Percutaneous transluminal coronary angioplasty (PTCA) in patients with relative contraindications: results of the National Heart, Lung, and Blood Institute PTCA Registry

Impact of age on procedural and 1-year outcome in percutaneous transluminal coronary angioplasty: a report from the NHLBI Dynamic Registry

BACKGROUND

Older age has been associated with adverse outcomes in patients undergoing percutaneous coronary intervention (PCI). As PCI technology evolves and the US population becomes proportionally older, assessment of PCI in older age groups is essential.

METHODS

From the National Heart, Lung, and Blood Institute Dynamic Registry, 4620 PCI-treated patients (1997 to 1999) were studied. Differences in clinical presentation, treatment strategy, and inhospital and 1-year outcomes were compared between patient age groups: younger (<65 years, n = 2537); older (65 to 79 years, n = 1776); and elderly (> or =80 years, n = 307).

RESULTS

Older and elderly patients had more cardiac and comorbid noncardiac conditions and more extensive and complex arteriosclerosis, including stenoses in bypass grafts. Stent use was similar as age increased (72% vs 73% vs 73%), as was the use of IIb/IIIa receptor antagonists (29% vs 26% vs 28%). Rates of successful treatment of all attempted lesions were 93%, 92%, and 89%, respectively. Adjusted relative risks of inhospital death (1.0 vs 2.91 vs 3.64) and myocardial infarction (1.0 vs 1.35 vs 2.57) increased by age group, as did 1-year mortality rates (1.0 vs 1.87 vs 3.02). However, the relative magnitude of excess mortality rates at 1 year was comparable to that observed by age in the US general population. Age was not associated with 1-year risk of myocardial infarction or coronary artery bypass grafting.

CONCLUSIONS

Although new technologies may allow for treatment of complex disease in older and elderly patients with comorbid disease, the increased procedural risk remains substantial in these patients. After PCI, the long-term relative risk of death is similar to that expected among persons of similar ages in the general population.

Short- and long-term results of emergency and elective percutaneous interventions on left main coronary artery stenoses

In this prospective study, we analyzed the short- and long-term outcomes of percutaneous interventions on significant left main coronary artery (LM) stenoses. Between January 1998 and June 2000, 18 patients underwent emergency interventions on unprotected LM stenoses (group 1), while 15 patients had elective interventions on protected LM stenoses (group 2). Despite a procedural success of 88.9% in group 1, event-free in-hospital and mortality rates were 50.0% and 38.9%. After 6.4 +/- 4.4 months of follow-up, late event-free survival and mortality rates were 33.3% and 38.9%. In group 2, procedural success was 100%, with 100% event-free in-hospital survival; late event-free survival and mortality rates were 93.3% and 0% after 6.7 +/- 4.1 months of follow-up. Emergency interventions on LM stenoses remain a procedure with high acute and mid-term mortality. In spite of the high rate of major adverse cardiac events, an acceptable long-term survival can be achieved.

Initial and long-term results of directional coronary atherectomy in unprotected left main coronary artery

Angioplasty in the unprotected left main coronary artery (LMCA) has been controversial. Recently, several studies have suggested that new procedures and devices such as directional coronary atherectomy (DCA) and stents may change this situation. Although there are many reports of unprotected LMCA stenting, there are few reports of DCA of this lesion. Therefore, initial and long-term results were evaluated in 101 patients who underwent DCA for unprotected LMCA in our hospital. Emergency procedures were performed in 15 patients and electively in 86 patients. Scheduled angiographic follow-up was routinely performed, and all patients were clinically followed for >4 months after DCA. Technical success was achieved in 99%, and in-hospital outcomes were cardiac death (2%), noncardiac death (4%), Q-wave myocardial infarction (1%), non-Q-wave myocardial infarction (8.9%), coronary artery bypass grafting (0%), and repeat angioplasty (4%). In-hospital results varied considerably, depending on presentation. In-hospital mortality was significantly higher in the emergency, left ventricular ejection fraction < or =35%, and high-risk surgical subgroups. The angiographic restenosis rate was 20.4% at follow-up, and its predictor was postminimal lumen diameter by multivariate analysis. Mean clinical follow-up was 2.8 years; estimated 1- and 3-year survival rates were 87% and 80.7%, respectively. The cardiac survival rate of the low-risk surgical subgroup was significantly higher than that of the high-risk surgical subgroup (p <0.05). Thus, our data show that DCA can be performed safely and effectively in unprotected LMCA with an acceptable low restenosis rate and high survival rate.

Repeated balloon rupture during coronary stenting due to a calcified lesion: an intravascular ultrasound study

We describe a patient in whom balloon rupture occurred three times during inflation in a stent with restenosis in the left anterior descending artery. The cause of rupture was detected by intravascular ultrasound: a calcified ridge that protruded between the stent struts in the distal stent body.

Initial and long-term results of angioplasty in unprotected left main coronary artery

Angioplasty of the unprotected left main coronary artery (LMCA) has been controversial. Although recent single-center studies suggest that new devices may change the situation, many questions and problems remain. Therefore, the results of unprotected left main coronary angioplasty of 175 procedures in 107 patients were analyzed to evaluate its feasibility and effectiveness. The treatment of the initial 107 cases included balloon angioplasty (39 cases, 36%), directional coronary atherectomy (53 cases, 50%), and stents (15 cases, 14%). They were divided into 3 major subgroups: (1) acute group (n = 14), in which LMCA angioplasty was performed in patients with acute myocardial infarction; (2) emergency group (n = 10); and (3) elective group (n = 83). In-hospital mortality was higher in the acute (35.7%) and emergency (40.0%) groups than in the elective group (3.6%; p <0.0001). Angiographic follow-up was routinely performed and the restenosis rate including in-hospital restenosis was 70% in the acute group, 37.5% in the emergency group, and 40% in the elective group (p = NS). The mean clinical follow-up period was 2.9 years, and the estimated 5-year survival rates of the acute and emergency groups were 50% and 48.2%, respectively. However the 5-year survival rate of the elective group was higher than that seen in the acute or emergency group (77.5%; p <0.05). Repeat LMCA angioplasty was performed in 37 of 68 patients with 8.8% mortality (38.5% of acute and emergency cases and 1.8% of elective cases). The results indicated that elective unprotected LMCA angioplasty is relatively feasible and effective under scheduled angiographic follow-up.

Cardiopulmonary bypass support of high risk coronary angioplasty patients: registry results

Coronary angioplasty has been increasingly utilized in patients with extensive coronary disease, severe and acute chest pain syndromes, and poor ventricular function. This process has been facilitated in part by use of circulatory support, including perfusion balloons, intraaortic balloon pumps and cardiopulmonary bypass support systems. Percutaneous cannulation has facilitated elective and emergency application of cardiopulmonary bypass support in patients undergoing high risk coronary angioplasty. A National Registry of 25 centers has accumulated data on 801 elective and 210 emergency support angioplasty patients. Standby cardiopulmonary bypass support of elective high risk patients was associated with fewer complications and less in-hospital mortality in patients other than those with left ventricular ejection fraction < or = 20% and possibly older high risk patients. In elective cases, circulatory support was required in only approximately 7% of high risk patients, although need appeared to be unpredictable. Emergency use of cardiopulmonary bypass support, initiated < 20 minutes from the time of circulatory collapse, was associated with improved patient prognosis. Overall, patients undergoing circulatory cardiopulmonary bypass supported angioplasty had a marked reduction in anginal status, improvement in left ventricular ejection fraction and good (80%) 2-year survival. Although used only occasionally, circulatory support remains an important prophylactic interventional tool for the extremely high risk patient (left ventricular ejection fraction < or = 20%) and a lifesaving emergency technique for the occasional patient with circulatory collapse.

Left main coronary artery disease: assessment, diagnosis, and therapy

This article reviews and updates the current literature concerning the assessment, diagnosis, and therapy of coronary disease involving the LMCA. Included is recent information regarding the natural history, congenital abnormalities, noninvasive diagnostic studies, and role of coronary bypass surgery and percutaneous coronary interventions in treating disease of the LMCA. At present, it remains that the LMCA is a difficult segment to assess angiographically. The use of noninvasive imaging does not specifically distinguish LMCA from other types of coronary disease. Coronary bypass surgery has a proven benefit in the treatment of disease of the LMCA. Currently, interventional procedures are limited by significant risks, and surgical treatment with coronary bypass surgery remains the therapy of choice.

Outcome of percutaneous transluminal coronary angioplasty in subsets of unstable angina pectoris

OBJECTIVES

The purpose of this study was to characterize the outcome of coronary angioplasty according to the various presentations of unstable angina pectoris.

BACKGROUND

Although unstable angina is a mosaic of clinical manifestations, a comprehensive analysis of short- and long-term outcome of coronary angioplasty in subsets of unstable angina is not available.

METHODS

Data from 15 clinical centers for the 857 patients with unstable angina in the 1985-1986 National Heart, Lung, and Blood Institute percutaneous transluminal coronary angioplasty registry were analyzed. Five-year follow-up was available in > 96.5%. Patients were first classified as those with (679 [79%]) or without (178 [21%]) rest angina. Patients were also allocated to five mutually exclusive categories of decreasing unstable angina severity: postinfarction angina, acute coronary insufficiency, plain rest angina, accelerating angina and new onset angina.

RESULTS

The group with rest angina had more older patients (p < 0.01) and women (p < 0.001), and a greater proportion had a previous myocardial infarction (p < 0.001) and a left ventricular ejection fraction < or = 50% (p < 0.01) than did the group without rest angina. Angiographic characteristics were nearly the same, whereas procedural characteristics and outcome were the same for both categories. At 5-year follow-up, there was a higher crude mortality rate in patients with than without rest angina (p < 0.05). Resolution into five subsets yielded additional information. Women were more represented only in the acute coronary insufficiency and plain rest angina subsets (p < 0.001). Patients with angina after myocardial infarction had the second shortest history of angina (p < 0.001), the highest percent of smokers (p < 0.01) and, with those with acute coronary insufficiency, the highest incidence of congestive heart failure (p < 0.05) and an ejection fraction < or = 50% (p < 0.001). They had the highest percent of totally occluded arteries, coronary thrombus and collateral blood flow received but also the lowest rate of severe stenoses (p < 0.001 for all). Patients with new onset angina had the highest prevalence of single-vessel disease (p < 0.05), critical and complex stenoses (p < 0.001) and no coronary angioplasty-related deaths. The crude 5-year mortality rate was higher for both postinfarction and acute insufficiency groups (p < 0.05) than for the other subsets. After adjustments for risk factors, no significant differences in adverse event rates remained among the different unstable angina subgroups.

CONCLUSIONS

Analysis of the diverse clinical presentations of unstable angina supports underlying pathogenetic differences. Coronary angioplasty is safe and effective in all subsets of unstable angina. Long-term survival is good in general but is related to the baseline status of left ventricular function.

Circumferential balloon rupture and catheter fracture due to entrapment in a calcified coronary stenosis

We report a case of coronary angioplasty balloon rupture and catheter fracture within a calcified lesion, requiring emergency coronary bypass surgery. The entrapped catheter could not be removed at surgery. This case re-emphasizes the hazards associated with angioplasty of calcified lesions.

Late results of coronary angioplasty in patients with left ventricular ejection fractions < or = 40%

Left ventricular (LV) function is the most important independent predictor of long-term survival in patients with coronary artery disease, and results of bypass surgery improving survival in the setting of depressed LV function are well documented. Data regarding long-term outcome in patients undergoing coronary angioplasty are limited. From 1983 through 1989, 343 consecutive patients with an ejection fraction (EF) < or = 40% (mean 34% +/- 5%) undergoing elective coronary angioplasty were evaluated, retrospectively. The mean age was 61 +/- 10 years and 80% were men. Angiographic success (469 of 496 narrowings) was 95%. Major complications occurred in 26 patients (7.6%): emergency bypass surgery (n = 11), nonfatal myocardial infarction (n = 8), and death (n = 9). Follow-up was available for 99% of patients with clinical success (mean = 36 +/- 22 months). Fourteen patients (4.5%) developed nonfatal myocardial infarction and 72 patients (23%) had symptomatic restenosis, 32 patients requiring repeat angioplasty or atherectomy and 29 bypass surgery. Fifty-six patients (18.2%) died. Three-year survival was 84%. EF was a significant predictor of death: 3-year survival was 69%, 83% and 92%, respectively, in patients with EF < or = 30%, 31% to 35%, and 36% to 40% (p = 0.0001). A high angiographic success rate and an acceptable procedural risk were encountered in patients with depressed LV function undergoing angioplasty. The 3-year mortality rate, however, is substantial and directly related to the degree of LV dysfunction.

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.

Factors affecting the restenosis rate after percutaneous transluminal coronary angioplasty

In an open study follow-up angiographies were performed independently from the clinical course on altogether 131 consecutive patients (99 men, 32 women) six months after percutaneous transluminal coronary angioplasty (PTCA). During this period patients received at least 320 mg of aspirin daily. Possible factors affecting the restenosis rate included age, sex, diabetes mellitus, arterial hypertension, abnormal lipid metabolism, smoking, dosage of aspirin administered, degree of stenosis shown by affected vessels before dilatation, number of vascular segments dilated and platelet reactivity. Restenosis was defined as a renewed narrowing of the dilated segment by 50% or more, with an increase in stenosis by at least 20%. In the present study the following restenosis rates were found six month after a primarily successful PTCA: 30% for the entire sample (39 out of 131 patients); 25% in patients with normal platelet function, 50% in those with mildly abnormal platelet function, and 60% in those with frankly abnormal platelet function; 24% in non-diabetic patients and 45% in diabetics. Analysis of the findings showed that abnormal platelet function and the presence of diabetes mellitus were the most important factors in the subsequent development of restenosis after angioplasty. The same also applied in a more restricted manner to the degree of stenosis present before angioplasty.

Coronary angioplasty in the elderly: immediate and long-term results

Coronary angioplasty was performed in 37 elderly patients (> sixty-eight years) with unstable or stable angina, refractory to medical treatment. History of myocardial infarction was present in 38% and of previous bypass surgery in 5% of patients. Coronary angiography revealed single-vessel disease in 22 (59%) and multivessel disease in 15 (41%) of patients. The mean left ventricular ejection fraction was 53 +/- 17%. Percutaneous transluminal coronary angioplasty (PTCA) was successful in 92% of patients; there were two angioplasty failures and 1 acute occlusion leading to Q wave myocardial infarction. In patients with multivessel disease complete revascularization was achieved in 33%. Follow-up data (21.29 +/- 9.23 months) are available in all patients with primary angiographic success. There was 1 death. Seventy-nine percent of patients had an improved anginal status, and repeat PTCA was performed in 2 patients because of clinical recurrence. Thus, coronary angioplasty is a safe and efficacious method of revascularization in symptomatic patients over the age of sixty-eight years.

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.

Coronary angioplasty in high-risk patients with left main coronary stenosis: results from the National Registry of Elective Supported Angioplasty

To assess the outcome of PTCA in circulatory supported patients with left main coronary artery (LMCA) stenosis, the National Registry of Elective Supported Angioplasty data bank was searched. Patients entered in the registry were considered high-risk PTCA and the PTCA was performed using percutaneous cardiopulmonary bypass (PCPB). Criteria for high risk was left ventricular ejection fraction less than or equal to 25% or a target lesion supplying greater than or equal to 50% of functioning myocardium. Of 455 patients entered in the registry, 61 (13.3%) had LMCA stenosis greater than or equal to 60%. There were 42 patients in whom the PTCA target vessel was the LMCA (PTCA-LMCA) and 19 in whom it was vessel(s) other than the LMCA (PTCA-OTHER). The mean age was similar in the 2 groups (65 +/- 10 vs. 68 +/- 9 yrs, p = ns). The left ventricular ejection fraction (LVEF) was higher in PTCA-LMCA than in PTCA-other (38 +/- 16% vs. 27 +/- 16%, p less than 0.05). The number of vessels dilated/patient was higher in PTCA-LMCA than in PTCA-OTHER (2.1 +/- 1.0 vs. 1.1 +/- 0.3, p less than 0.001). There were a total of 10 in-hospital deaths (16%) in patients with LMCA greater than or equal to 60% stenosis. This exceeds the mortality of the patients with less than 60% LMCA stenosis entered in the registry (4.5%, p less than 0.001). There were 6 in-hospital deaths (14%) in PTCA-LMCA and 4 (21%) in PTCA-OTHER (p = ns).(ABSTRACT TRUNCATED AT 250 WORDS)

Short and long term outcome of percutaneous transluminal coronary angioplasty in unstable versus stable angina pectoris: a report of the 1985-1986 NHLBI PTCA Registry

In a cohort of 1,720 consecutive patients from the National Heart, Lung, and Blood Institute, Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry (August 1985-May 1986), we compared 768 patients (45%) with stable angina and 952 patients (55%) with unstable angina pectoris. Unstable angina patients exhibited at least one of the following characteristics: new onset angina, rapidly progressing angina, angina at rest, angina refractory to medication, variant angina, acute coronary insufficiency, or angina recurring shortly after an acute myocardial infarct. The distribution of single- and multi-vessel disease was similar among stable and unstable angina patients; multi-vessel disease predominated. Average severity of stenosis and incidence of tubular and diffuse stenosis morphology were higher among patients with unstable angina (both p less than 0.001). Patient success rates were similar in stable and unstable patients. However, on a per lesion basis, overall angiographic success rate and average reduction of severity of stenosis in successfully dilated lesions were significantly higher among patients with unstable angina (both p less than 0.001). Incidence of major patient complications (p less than 0.01) and of emergency coronary bypass surgery (p less than 0.05) were also higher in patients with unstable angina but consistent with their more precarious clinical condition and stenosis morphology. During a two year follow-up, the cumulative distributions of death, myocardial infarct, repeat PTCA, and coronary bypass surgery were not significantly different in patients with stable angina compared to patients with unstable angina. Comparison of the current PTCA Registry cohort with the cases reported in the 1979-1982 Registry revealed a 19% higher success rate for both stable and unstable angina patients. Major complication rates decreased between time periods for stable but not for unstable angina patients. Incidence of emergency bypass surgery decreased more for stable than for unstable angina patients. Coronary angioplasty is indicated in properly selected patients with unstable angina and both single- and multi-vessel coronary disease.

Coronary angioplasty in octogenarians: comparisons to coronary bypass surgery

Coronary angioplasty was performed in 74 patients 80 years of age and older (mean 83 +/- 3). Single vessel coronary disease was present in 34% and multivessel coronary disease in 66%. Angioplasty of a single vessel was performed in 51 patients (69%), while 23 (31%) had angioplasty of multiple vessels. Angioplasty was successful in 59 of 74 patients (80%). Angioplasty was unsuccessful but uncomplicated in 12 (16%) due to (unyielding) calcified lesions or (impassable) old occlusions. Of these 12, 8 were discharged on medical therapy and 4 underwent elective uncomplicated bypass surgery prior to discharge. Three (4%) patients required emergency coronary bypass surgery due to abrupt vessel closure during the angioplasty procedure, with one hospital death (1.4%). Follow-up (mean 24 +/- 22 months) was obtained in all patients. Of the 59 successful angioplasty patients, late mortality was 10% (cardiac 7% and non-cardiac 3%). Survival and survival without myocardial infarction were both 90%; survival without either infarction or bypass surgery was 86%. Actuarial 3-year survival was 91% and 3-year freedom from death, infarction or bypass surgery was 87% by life-table analysis. Repeat angioplasty for restenosis was performed in 7 patients (12%) without complications.

Percutaneous support devices for high risk or complicated coronary angioplasty

Indications for coronary angioplasty have expanded to include patients with unstable acute ischemic syndromes, severe multivessel coronary artery disease and impaired left ventricular function. Several mechanical approaches have been developed as adjuncts to high risk coronary angioplasty to improve patient tolerance of coronary balloon occlusion and maintain hemodynamic stability in the event of complications. These percutaneous techniques include intraaortic balloon counterpulsation, anterograde transcatheter coronary perfusion, coronary sinus retroperfusion, cardiopulmonary bypass, Hemopump left ventricular assistance and partial left heart bypass. The intraaortic balloon pump provides hemodynamic support and ameliorates ischemia by decreasing myocardial work; it may be inserted for periprocedural complications or before angioplasty in patients with ischemia or hypotension. Anterograde distal coronary artery perfusion may be accomplished passively through an autoperfusion catheter or by active pumping of oxygenated blood or fluorocarbons through the central lumen of an angioplasty catheter. Synchronized coronary sinus retroperfusion produces pulsatile blood flow via the cardiac veins to the coronary bed distal to a stenosis. Both perfusion techniques limit development of ischemic chest pain and myocardial dysfunction in patients undergoing prolonged balloon inflations. Percutaneous cardiopulmonary bypass provides complete systemic hemodynamic support which is independent of intrinsic cardiac function or rhythm and has been employed prophylactically in very high risk patients before coronary angioplasty or emergently for abrupt closure. These and newer support devices, while associated with significant complications, may ultimately improve the safety of coronary angioplasty and allow its application to those who would otherwise not be candidates for revascularization.

Results of percutaneous transluminal coronary angioplasty in patients greater than or equal to 65 years of age (from the 1985 to 1986 National Heart, Lung, and Blood Institute's Coronary Angioplasty Registry)

The 1985 to 1986 National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry series of 1,801 initial procedures included 486 patients age greater than or equal to 65 years (elderly). In comparison to younger patients, a greater proportion of elderly patients were women and had unstable angina. Elderly patients had more history of hypertension and more history of congestive heart failure. Although the elderly had more extensive vessel disease, the numbers of lesions and vessels attempted with PTCA were similar in the older and younger cohorts. Angiographic success rates were similar for all age groups. Although complication rates in the catheterization laboratory did not differ, patients greater than or equal to 65 years were much more likely to require emergency coronary artery bypass graft surgery (CABG) (5.4 vs 2.8%, p less than 0.05) or elective CABG (3.9 vs 1.6%, p less than 0.01). The in-hospital death rate was considerably higher among the elderly (3.1 vs 0.2%, p less than 0.01). At 2-year follow-up, symptomatic status and cumulative rates of myocardial infarction, CABG and repeat PTCA were similar for elderly and younger patients. The death rate after 2 years was higher among elderly patients (8.8% of patients greater than or equal to 65 years vs 2.9% of patients less than 65 years, p less than 0.01). When the relative risk of death for the elderly was adjusted for factors more prevalent among those greater than or equal to 65 years (history of congestive heart failure, multivessel disease, unstable angina, history of hypertension and female gender), the relative risk remained significant but was substantially reduced (from 3.3 to 2.4).

Management of high-risk coronary angioplasty

Many advances have been made in the decade since Dr. Andreas Gruentzig performed the first percutaneous transluminal coronary angioplasty. The technique, which started out as a nonsurgical revascularization procedure for 1-vessel disease, has spread to use in multivessel disease and acute myocardial infarction. Over the last several years, a number of refinements have made angioplasty safer. These techniques/devices have been applied to high-risk patients to allow angioplasty to be performed safely. High-risk patients include those with large amounts of myocardium at jeopardy from a single target lesion and those patients with reduced left ventricular function. The techniques/devices that enhance safety include: (1) the use of a perfusion balloon catheter, (2) infusion of oxygen-carrying substances to the distal coronary artery, (3) coronary sinus retroperfusion, (4) intraaortic balloon pump support, and (5) supported angioplasty.

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)

The combined use of diastolic counterpulsation and coronary dilation in unstable angina due to multivessel disease under unstable hemodynamic conditions

Sixteen patients with multivessel ischemic heart disease and severely jeopardized myocardium required intra-aortic balloon counterpulsation subsequent to a deterioration in hemodynamics during or following a coronary angioplasty procedure. They had all suffered unstable angina which was refractory to intensive medical therapy, consisting of a combination of nitroglycerin, beta-adrenergic antagonists, and calcium blockers. Thirty angioplasties had been attempted (1.9 artery stem/patient) with a primary success rate of 90%. The symptoms of prolonged myocardial ischemia had disappeared, and the patient's blood pressure had normalized. No complications were associated with the use of the mechanical circulatory assistance. There were no deaths related to the procedure itself, and no myocardial infarctions. Emergency surgery was not required. One patient did die in hospital, however, due to cerebrovascular accident which occurred 4 days after removal of the mechanical circulatory support. Two also died suddenly later. One patient also required later elective coronary arterial bypass surgery and another needed repeated coronary dilation. The 12 remaining patients are asymptomatic at a follow-up with mean value of 22 months. Temporary intra-aortic diastolic counterpulsation is a useful adjunct to coronary angioplasty in patients with multivessel unstable angina and compromised hemodynamics.

Coronary angioplasty

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High risk percutaneous transluminal coronary angioplasty in the treatment of severe coronary artery disease

We report on 27 "high risk" patients out of 171 consecutive patients undergoing percutaneous transluminal coronary angioplasty from June 1984 to August 1985. The ages ranged from 31-80 years (mean 62.7 +/- 10) years. High risk percutaneous transluminal coronary angioplasty was defined as: salvage cases (3 patients) where the patients presented in cardiogenic shock or the vessels were not bypassable; multivessel coronary artery disease (22 patients) where a large area of jeopardized myocardium was dependent on the angioplasty vessel(s); left ventricular dysfunction (7 patients) as defined by two of the three criteria: left ventricular end-diastolic volume index greater than 100 ml/m2; ejection fraction less than 30%; and left ventricular end-diastolic pressure greater than 20 mm Hg. The initial success rate in the high risk patients was 85.2%. Emergency coronary artery bypass surgery in these patients was 7.4%. There was one death in the high risk group, as one of the salvage cases died 24 hours after successful percutaneous transluminal coronary angioplasty due to severe underlying myocardial disease. In conclusion percutaneous transluminal coronary angioplasty can be successfully performed in high risk patients with a low complication rate and should be considered as an alternative to coronary artery bypass graft surgery in selected high risk patients.

Previous coronary artery bypass grafting as an adverse prognostic factor in unstable angina pectoris

Among 252 patients hospitalized for unstable angina in 1982 and 1983, 54 (21%) had undergone coronary artery bypass grafting (CABG) a mean of 55 months earlier (range 1 to 168) (CABG patients). This group was compared with a group of 54 randomly selected patients with unstable angina without previous CABG (control patients). The 2 groups did not differ with respect to clinical characteristics at admission or hospital course. Coronary arteriograms, recorded in all but 4 CABG patients, revealed multivessel stenoses of at least 70% luminal diameter in 40 CABG and 32 control patients (p less than 0.05), but when patent grafts were considered, the groups were comparable. Overall, 48 of 112 grafts were totally occluded and 14 had stenoses at least 70% in diameter. Complete or almost complete revascularization was feasible in 39 of 52 control and only 9 of 42 CABG patients (p less than 0.001). By 1 year, 46 control patients and 20 CABG patients had undergone CABG or coronary angioplasty (p less than 0.001); 42 of 53 control patients and only 22 of 50 CABG patients were in functional class 0 or I (p less than 0.001). Cumulative adverse events (5 deaths, 10 myocardial infarctions and 15 cases of recurrent unstable angina) were more frequent in the CABG group, 20 vs 10 (p less than 0.05). Thus, although their clinical features and hospital course are similar, patients with unstable angina who have undergone previous CABG do not do as well as other patients with unstable angina because they are less amenable to revascularization.

Digital coronary roadmapping as an aid for performing coronary angioplasty

In an attempt to improve visualization of the position of the guidewire and dilatation balloon during coronary angioplasty, a method was developed called digital coronary roadmapping. With this method a digitally acquired coronary angiogram is interlaced with the live fluoroscopic image of the guidewire and balloon catheter. The digital coronary angiogram is superimposed at the same magnification and radiologic projection as the live fluoroscopic image onto the video monitor above the catheterization table. The digital roadmap image thus provides immediate feedback to the angiographer to assist in directing the guidewire into the appropriate coronary artery branch and to help in placement of the balloon so that it straddles the site of stenosis.