John S. Douglas

Percutaneous transluminal coronary angioplasty in patients with prior coronary bypass surgery

To improve symptomatic status and avoid reoperation, 122 initial and 7 repeat percutaneous transluminal coronary angioplasty procedures were performed in 116 patients with disabling angina pectoris at a mean of 26.8 months (range 2 to 132) after coronary bypass surgery. Marked angiographic improvement (greater than 30% reduction in diameter stenosis) was obtained in 107 (88%) of the 122 initial procedures and in all 7 repetitions. Mean stenosis was reduced from 78 +/- 13% (mean +/- standard deviation) to 25 +/- 13% (p less than 0.0001) and mean pressure gradient from 49 +/- 15 to 11 +/- 8 mm Hg (p less than 0.0001). Complications were: emergency surgery (three patients), Q wave infarction (one patient), myocardial infarction by enzyme criteria only (four patients) and non-occluding coronary dissection (one patient). There were no neurologic or peripheral vascular complications and no early deaths. One late death occurred 14 months after an unsuccessful but uncomplicated angioplasty procedure. At a mean follow-up of 8.3 months, 88 patients (76%) were free of angina or in improved condition. In patients followed up for at least 6 months, evidence of restenosis occurred in 9 (53%) of 17 saphenous veins, 1 (50%) of 2 proximal graft anastomoses, 4 (18%) of 22 distal graft anastomoses and 5 (14%) of 37 native coronary arteries. When coronary anatomy is suitable, percutaneous transluminal angioplasty is an attractive alternative to reoperation in symptomatic patients with prior coronary bypass surgery.

Percutaneous transluminal coronary angioplasty in women compared with men

OBJECTIVES This study compares in-hospital and long-term outcome after angioplasty in women and men. BACKGROUND The recognition that coronary artery disease is the most common cause of death in women has increased interest in outcome studies of coronary artery disease in women. METHODS Patients who had previous coronary revascularization and those who underwent angioplasty in the setting of acute myocardial infarction were excluded. Angioplasty was performed with standard methods. Clinical data were retrieved from a clinical data base and analyzed with standard statistical methods. RESULTS There were 2,845 women and 7,940 men. The women were older (62 +/- 11 vs. 57 +/- 10 years) and had more hypertension (54.5% vs. 40.1%), diabetes (19.3% vs. 11.7%), grade III to IV angina (71.5% vs. 58.4%) and congestive failure (4.3% vs. 2.1%) than men (all p < 0.0001). More men had a previous myocardial infarction (35.4% vs. 31.0%) and were taller and weighed more (all p < 0.0001). The men had lower ejection fractions and more multivessel disease (31.0% vs. 25.2%) (both p < 0.0001). In women there was a trend toward more Q wave myocardial infarctions (1.1% vs. 0.75%, p = 0.10), and hospital mortality was higher (0.7% vs. 0.1%, p < 0.0001). Angina at follow-up was more common in women 40.2% vs. 26.7%, p < 0.0001). The multivariate correlates of in-hospital death were short stature, reduced ejection fraction and multivessel disease, with trends for older age and female gender. Five-year survival was 95% in men and 92% in women (p = 0.0002). However, female gender was not a multivariate correlate of long-term survival and was accounted for by other characteristics, primarily age. The multivariate correlates of long-term survival were older age, congestive failure, reduced ejection fraction, multivessel disease, diabetes, hypertension and a trend for severe angina. No difference between women and men was noted in long-term freedom from myocardial infarction. There were more additional procedures in men than in women. CONCLUSIONS Despite higher in-hospital mortality, long-term mortality and clinical outcome were similar in both genders when age and body habitus were accounted for.

Coronary artery spasm at the site of angioplasty in the first 2 months after successful percutaneous transluminal coronary angioplasty

The clinical course of five patients manifesting coronary artery spasm at the site of previous successful percutaneous coronary angioplasty is reviewed. All patients showed this spasm on hemodynamically insignificant (less than 50% diameter narrowing) obstruction. Four patients did not respond to therapy with calcium channel antagonists and nitrates and subsequently developed recurrent stenosis. One patient died 2 months after angioplasty and 1 day after coronary bypass surgery. Pathologic study at the site of angioplasty revealed new artherosclerotic disease. Coronary spasm may occur during the healing period after coronary angioplasty and should be distinguished from fixed obstruction.

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.

Coronary aneurysms after stent placement: a suggestion of altered vessel wall healing in the presence of anti-inflammatory agents.

Coronary aneurysms are rare after conventional angioplasty and have not been reported after coronary stenting. Coronary artery stent sites were examined by follow-up angiography at a median of 4 months in 29 patients who received the Cook stent (Gianturco-Roubin) for acute coronary closure. Nineteen patients were treated with glucocorticoids administered intravenously or orally, or both, with or without colchicine and results were compared with those in 10 patients who were treated with neither agent. Standard therapy for all patients included routine administration of aspirin and heparin before and warfarin sodium (Coumadin) and aspirin after stent placement. Most patients also received dipyridamole and lovastatin during the follow-up period. Compliance with medications was confirmed by telephone conversation with each patient. Six (32%) of the 19 stented arteries showed evidence of coronary artery aneurysm, defined as expansion of the lumen outside the margins of the stent. None of the patients in the control group (who did not receive steroids or colchicine) developed aneurysm. This pattern of altered vascular healing in stented coronary segments appears to be due to the addition of multiple anti-inflammatory drugs rather than to stent presence alone. This observation demonstrates the possibility of medical impairment of normal vascular remodeling after acute injury and stent placement, which may be of benefit in designing future trials on restenosis.

Comparative costs of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting in multivessel coronary artery disease

Abstract The cost of percutaneous transluminal coronary angioplasty (PTCA) has been shown in a number of studies 1–3 to be significantly below that of coronary artery bypass grafting (CABG). It has been suggested that the cost of PTCA may be greater if there is a need to have a subsequent revascularization procedure for restenosis 2 or if there is a low primary success rate necessitating urgent or early elective CABG. 1,2 These earlier studies have concentrated on the traditional candidates for PTCA: patients requiring single-vessel revascularization. The relative cost of multivessel PTCA has not been examined and it is possible that the higher acute complication and restenosis rates noted in this subgroup of patients 4,5 may diminish the cost advantage of PTCA. This study examines the total 1-year revascularization costs in patients with multivessel coronary artery disease undergoing multivessel PTCA or CABG.

Hemodynamic effects of nifedipine in primary pulmonary hypertension

Progressive dyspnea and syncope occurred in a young woman with primary pulmonary hypertension despite therapy with hydralazine. Abnormal pulmonary artery reactivity was documented by an additional increase in pulmonary artery pressure and pulmonary vascular resistance during exercise and after an episode of hydralazine-induced hypotension. Nifedipine reduced rest and exercise pulmonary artery pressure, pulmonary vascular resistance and right ventricular stroke work, and increased cardiac output and markedly improved exercise capacity. Reevaluation after 6 months showed persistence of the favorable hemodynamic and clinical effects. Vasodilator therapy, potentially hazardous because of effects on systemic vascular resistance, can be evaluated safely only with hemodynamic monitoring. Nifedipine may be a useful drug in selected patients with primary pulmonary hypertension.