Coronary angioplasty of diffuse coronary artery disease

Early and long-term results of stenting of diffuse coronary artery disease

Diffuse coronary artery disease (CAD) is considered unfavorable for interventional procedures; however, the results of stenting of diffuse CAD have not been completely characterized. We performed stenting in 100 consecutive patients with diffuse CAD, defined as significant stenosis >20 mm (n = 59 patients), multiple significant stenoses in the same artery (n = 23 patients), or significant narrowing involving the whole length of the coronary artery (n = 18 patients). Angiographic success was achieved in 103 arteries (100%) and clinical success was obtained in all 100 patients. There were no deaths; no patient had stent closure, acute myocardial infarction, or required emergency coronary artery bypass surgery. All 100 patients had >6 months follow-up (mean 18 +/- 7 months, range 7 to 31); 77 (77%) remained asymptomatic, and 5 (5%) had acute myocardial infarction, of whom 2 died (2%). In-stent restenosis was observed in 12 patients (12%) and repeat angioplasty was performed in 10. Including those patients who underwent repeat angioplasty, 89 (89%) maintained clinical improvement and 95 (95%) were alive and free of bypass surgery during follow-up. Life-table analysis showed 86% freedom from death, myocardial infarction, and target lesion revascularization at 28 months. Thus, selected patients with diffuse CAD may be treated with satisfactory acute and long-term results by stent implantation.

Acute and late clinical outcome after rotational atherectomy for complex coronary disease

Rotational atherectomy is effective acutely in treating complex coronary disease, but less is known about its long-term clinical outcome. We examined the acute results and late clinical outcome in 178 patients undergoing treatment with this device. Rotational atherectomy was used to treat 240 lesions in 178 individual patients. Nineteen percent had multilesion or staged multivessel procedures, and 71% had AHA-ACC Type B2/C lesions. The procedure was completed successfully in 94% of patients. Major complications occurred in 6% (death 1%, Q-MI 2.8%, and emergency bypass surgery 2.2%). Clinical follow-up was available for 167 (94%) patients at 13+/-6 months. Thirty-five percent required additional catheterization because of recurrent symptoms or an abnormal stress test. Clinical restenosis was confirmed in 18%, and an additional 2.2% of patients had progression of disease in previously untreated segments. At the end of 1 year, 14% had undergone repeat target vessel revascularization. Cumulatively at follow-up, approximately 80% had avoided an acute major complication and repeat revascularization for restenosis. Rotational atherectomy provides excellent acute and good late clinical results. At 1 year follow-up, the likelihood of developing clinical restenosis or significant progression of disease was 1 in 5, and patients had a 1 in 7 chance of requiring revascularization because of restenosis. These findings are encouraging and indicate that rotational atherectomy can be performed safely and with a high degree of acute and late clinical success in complex coronary disease characterized by multivessel or multilesion involvement and a predominance of B2 and C lesions.

Smokers undergoing percutaneous coronary revascularization present with fewer narrowings in the target coronary artery

Among patients undergoing percutaneous coronary revascularization, cigarette smoking remained associated with fewer lesions in the target artery even after adjusting for age, extent of coronary artery disease, diabetes mellitus, and hypertension. These findings support the hypothesis that smokers have less active, yet more active, coronary artery disease.

Treatment of diffuse coronary artery and vein graft disease with a 60-mm-long balloon: early clinical experience

OBJECTIVE

To report our preliminary clinical experience with a new 60-mm-long angioplasty balloon.

DESIGN

We reviewed the results in patients who underwent this type of angioplasty between May and October 1993 at our institution.

MATERIAL AND METHODS

The study group consisted of 14 high-risk patients (57% with rest-related angina) and 19 treated coronary segments--52% in native coronary arteries and 48% in saphenous vein grafts (mean age, 9 years). Often, long balloon angioplasty was used in conjunction with laser or transluminal extraction atherectomy.

RESULTS

Angiographic success (40% or more visual reduction in diameter stenosis) was achieved in all patients. Intimal dissection occurred in 4 of the 19 treated segments (21%), but each was less than 50% obstructive. No patient required intracoronary stenting. Clinical success was achieved in 13 patients (93%). The one death that occurred was from vein graft distal embolization. At a mean follow-up of 9 months, three patients had required reinterventional procedures, and one patient had undergone a coronary artery bypass operation. No myocardial infarction or death occurred during this period.

CONCLUSION

Preliminary clinical experience with a 60-mm-long angioplasty balloon to treat complicated coronary lesions in high-risk patients suggests that, when used alone or in combination with other devices, this new balloon results in high initial success and low complication rates. A larger clinical experience is necessary for accurate assessment of the role of this new balloon catheter.

In-hospital outcome of percutaneous transluminal coronary angioplasty for long lesions and diffuse coronary artery disease

We performed coronary angioplasty on 151 long or diffuse lesions (120 long and 31 diffuse) in 141 patients (86% male, mean age 50 +/- 9 years). Long lesions were defined as lesions 11-20 mm in length and diffuse lesions as lesions longer than 20 mm, or three or more lesions in the same vessel. One or more adverse morphologic features were present in 131 (93%) lesions. Long balloons were used in 44%, significantly more often for diffuse disease (long lesions 39% and diffuse disease 64%; P = 0.004). Newer devices including the rotational atherectomy device (9 lesions), stents and perfusion balloons were employed in 18 (12%) lesions, more often for diffuse lesions (long lesions 8% vs. diffuse lesions 26%; P = 0.017). Lesion severity was comparable in the two groups (long lesions: 88 +/- 7%; diffuse lesions: 88 +/- 8%), but diffuse lesions were associated with significantly higher residual stenosis (long lesions: 6 +/- 8%; diffuse lesions: 12 +/- 13%, P = 0.01). Major complications occurred in five (3.5%) patients, including one death (0.7% mortality). The angiographic and clinical success rates for all patients were 99% and 96%, respectively, and were comparable for long and diffuse lesions. Judicious case selection and the use of long balloons and newer interventional devices permit coronary angioplasty for long lesions and diffuse disease with excellent success and a low risk of complications. Diffuse lesions are associated with more frequent use of long balloons and newer devices, especially rotational atherectomy and slightly higher residual stenosis as compared to long lesions.

Effectiveness of percutaneous transluminal coronary angioplasty for patients with medically refractory rest angina pectoris and high risk of adverse outcomes with coronary artery bypass grafting

This study was undertaken to test the hypothesis that percutaneous transluminal coronary angioplasty (PTCA) is a reasonable alternative to coronary artery bypass grafting (CABG) for some high-risk patients with medically refractory rest angina. Over a 5-year period, 1 operator at a tertiary Veterans Affairs Medical Center performed angioplasty on 624 patients, of whom 441 had unstable angina. Of these 441 patients, 288 had rest angina and 225 had medically refractory rest angina. Medically refractory unstable angina was defined as reversible myocardial ischemia occurring at rest in an intensive care unit setting with low flow oxygen despite the following medications: (1) oral aspirin, intravenous heparin, or both; (2) some combination of beta blocker, calcium blocker, and/or nitrate so that resting heart rate is < 70 beats/min or resting blood pressure < 140 mm Hg, or both. There were 207 patients with medically refractory rest angina who had > or = 1 of the following characteristics predictive of a more than twofold increased risk of operative death at CABG: age > 70 years, prior CABG, recent myocardial infarct, need for intravenous nitroglycerin, need for intraaortic balloon pump, and left ventricular ejection fraction < 0.35. Of these 207 patients, 11 died (5%) during index hospitalization, 196 (95%) were discharged, and 186 (90%) went home angina free. There were 2 emergency CABGs and 9 acute myocardial infarctions. At follow-up (3 to 60 months, average 24), there were 27 late deaths (for a total of 38 [18%]), 8 (4%) late CABGs, and 44 (21%) late PTCAs (with 17 [8%] late myocardial infarctions). The 2-year mortality of 18% for this cohort is comparable to a 21% 2-year mortality observed in a group of 1,073 "high-risk" patients who underwent CABG in the Veterans Affairs Medical Center from 1987 to 1988. These data support the hypothesis that PTCA provides an alternative to CABG in some high-risk patients with medically refractory rest angina.

Acute angiographic and clinical results of long balloon percutaneous transluminal coronary angioplasty and adjuvant stenting for long narrowings

Historically, long coronary artery stenoses undergoing percutaneous transluminal coronary angioplasty (PTCA) are reported to have reduced procedural and clinical success in comparison with shorter lesions. The efficacy of long balloons (30 or 40 mm) in long lesions was evaluated. Eighty-two patients had 84 PTCA procedures with a primary long balloon. In all, 86 lesions were available for analysis. Data were collected prospectively on standard PTCA procedure forms. Coronary angiograms were reviewed and measured with digital calipers. Hospital charts were examined for complications. PTCA was performed in the left anterior descending artery in 44 cases (51%), the right coronary artery in 29 (34%) and the circumflex artery in 13 (15%). With the use of a modified classification system, 47 lesions (55%) were class C, 24 (28%) were class B2 and 15 (17%) were class B1. Mean lesion length was 22 +/- 11 mm (range 10 to 72), and 38 lesions (44%) were > or = 20 mm. Twelve patients received an intracoronary stent. The long balloon alone produced angiographic success (< 50% residual stenosis) in 77 lesions (90%). Angiographic success was achieved ultimately in all stenoses, using a stent in 7 patients and a short balloon in 2. There were 2 deaths (2%) and 1 Q-wave myocardial infarction (1%). One patient needed coronary artery bypass surgery. Clinical success without death, Q-wave infarction or bypass surgery was achieved in 83 of 86 procedures (97%). In conclusion, the use of long PTCA balloons with adjuvant stenting produced excellent results in these long stenoses. Lesion length was not a precursor of poor angiographic or clinical outcome.

Treatment of long coronary artery narrowings with long angioplasty balloon catheters

Balloon angioplasty of long coronary artery narrowings has been associated with a lower rate of acute success, and a higher rate of acute complications and restenosis than that observed for short narrowings. Angioplasty catheters with longer length balloons (30 and 40 mm) are now available, and the objective of this study was to determine the acute and long-term success for patients with long coronary artery narrowings treated with these longer balloons. All patients with long narrowings (> or = 10 mm) treated with long balloons at 1 institution over a 1-year period were identified (93 narrowings in 89 patients), and acute and long-term outcomes were carefully documented. Procedural success (residual stenosis < or = 50%) was 97%. Abrupt closure occurred in 6% and major dissection in 11% of narrowings. Clinical success (procedural success without in-hospital death, bypass surgery or myocardial infarction) was achieved in 90% of patients. Repeat catheterization was performed in 61 patients (76% of those eligible), and restenosis was found in 50 to 55%, depending on the definition used. The treatment of long coronary artery narrowings using angioplasty catheters with longer balloons leads to high rates of acute success. However, there is a high rate of restenosis. New interventional devices for long lesions should be compared with long balloons in a randomized controlled trial.

Percutaneous coronary intervention for diffuse coronary artery disease

Patients with diffuse coronary artery disease present a significant management problem. It has been proposed that diffuse coronary disease is unsuitable for balloon angioplasty and surgical treatment is not ideal either. We review the evidence that coronary balloon angioplasty is not a suitable treatment for diffuse coronary disease and examine the role of alternative interventional techniques. New techniques including long angioplasty balloon catheters and atherectomy devices have shown promise. If this is confirmed by prospective randomized trials then coronary angioplasty may yet prove an attractive treatment for diffuse coronary disease.

Salvage angioplasty: an alternative to high risk surgery for unstable angina?

This prospective, Human Subjects Committee and Ethics Committee approved investigation was performed to determine if coronary angioplasty (PTCA) might be a reasonable alternative revascularization method for unstable angina patients thought to be at high risk for operative (CABG) mortality. Between March 1990 and October 1991, thirty-four consecutive patients with medically refractory rest angina were deamed to have high risk of surgical mortality and underwent PTCA without surgical backup. Predicted operative mortality was calculated for each patient based upon the VA Surgical Risk Assessment model. Angioplasty of 52 vessels was attempted. Reduction in lumenal narrowing to < 50% and improved angiographic flow was obtained in 47 vessels. There were four complicating infarctions. One death occurred in the lab, and three patients with unsuccessful angioplasty died within 30 days of pump failure. Relief of angina occurred in 30/34. Thirty patients were discharged home. In follow-up from 1 to 12 months, there have been 2 late sudden deaths at 4 months and 9 months, 1 death from lung cancer; 4 patients have stable exertional angina; 2 are awaiting heart transplant but are pain free, and one patient who had PTCA during cardiogenic shock from acute myocardial infarction had elective coronary artery bypass surgery. There have been no late myocardial infarctions. The observed angioplasty 30-day mortality of 11.8% (95% confidence limit 1% to 22.6%) compares favorably with the predicted operative mortality of 23.8% for this group. This prospective but non-randomized series supports the concept that balloon angioplasty may be a reasonable alternative to surgical intervention in some patients with unstable angina and high risk for surgery. A prospective randomized trial is warranted.

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).

Exercise After Angioplasty: How Much? How Soon?

Less costly and less invasive than bypass graft surgery, percutaneous transluminal coronary angioplasty (PTCA) enables many patients who have mild or moderate coronary artery disease to resume normal activities-including exercise-within a few days of surgery. When formal, supervised exercise rehabilitation programs are not available, it's up to the primary care physician to design a program to help patients reduce their cardiac risk factors.

Effectiveness of decremental diameter balloon catheters (tapered balloon)

Natural tapering of coronary arteries from larger proximal to smaller distal diameters often creates a dilemma for optimal balloon sizing during percutaneous transluminal coronary angioplasty (PTCA). To demonstrate the need for new dilating catheters suitable for tapered coronary anatomy, 100 consecutive coronary arteries were measured by videodensitometry, 1 cm proximal and distal to the stenosis. In 23 arteries there was a 1 mm or greater taper and 19 arteries showed a 0.5 to 0.99 mm taper. Only 50 arteries showed a nearly uniform diameter at the site of the stenosis, and 8 arteries demonstrated reverse taper, i.e., distal was greater than proximal diameter. To avoid balloon size mismatch with significant tapering, decremental diameter balloon catheters were developed. Series I tapers from 3.5 to 3.0 mm and series II from 3.0 to 2.5 mm over a balloon length of 25 mm. Tapered balloons were used in 80 patients with 94 tapered coronary arteries. Before PTCA, proximal, stenotic and distal mean diameters measured 3.6, 1.1 and 2.6 mm, respectively; after PTCA, proximal, stenotic and distal diameters measured 3.6, 2.8 and 2.5 mm, respectively, thus maintaining the natural tapering after effective dilatation. Only 2 arteries (2.1%) showed significant dissection, with no abrupt occlusions, and none requiring bypass surgery. In summary, decremental diameter balloon catheters provide optimal dilation in tapered arterial segments with few complications and offer a new approach to balloon sizing.

Emergency coronary artery bypass surgery following failed balloon angioplasty: role of the internal mammary artery graft

During a 4-year period (1986-1989), 3,502 patients had percutaneous transluminal coronary angioplasty (PTCA) in our institution. One hundred nineteen (3.4%) patients required emergency coronary artery bypass graft surgery (CABG) because of abrupt vessel closure following PTCA. Factors associated with vessel closure included lesion angulation greater than or equal to 90 degrees (p less than 0.007), the presence of thrombus (p less than 0.02), or a long (greater than or equal to 2 cm) lesion (p less than 0.03). Of these 119 emergency CABG patients, 108 (91%) arrived in the operating room in a stable condition (group I) and 11 (9%) were in cardiogenic shock (group II). Five (45%) of the group II patients were admitted to the hospital with an acute myocardial infarction and all 11 patients had a higher incidence of multivessel disease (p less than 0.05) and lower left ventricular ejection fraction (p less than 0.001) than group I patients. The overall surgical mortality was 10.1%; however, in group I the mortality was 5.6% and in group II it was 54.5% (p less than 0.001). The vessel that abruptly closed ("culprit vessel") was the left anterior descending (LAD) in 60%, the right coronary artery in 27%, and the left circumflex in 13%. The internal mammary artery was utilized to bypass the culprit artery in 51 (43%) patients, including 50% of the culprit LADs. With group I culprit LAD patients, when the left IMA was the bypass conduit, there were no hospital deaths nor strokes and there was a 6.3% incidence of perioperative infarction.