Khosrow Dorosti

Clinical and angiographic features of coronary artery disease after chest irradiation

Coronary artery disease (CAD) developed in 15 patients at a mean of 16 years (range 3 to 29) after chest irradiation. The mean dose of radiation was 42 +/- 7 grays; irradiation was performed for Hodgkins disease in 9 patients, lymphoma in 2, breast carcinoma in 3 and cystic hygroma in 1 patient. Mean age was 48 years (range 26 to 63) at diagnosis of CAD; 4 patients were younger than 35 years. Nine were women. Ten presented with angina, 3 with acute myocardial infarction, 1 patient with syncope and 1 with dyspnea. Twelve had no more than 2 risk factors of atherosclerosis. At coronary angiography, 8 had at least 50% diameter narrowing of the left main coronary artery and 4 had severe ostial stenosis of the right coronary artery. Eight patients also had valvular heart disease, 4 pericardial disease and 4 complete heart block. Mean left ventricular ejection fraction was 67 +/- 11% (range 53 to 80%). Nine had undergone coronary artery bypass grafting, but surgery was difficult or impossible in 3 because of severe mediastinal and pericardial fibrosis. Radiation-associated CAD is characterized by a high incidence of left main and right ostial coronary disease and often occurs in women with relatively few conventional risk factors for CAD.

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.

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.

Angioplasty of the proximal left anterior descending coronary artery: Initial success and long-term follow-up

From 1984 to 1987, 537 consecutive patients (mean age 58 years; range 34 to 79) underwent angioplasty for proximal left anterior descending coronary artery disease. The procedure was clinically successful in 516 (96.1%). Procedural complications included myocardial infarction (2.2%; Q wave 0.9%, non-Q wave 1.3%), in-hospital bypass surgery (3%) and death (0.4%). Follow-up was obtained in 534 patients (99.8%) for a mean duration of 44 months (range 8 to 75). Follow-up cardiac catheterization, performed in 391 patients (76%), demonstrated a 39.6% angiographic restenosis rate. Ninety-eight (19%) of the patients with a clinically successful result required additional revascularization for recurrent left anterior descending artery disease by angioplasty (12.8%) or coronary artery bypass grafting (4.7%), or both (1.5%). During follow-up there was a 2.5% incidence rate of myocardial infarction (anterior myocardial infarction 1.6%), and 27 patients (5.2%) died, 14 (2.7%) of cardiac causes. The actuarial 5-year cardiac survival rate was 97%, freedom from cardiac death and myocardial infarction was 94% and freedom from cardiac death, myocardial infarction, coronary artery bypass surgery and repeat left anterior descending artery angioplasty was 77%. At last follow-up 76% of patients were free of angina and 88% reported sustained functional improvement. Angioplasty is an effective treatment for proximal left anterior descending coronary artery disease that has a high success rate, low incidence of procedural complications and provides excellent long-term cardiac survival, freedom from cardiac events and sustained functional improvement.

Determinants of primary success in elective percutaneous transluminal coronary angioplasty for significant narrowing of a single major coronary artery.

Clinical and angiographic characteristics, procedural details and outcome were analyzed in 2,677 consecutive patients who underwent elective single-artery, single-lesion percutaneous transluminal coronary angioplasty (PTCA) between December 1980 and May 1987. Primary success was achieved in 2,479 (93%) patients. The primary success rate was significantly lower during the first period, when nonsteerable systems were used (73%), than in later periods (94%) (p less than 0.0001), when steerable and low-profile systems became available. Univariate analysis revealed the following variables as predictors of lower primary success: totally obstructed arteries (p less than 0.0001), presence of calcium in the narrowing (p = 0.002), prior myocardial infarction (p = 0.005), stenoses located in the right coronary artery (p = 0.02), narrowings between 90 and 99% in diameter (p = 0.02) and patients older than 60 years of age (p = 0.07). Multivariate analysis revealed the following 4 independent predictors of lower primary success: 100% obstruction (p less than 0.0001), calcium (p = 0.005), previous myocardial infarction (p = 0.029) and patients older than 60 years of age (p = 0.036). With present technology, single-narrowing elective PTCA can be performed with a high success rate in most patients. Although total occlusion, presence of calcium, older age and history of myocardial infarction influence the outcome unfavorably, PTCA can still be performed with acceptable primary success rates.

Changing patterns in percutaneous transluminal coronary angioplasty

We analyzed the impact of evolving technology on percutaneous transluminal coronary angioplasty in 2677 patients. There were 168 patients in period 1 when fixed-wire catheters were used, 1117 patients in period 2 when steerable catheters were available, and 1392 patients in period 3 when low-profile systems were utilized. The age of patients (55 to 57 to 59 years) and the proportion of patients with severe angina increased over the three periods (25% to 36% to 54%). The percentage of high-grade stenosis and the proportion of distal lesions also increased. Primary success rate improved from 73% in period 1 to 94% in periods 2 and 3. Emergency bypass surgery decreased (8.3% to 4.2% to 2.5%), as did the incidence of myocardial infarction (7.1% to 3.3% to 2.4%). Mortality was 0% in period 1, 0.2% in period 2, and 0.4% in period 3. These results indicate that technological advancements and increased operator experience significantly improved the primary success rate and decreased the incidence of major complications.

Percutaneous transluminal coronary angioplasty in silent ischemia

The short- and long-term outcome of percutaneous transluminal coronary angioplasty were analyzed in 34 patients who had documented coronary artery disease without symptoms. Of the 34 patients, 33 had abnormal stress tests before angioplasty. Angioplasty was successful in 31 patients (91%). Follow-up was 100% for a mean period of 36 +/- 15 months. Follow-up exercise test was normal or improved in 29 of the 31 patients who had successful angioplasty. Follow-up catheterization was performed in 24 of the 31 patients (77%). Restenosis of the previously dilated segment was found in seven patients. Actuarial cardiac survival at 3 years was 100%. Freedom from myocardial infarction, bypass surgery, angioplasty for a new lesion, and death was 87%. We conclude that although the most effective treatment for silent ischemia remains to be determined, our data suggest that coronary angioplasty is a therapeutic option in these patients.

Long-term outcome of unsuccessful percutaneous transluminal coronary angioplasty

We analyzed the long-term outcome of 198 patients after unsuccessful percutaneous transluminal coronary angioplasty. Forty-nine percent underwent emergency coronary artery bypass grafting surgery, 17% had elective bypass surgery, and 34% were treated medically. The in-hospital mortality rate was 4%, and myocardial infarction occurred in 36% of patients. Follow-up was completed in 100% of patients with a mean follow-up period of 35 +/- 22 months. Actuarial cardiac survival at 4 years was 97% in the emergency bypass surgery group, 100% in the elective bypass surgery group, and 86% in the medically treated group. Actuarial event-free survival (freedom from myocardial infarction, bypass surgery, coronary angioplasty, and cardiac death) at 4-year follow-up was 81% in 198 patients, 90% in the emergency bypass surgery group, 85% in the elective bypass surgery group, and 65% in the medically treated group. Results of multivariate analysis showed that emergency or elective bypass surgery after failed coronary angioplasty, normal or mildly impaired left ventricular function, and male sex were predictors of better outcome at 4 years.

Evaluation of coexistent carotid and coronary disease by combined angiography.

We studied 247 patients who underwent combined coronary and carotid angiography to determine (a) the frequency of angiographic carotid stenosis (> 50%) in patients with coronary artery disease (CAD) and (b) the technical quality and safety of the combined procedure. All patients were evaluated primarily for CAD. Combined carotid angiography was performed for asymptomatic carotid bruits (115 patients, 47%), transient ischemic attacks (TIA) or stroke (66 patients, 26.5%), or inapparent/other reasons (66 patients, 26.5%). The extracranial internal carotid arteries were well visualized in 219 patients (89%); poor visualization of the internal carotid arteries was due to overlap by the vertebral or external carotid arteries. The frequency of >50% internal carotid stenosis was 36% in patients with asymptomatic carotid bruits, 42% in patients with TIA or stroke, and 8% in patients without TIA, stroke, or carotid bruits. Complication rates during combined coronary and carotid angiography in the 247 study patients were not statistically different from complication rates during coronary angiography alone in 686 control patients. These data indicate that (a) patients with CAD who have asymptomatic carotid bruits or a history of TIA or stroke have a high frequency of carotid stenosis, and (b) combined coronary and carotid angiography is a safe and technically adequate procedure.

Safe and efficacious use of Bivalirudin for percutaneous coronary intervention with adjunctive platelet glycoprotein IIb/IIIa receptor inhibition

22 (13%) 16 (10%) 0.32 Prior MI 57 (33%) 53 (33%) 0.97 Prior coronary angioplasty 76 (44%) 62 (38%) 0.08 Prior coronary bypass 62 (36%) 66 (41%) 0.21 Smoker 34 (20%) 24 (15%) 0.38 Chronic renal insufficiency 6 (3.4%) 6 (3.7%) 0.92 ACE inhibitor 38 (22%) 42 (26%) 0.28 blockers 57 (33%) 39 (24%) 0.07 Thienopyridines 60 (35%) 66 (41%) 0.33 Statins 69 (40%) 65 (40%) 0.92 GP IIb/IIIa inhibitor use 155 (90%) 133 (82%) 0.02 Ejection fraction 50% 12% 50% 11% 0.12 ACC/AHA score B2/C 84 (49%) 96 (59%) 0.19 Closure device 115 (67%) 104 (64%) 0.12 Multivessel intervention 29 (17%) 24 (15%) 0.45 Stents 138 (80%) 125 (77%) 0.41