Simon H. Stertzer

Morphology after Transluminal Angioplasty in Human Beings

PERCUTANEOUS transluminal angioplasty is frequently used in selected patients to decrease stenoses in atherosclerotic peripheral arteries,1 , 2 renal arteries,3 4 5 6 and coronary arteries.7 8 9 Th...

Lesion morphology and coronary angioplasty: Current experience and analysis

From July 1, 1990 to February 28, 1991, 533 consecutive patients with 764 target vessels and 1,000 lesions underwent coronary angioplasty. Procedural success was achieved in 92.3%, untoward (major cardiac) events occurred in 3% (0.8% myocardial infarction, 1.3% emergency coronary bypass grafting and 0.9% both; there were no deaths). An unsuccessful uncomplicated outcome occurred in 4.7%. Lesion analysis using a modified American College of Cardiology/American Heart Association classification system showed that 8% were type A, 47.5% were type B and 44.5% were type C (36% of type B and 11% of type C were occlusions). Angioplasty success was achieved in 99% of type A, 92% of type B and 90% of type C lesions (A vs. B, p less than 0.05; B vs. C, p = NS; A vs. C, p less than 0.01). Untoward events occurred in 1.2% of type A, 1.9% of type B and 2% of type C lesions (p = NS). An unsuccessful uncomplicated outcome occurred in 0% of type A, 6% of type B and 7% of type C lesions (A vs. B, p less than 0.05; B vs. C, p = NS; A vs. C, p less than 0.05). Among the unsuccessful uncomplicated outcome group, occlusion occurred in 49%: 38% of type B and 59% of type C lesions. With B1 and B2 subtypes, success was obtained in 95% and 89.5% and untoward events occurred in 1.5% and 2.3% and an unsuccessful uncomplicated outcome in 3.7% and 8%, respectively. C1 and C2 subtyping showed success in 91% and 86%, untoward events in 1.3% and 6% and an unsuccessful uncomplicated outcome in 7.5% and 8.5%, respectively. Among the 764 vessels, success was obtained in 89.5% and untoward events occurred in 2.5% and an unsuccessful uncomplicated outcome in 8%. Assessment of lesion-vessel combinations showed a less favorable outcome with type C lesions and combinations of A-B, B-C and multiple (more than three lesions) type B and C vessels. Statistical analysis of morphologic factors associated with angioplasty success included absence of (old) occlusion (p less than 0.0001) and unprotected bifurcation lesion (p less than 0.001), decreasing lesion length (p less than 0.003) and no thrombus (p less than 0.03). The only significant factor associated with untoward events was the presence of thrombus (p less than 0.003). Predictors of an unsuccessful uncomplicated outcome included old occlusion (p less than 0.0001) and increasing lesion length (greater than 20 mm) (p less than 0.001), unprotected bifurcation lesion (p less than 0.05) and thrombus (p less than 0.03).

In-hospital cardiac mortality after acute closure after coronary angioplasty: Analysis of risk factors from 8,207 procedures

Cardiac death consequent to acute vessel closure after coronary angioplasty occurred in 13 of 294 closures from 8,207 consecutive procedures performed at two centers since 1981 (0.16% cardiac mortality rate). To determine the predictors of cardiac death after acute coronary closure, 50 clinical, angiographic and procedural variables were analyzed by an observer unaware of the clinical outcome for each of the 13 patients who died and also 100 patients randomly chosen, in whom vessel closure after angioplasty did not result in death during hospitalization. Univariate analysis found female gender (p less than 0.0001), collateral channels from the vessel dilated (p less than 0.0001), use of balloon counterpulsation (p less than 0.0002), pre- and postprocedural hypotension (p = 0.0003 and p = 0.003, respectively), jeopardy score greater than or equal to 2.5 (p = 0.003), left ventricular hypertrophy (p = 0.013), hypertension (p = 0.02), diabetes (p = 0.02) and multivessel disease (p = 0.03) to be predictive of death. Multivariate analysis found collateral vessels, female gender and multivessel disease to be independent predictors of death. Thus, cardiac death after elective coronary angioplasty is very rare in experienced centers and occurs most often in women with a large amount of potentially ischemic myocardium. Hypotension often precedes the fatal closure event. Close attention to the amount of potentially ischemic myocardium and to the fluid volume status of these patients would seem to be especially warranted.

Laser coronary angioplasty: experience with 9 cadaver hearts.

Experience with laser angioplasty in 16 coronary arteries in 9 cadaver hearts is presented. Coronary obstructions were due to experimentally created thrombi as well as to naturally occurring calcified plaques. Successful laser angioplasty was achieved in 14 of 15 arteries. One artery was sacrificed to determine factors necessary for deliberate perforation of the arterial wall. This procedure required more than 30 seconds of laser energy at 3.0 W with the catheter tip almost perpendicular to the wall. Penetration of the arterial wall occurred only in the second left anterior descending artery which was plaque-occluded because of operator inexperience.

Coronary Arterial Bypass Grafts

ostmortem examination of the hearts of patients with atherosclerotic coronary occlusive disease has shown that the arteries P of the distal third of the coronary tree are usually not affected by the occlusive process [7, 12, 13, 16, 17, 221. This is particularly true of the left coronary artery [12]. The arteries of the distal third measure 1 to 2 mm. in external diameter. Blumgart et al. [4] expressed the opinion that bypass grafting to such arteries “would offer important relief” to patients with coronary occlusive disease. This report evaluates the feasibility of bypass grafting to coronary segments of 1 mm. in diameter.

Long-term efficacy of percutaneous transluminal coronary angioplasty (PTCA): Report from the national heart, lung, and blood institute PTCA registry

The NHLBI PTCA Registry has collected data from 3,079 patients who underwent PTCA at 105 centers from September 1977 through September 1981 that document the initial risks and benefits of PTCA. A subgroup of 2,272 patients at 65 centers was chosen to examine the long-term effects of PTCA (97% follow-up). All patients were followed for 1 year, 191 for 3 years and 57 for 4 years. Initial success occurred in 1,397 (61%), and 72% remained improved at 1 year with no further procedures; during the first year of follow-up, 14% had repeat PTCA, 12% had CABG, 3% had MI and 1.6% died. After 1 year, 67% were asymptomatic; of these, 52% had no other procedure, 7% had a second PTCA and 8% had CABG. Follow-up at 2 to 4 years was similar except that there were few repeat PTCA or CABG procedures after 1 year. The annual mortality rate after PTCA in patients with 1-vessel diseases was less than 1% per year and with multivessel CAD, 3% per year. Thus, successful PTCA alone results in sustained improvement in 84% of patients; 59% were asymptomatic (12% had repeat PTCA). PTCA offers extended effective therapy in selected patients with CAD.

Percutaneous transluminal angioplasty of stenotic coronary artery bypass grafts: 5 years' experience.

In a 60 month period (January 1981 to December 1985), 82 patients (79% male with a mean age of 60 years) had 83 saphenous vein grafts and 5 internal mammary artery grafts with a total of 101 stenotic sites treated with percutaneous transluminal coronary angioplasty. The mean time between bypass surgery and angioplasty was 51.2 months. The procedure was technically successful in 85% of patients, 86% of grafts and 85% of the sites attempted. In these cases, the mean diameter stenosis was reduced from 77 +/- 14 to 27 +/- 20% (p less than 0.001), the mean pressure gradient from 49 +/- 16 to 7 +/- 6 mm Hg (p less than 0.001). Emergency coronary artery bypass graft surgery was necessary in one patient (1.2%) whereas myocardial infarction occurred in three patients (3.6%). There were no hospital deaths. Clinical follow-up was obtained in all 82 patients. Before angioplasty, 23% were in Canadian Cardiovascular Society functional class II, 60% in class III and 17% in class IV. With a mean clinical follow-up period of 21.4 +/- 2.3 months, 71% are in class I, 17% in class II and 12% in class III. There were two deaths, 3 months or more after angioplasty, one probably due to graft closure. So far, angiographic follow-up (at 7.9 +/- 2.1 months) has been available in 26 patients. Ten patients (with 10 grafts) exhibited graft restenosis; six of them have had second successful repeat angioplasty. Among the many variables analyzed, statistically significant predictors of success were a higher measured balloon/graft ratio (p less than 0.001), smaller diameter graft (p less than 0.001), and shorter lesion length (p less than 0.01). The only predictor of complication was diffuseness of disease in the graft (p less than 0.05). The statistically significant predictors of recurrence were the residual stenosis after the initial angioplasty (p less than 0.01) and the measured balloon/graft ratio (p less than 0.01). Angioplasty of coronary artery grafts appears to be a feasible and efficacious procedure with a low complication rate. The technique is a satisfactory alternative to repeat surgery in selected patients.

Multicenter study of percutaneous transluminal angioplasty for right coronary artery ostial stenosis

Over a 5 year period at three centers, 53 patients underwent percutaneous transluminal angioplasty of a right coronary artery ostial stenosis. The procedure was successful in 42 patients (79%) and unsuccessful in 11, of whom 5 (9.4%) required emergency coronary artery bypass grafting because of abrupt closure. The right coronary ostial lesion had distinctive technical requirements to achieve success, including high pressure balloon inflation (10 +/- 4 atm) and the need for unconventional right coronary guide catheters. Technical factors that account for increased difficulty in these patients include: problems with guide catheter impaction and ostial trauma; inability to inflate the balloon with adequate guide catheter support; and need for increased intracoronary manipulation. The stenoses were quite discrete (4 +/- 5 mm) and calcified in the majority (40) of the 53 patients. Long-term follow-up (mean 12.5 months, range 4 to 60) of these patients demonstrated clinical recurrence of angina in 20 patients (48%) and angiographically proved restenosis in 16 (38%). Repeat coronary angioplasty was successful in three of six patients for relief of symptoms for over 6 months. In conclusion, angioplasty of the right coronary ostial lesion compared with nonostial dilation leads to a suboptimal early success rate; an apparent high risk of emergency bypass surgery; and a high restenosis rate. Careful assessment of the patient with this lesion and improved technology appear to be warranted.

Transluminal laser catheter angioplasty

The first transluminal laser angioplasty in animals is reported herein. An Argon laser and a specialized coronary arterial catheter with a fiberoptic wave guide were used. Immediate histologic changes consisted of a moderate degree of intimal necrosis and some loss of elastic tissue. At 5 days the intima was repaired, but focal elastic tissue loss persisted.

Silent ischemia after coronary angioplasty: Evaluation of restenosis and extent of ischemia in asymptomatic patients by tomographic thallium-201 exercise imaging and comparison with symptomatic patients

One hundred sixteen patients were evaluated to determine the ability of single photon emission computed tomographic (SPECT) thallium-201 exercise and redistribution imaging to detect silent ischemia secondary to restenosis in asymptomatic patients after single and multiple vessel percutaneous transluminal coronary angioplasty and the findings were compared with SPECT imaging detection of restenosis in symptomatic patients. The value of exercise electrocardiography (ECG) and the amount of ischemic myocardium in symptomatic and asymptomatic patients were determined. Forty-one patients were asymptomatic after angioplasty; 77% of these had chest pain before angioplasty. Seventy-five patients had chest pain after angioplasty; 99% of these had chest pain before angioplasty. Restenosis occurred in 61% of asymptomatic and 59% of symptomatic patients and in 46% of the vessels in both asymptomatic and symptomatic patients. Sensitivity, specificity and accuracy for detection of restenosis by SPECT in individual patients were 96%, 75% and 88% versus 91%, 77% and 85%, respectively, in the asymptomatic versus symptomatic groups (p = NS). Sensitivity, specificity and accuracy for restenosis detection in individual vessels were 90%, 89% and 89% versus 84%, 77% and 84%, respectively, in the asymptomatic and symptomatic groups (p = NS), with similar results for the three major arteries. Sensitivity and accuracy of exercise ECG were significantly less than those of SPECT imaging for the patients with silent (40% and 44%) and symptomatic (59% and 64%) ischemia (p less than 0.001). Restenosis of vessels in the patients with silent and symptomatic ischemia was associated with an equal amount and degree of severity of ischemic myocardium in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)