate P = .001), right coronary artery stenosis (incidence, 17%; odds ratio, 4.5; P = .009), and to a lesser extent with recent myocardial infarction in the treated territory (44%; odds ratio, 4.3; P = .08). ConclusionsThe procedural outcome of rotational atherectomy is highly correlated with stenosis morphology and location and sex of the patient. After stratification for these parameters, overall outcome with the Rotablator appears to be similar to that with balloon angioplasty and other competing techniques. Short-term outcome with specific subsets of patients may be superior with the Rotablator calcified stenoses), but this technique might best be avoided in some patients (those with irregular or possibly thrombuscontaining stenoses, highly angulated stenoses, and possible right coronary artery stenoses or those associated with impaired distal runoff caused by a recent myocardial infarction or manifest by a fixed thallium defect).

Safety of femoral closure devices after percutaneous coronary interventions in the era of glycoprotein IIb/IIIa platelet blockade.

We compared in-hospital femoral complications of Angio-Seal, Perclose, and manual compression in consecutive patients who underwent percutaneous coronary interventions in the era of glycoprotein IIb/IIIa platelet inhibition. Femoral closure devices have a similar overall risk profile as manual compression, even in patients treated with glycoprotein IIb/IIIa platelet inhibition, although certain rare complications such as retroperitoneal hemorrhage and severe access-site infection may be more common with the use of these devices.

Percutaneous transluminal coronary angioplasty after previous coronary artery bypass surgery

To improve symptomatic status and avoid repeat coronary artery bypass graft surgery (CABG), 115 lesions were approached for transluminal coronary angioplasty (PTCA) in 94 patients (82 men, 12 women) with angina pectoris and prior CABG at a mean of 60 months (range 4 to 192) after CABG. Fifteen patients were in Canadian Cardiovascular Society functional class I, 32 were in class II, 31 were in class III, and 16 were in class IV. Patients were 37 to 76 years old (mean 57). PTCA was successful (at least a 40% reduction in stenosis diameter and improvement in symptomatic status) in 83 patients (88%) and 103 (90%) lesions. Mean stenosis was reduced from 80 +/- 14% to 20 +/- 16% (mean +/- standard deviation) and mean pressure gradient from 41 +/- 7 mm Hg to 14 +/- 6 mm Hg. Seven patients had lesions that could not be crossed for technical reasons and these patients underwent non-emergency CABG. Four patients required emergency CABG after PTCA; 1 patient subsequently died and 2 survived acute myocardial infarction. One patient had a femoral artery laceration, which required surgical repair. At a mean follow-up of 8 +/- 4 months, 63 patients (76%) with initially successful results were free of angina or in improved condition. Of the remaining 20 patients, 18 consented to repeat coronary angiography. Four patients did not have restenosis. Of the 14 patients with documented restenosis, 5 underwent successful repeat PTCA, 5 had repeat CABG, and 4 were treated medically. Thus, when coronary anatomy is suitable, PTCA is an effective alternative to reoperation in symptomatic patients with prior CABG.

Early and 1-year survival rates in acute myocardial infarction complicated by cardiogenic shock : a retrospective study comparing coronary angioplasty with medical treatment

Cardiogenic shock remains a frequently lethal complication of acute myocardial infarction. Early revascularization of the infarct-related artery by coronary angioplasty has been suggested to significantly improve patient survival. In-hospital and 1-year survival was assessed in 50 patients hospitalized for acute myocardial infarction complicated by cardiogenic shock. All patients received medical treatment and intraaortic balloon pump support. Thirty-three patients underwent coronary angioplasty (PTCA group), while 17 patients remained on conventional therapy (no PTCA group). The two groups were comparable for all baseline characteristics. Survival was significantly better in the PTCA group than in the no PTCA group: 64% versus 24% in-hospital survival (p = 0.007) and 52% versus 12% at 1 year (p = 0.006). When angioplasty was successful in achieving reperfusion, survival was further enhanced: in-hospital survival rate was 76% versus 25% in patients with unsuccessful angioplasty and 60% versus 25% at 1 year.

The importance of proteinuria as a determinant of mortality following percutaneous coronary revascularization in diabetics.

OBJECTIVES The aims of this study were to compare mortality and clinical events following percutaneous coronary intervention (PCI) between nondiabetics and diabetics with and without proteinuria. BACKGROUND Diabetics have increased rates of late myocardial infarction, repeat revascularization and mortality when compared with nondiabetics following PCI. Proteinuria is a marker for diabetic nephropathy and potentially a surrogate marker for advanced atherosclerosis. It is unknown if proteinuria is a predictor of outcome in diabetics following PCI. METHODS We performed an observational study of 2,784 patients who underwent PCI at the Cleveland Clinic between January 1993 and December 1995. There were 2,247 nondiabetics and 537 diabetics with urinalysis and follow-up data available (proteinuria n = 217, nonproteinuria n = 320). The diabetic proteinuria group was further prospectively stratified into low concentration (n = 182) and high concentration (n = 35). The end points were all-cause mortality and the composite end point of death, nonfatal myocardial infarction (MI) and need for revascularization. RESULTS The mean follow-up time was 20.2 months. The two-year mortality rate was 7.3% and 13.5% for nondiabetics and diabetics, respectively (p < 0.001). The two-year mortality rate was 9.1% and 20.3% for the nonproteinuria and proteinuria groups, respectively (p < 0.001). There was a graded increase in mortality comparing the diabetic group. The two-year mortality rate was 9.1%, 16.2% and 43.1% for the nonproteinuria, low concentration and high concentration groups, respectively (p < 0.001). The difference in survival between the nondiabetic and nonproteinuric diabetics was not significant (p = 0.8). CONCLUSIONS The presence of proteinuria is the key determinant of risk following PCI for diabetics. Diabetics without evidence of proteinuria have similar survival compared with nondiabetics.

Percutaneous transluminal angioplasty involving internal mammary artery grafts

With the increasing use of the internal mammary artery as the conduit of choice in coronary bypass surgery, it is anticipated that an expanding patient population will have stenosis, usually at the site of internal mammary-to-coronary artery anastomosis. In our series 31 patients underwent dilatation at either the site of anastomosis (24), the native coronary artery beyond the anastomosis (4), or both (3) with no mortality, myocardial infarction, or need for emergency coronary artery bypass surgery. Angiographic and clinical success was achieved in 28 patients (90%). There were two internal mammary artery dissections with both patients requiring elective coronary bypass surgery. Of the patients in whom dilatation was successful, 22 (79%) have been followed for longer than 6 months and 19 (86%) have had sustained functional improvement at a mean of 35 months after angioplasty. One patient is to undergo repeat coronary bypass surgery. No patient has had a myocardial infarction or died during follow-up. Although percutaneous transluminal coronary angioplasty of the internal mammary artery has inherent difficulties because of the anatomic characteristics of the vessel, it can be performed with a high degree of primary success and a low incidence of complications and can provide long-term clinical improvement.

Acute occlusion in multiple lesion coronary angioplasty: frequency and management

Among 3,548 patients undergoing a percutaneous transluminal coronary angioplasty procedure, 714 had multilesion angioplasty (1,550 lesions) in a single session. Acute occlusion occurred in 22 patients (3.1%) and 29 lesions (1.9%). The patients were classified into a group undergoing multivessel angioplasty (348 patients, 785 lesions) and a group undergoing multilesion single vessel angioplasty (366 patients, 765 lesions). The rate of acute occlusion was similar in both patient groups. The multivessel angioplasty group had a 2.9% rate per patient (n = 10) and a 1.7% rate per vessel; the multilesion single vessel group had a 3.3% rate per patient (n = 12) and a 2.1% rate per lesion. Five of the 10 patients from the multivessel group with acute occlusion, but only 1 of the 12 patients with occlusion in the single vessel multilesion group, required emergency open heart surgery. No patient in either group died as a consequence of coronary angioplasty. Occlusion occurred during angioplasty in 15 of the 22 patients, and 1 to 24 h after angioplasty in 7 of 22 patients. In the group with multivessel angioplasty, acute occlusion during the procedure was mainly linked with hypotension during the second vessel dilation, whereas in this group with delayed vessel closure and in the multilesion single vessel group, existence of intimal tearing constituted the most important factor for acute occlusion (12 of 16 patients). Closure of vessel per major coronary system was evenly distributed in the multivessel group, whereas significantly more left circumflex vessels closed in the single vessel multilesion group (6.1% versus 1.3% in the left anterior descending coronary artery and 1.1% in the right coronary artery; p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Early and long-term results of percutaneous transluminal coronary angioplasty in patients 70 years of age and older with angina pectoris

Abstract Patients more than 70 years old constitute a growing segment of our population. Although older patients with coronary artery disease are in general treated conservatively, of >200,000 coronary bypass operations performed in the US in 1984, 36% were in patients 65 years of age or older. 1 Most coronary surgery studies recognize that advanced age is associated with increased mortality. 2–5 Percutaneous transluminal coronary angioplasty (PTCA), a less invasive procedure, appears particularly attractive as a therapeutic alternative in the elderly. This report evaluates early and late results of PTCA in patients 70 years or older and investigates whether PTCA can be carried out with similar results in patients with stable and unstable angina.