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Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1-121. [PMID: 16386656 DOI: 10.1016/j.jacc.2005.12.001] [Citation(s) in RCA: 309] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Smith SC, Dove JT, Jacobs AK, Ward Kennedy J, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO, Gibbons RJ, Alpert JP, Eagle KA, Faxon DP, Fuster V, Gardner TJ, Gregoratos G, Russell RO, Smith SC. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines)31This document was approved by the American College of Cardiology Board of Trustees in April 2001 and by the American Heart Association Science Advisory and Coordinating Committee in March 2001.32When citing this document, the American College of Cardiology and the American Heart Association would appreciate the following citation format: Smith SC, Jr, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO. ACC/AHA guidelines for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiol 2001;37:2239i–lxvi.33This document is available on the ACC Web site at www.acc.organd the AHA Web site at www.americanheart.org(ask for reprint no. 71-0206). To obtain a reprint of the shorter version (executive summary and summary of recommendations) to be published in the June 15, 2001 issue of the Journal of the American College of Cardiology and the June 19, 2001 issue of Circulation for $5 each, call 800-253-4636 (US only) or write the American College of Cardiology, Educational Services, 9111 Old Georgetown Road, Bethesda, MD 20814-1699. To purchase additional reprints up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1,000 or more copies, call 214-706-1466, fax 214-691-6342, or E-mail: pubauth@heart.org(ask for reprint no. 71-0205). J Am Coll Cardiol 2001. [DOI: 10.1016/s0735-1097(01)01345-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Bhargava B, Kornowski R, Mehran R, Kent KM, Hong MK, Lansky AJ, Waksman R, Pichard AD, Satler LF, Leon MB. Procedural results and intermediate clinical outcomes after multiple saphenous vein graft stenting. J Am Coll Cardiol 2000; 35:389-97. [PMID: 10676686 DOI: 10.1016/s0735-1097(99)00564-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We evaluated the early and mid-term (18-month) clinical events in a consecutive series of patients undergoing a nonstaged multiple saphenous vein grafting (SVG) intervention with stents as compared with a single SVG stent procedure. BACKGROUND Saphenous vein graft angioplasty has been limited by high rates of distal embolization, myocardial infarction, restenosis and late mortality. It is unknown whether stenting of multiple, different SVGs at the same setting is associated with higher risk. METHODS We evaluated in-hospital and mid-term clinical outcomes (death, Q wave myocardial infarction [MI] and repeat revascularization rates up to 18 months) in 70 consecutive patients treated with coronary stents in 2 (93% of patients) or 3 SVGs, as compared with 649 patients undergoing stenting of a single SVG between January 1, 1994 and December 31, 1997. RESULTS Overall procedural success was obtained in 97% of patients with 2 or 3 SVGs and 97% of patients with a single SVG (p = 0.94). Procedural complications were also similar (2.8% for multiple SVGs vs. 2.7% for a single SVG, p = 0.94). There was a higher prevalence of periprocedural non-Q wave MI (28% vs. 16%, p = 0.009) in the multiple SVG group. During follow-up (18 months), target lesion revascularization was 11% in multiple SVG and 15% in single SVG interventions (p = 0.19), and repeat revascularization (calculated per treated patient) was also similar for both groups (19% vs. 18%, p = 0.94). There was no difference in death (5.6% vs. 5.3%, p = 0.92) and Q wave MI rate (4.3% vs. 2.9%, p = 0.55) after the multiple SVG intervention. Overall cardiac event-free survival was similar for both groups (62% vs. 60%, p = 0.75). The study was powered to detect a clinically meaningful difference of 10% in mortality; smaller differences could not be evaluated on the basis of this sample size. CONCLUSIONS Simultaneous stenting of multiple SVGs in carefully selected patients has similar in-hospital procedural success and major complications rates, as well as mid-term (18-month) clinical outcomes, as compared with single SVG stenting. Thus, multiple SVG interventions using stents may be a viable revascularization strategy for carefully selected patients and suitable lesions in multiple SVG disease.
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Affiliation(s)
- B Bhargava
- Cardiac Catheterization Laboratory, Division of Cardiology, Washington Hospital Center, Washington, DC, USA
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Vaitkus PT, Laskey WK. Efficacy of adjunctive thrombolytic therapy in percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 1994; 24:1415-23. [PMID: 7930268 DOI: 10.1016/0735-1097(94)90128-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Adjunctive thrombolysis has not been shown to improve angioplasty success or complication rates in elective angioplasty or myocardial infarction and may be detrimental in unstable angina. Thrombolysis of chronically occluded vessels achieves recanalization at a rate comparable to conventional angioplasty and is associated with a high rate of complications and limited long-term patency. Thrombolysis administered for thrombus or acute occlusion complicating angioplasty usually achieves coronary artery patency but is unable to forestall complications in many cases. A benefit of thrombolysis in reducing restenosis has not been conclusively demonstrated.
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Affiliation(s)
- P T Vaitkus
- Cardiology Unit, Medical Center Hospital of Vermont, University of Vermont, Burlington 05401
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Hong MK, Popma JJ, Pichard AD, Kent KM, Satler LF, Chuang YC, Mintz GS, Keller MB, Leon MB. Clinical significance of distal embolization after transluminal extraction atherectomy in diffusely diseased saphenous vein grafts. Am Heart J 1994; 127:1496-503. [PMID: 8197974 DOI: 10.1016/0002-8703(94)90376-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Standard balloon angioplasty of degenerated saphenous vein graft lesions may be complicated by distal embolization, particularly in the presence of intragraft thrombus. Transluminal extraction atherectomy may be useful in this setting because of its ability to remove particulate debris. This study was designed to identify the incidence and prognostic significance of distal embolization after transluminal extraction atherectomy in high-risk saphenous vein graft lesions. To address these issues the clinical course of 65 consecutive patients (86 high-risk saphenous vein graft lesions) was reviewed after extraction atherectomy. Distal embolization occurred in 11 (12.8%) of 86 high-risk lesions. The majority (63.6%) of these episodes occurred after adjunct balloon dilatation following uncomplicated use of the extraction atherectomy catheter. Correlates of distal embolization included patient age and the presence of intragraft thrombus. Major in-hospital complications developed more often in patients with distal embolization (46% vs 2% in those without distal embolization, p < 0.001), resulting in a reduced procedural success rate in this group (55% vs 91%, p = 0.01). We conclude that the risk of distal embolization after saphenous vein graft angioplasty, although potentially reduced, is not eliminated with transluminal extraction atherectomy, particularly in lesions with superimposed thrombus.
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MESH Headings
- Aged
- Angioplasty, Balloon, Coronary/adverse effects
- Angioplasty, Balloon, Coronary/statistics & numerical data
- Atherectomy, Coronary/adverse effects
- Atherectomy, Coronary/instrumentation
- Atherectomy, Coronary/methods
- Atherectomy, Coronary/statistics & numerical data
- Cineangiography
- Coronary Angiography
- Female
- Graft Occlusion, Vascular/diagnostic imaging
- Graft Occlusion, Vascular/epidemiology
- Graft Occlusion, Vascular/etiology
- Graft Occlusion, Vascular/therapy
- Humans
- Incidence
- Male
- Middle Aged
- Prognosis
- Risk Factors
- Saphenous Vein/diagnostic imaging
- Saphenous Vein/transplantation
- Statistics as Topic
- Thromboembolism/diagnostic imaging
- Thromboembolism/epidemiology
- Thromboembolism/etiology
- Thromboembolism/therapy
- Treatment Outcome
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Affiliation(s)
- M K Hong
- Department of Internal Medicine (Cardiology Division), Washington Hospital Center, Washington, DC 20010
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6
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Faxon, Mehra. Current status of percutaneous transluminal coronary angioplasty. Curr Probl Cardiol 1994. [DOI: 10.1016/0146-2806(94)90021-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Morrison DA, Crowley ST, Veerakul G, Barbiere CC, Grover F, Sacks J. Percutaneous transluminal angioplasty of saphenous vein grafts for medically refractory unstable angina. J Am Coll Cardiol 1994; 23:1066-70. [PMID: 8144769 DOI: 10.1016/0735-1097(94)90591-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES We attempted to answer the question, Is balloon angioplasty a reasonable alternative to repeat coronary artery bypass graft surgery in patients with previous coronary bypass graft surgery, medically refractory unstable angina and vein graft lesions? BACKGROUND Patients with medically refractory unstable angina need revascularization. Patients with previous coronary artery bypass graft surgery and medically refractory angina are at "high risk" for adverse outcomes with repeat coronary bypass graft surgery. Conversely, patients with angioplasty of old vein grafts are also at "high risk" for adverse outcomes. METHODS Balloon angioplasty of 89 lesions in saphenous vein grafts was performed in 75 consecutive patients with medically refractory unstable angina. Of these 75 patients, 24 (32%) had myocardial infarct within 30 days, 23 (31%) had left ventricular ejection fraction < 0.35, and 50 (67%) had major comorbidity. Patients underwent standard balloon angioplasty with aggressive use of intravenous and intracoronary heparin, urokinase, nitroglycerin, oral aspirin, calcium channel blocking agents and coumadin. RESULTS Angiographic success (reduction of stenosis < or = 50% without major complication) was seen in 84 of 89 lesions. Clinical success (angiographic success plus hospital discharge without major complication) was seen in 70 of 75 patients. During index hospitalization, two patients (3%) died, two (3%) had nonfatal infarcts, and one (1%) had emergency reoperation (coronary bypass graft surgery). In late follow up (3 to 66 months), 14 (20%) patients were lost to follow-up, 17 (23%) had repeat percutaneous transluminal coronary angioplasty, 2 (3%) had late bypass graft reoperation, 18 (25%) had late death, and 1 (< 1%) had a heart transplant. Of the 41 patients alive after one or more angioplasties, 25 have little or no angina, and 16 have occasional or more angina. We compared long-term survival rate in these 75 patients with a cohort of patients with high risk, unstable angina from the Veterans Affairs Surgical Registry (2,570 patients). The 30-day survival rate was better in patients with coronary angioplasty (97% vs. 92%, p < 0.05), but by 6 months there was no difference, and by 5 years a trend toward a higher survival rate with coronary artery bypass graft surgery was seen. CONCLUSIONS Balloon angioplasty of saphenous vein grafts with aggressive adjunctive pharmacotherapy is a reasonable alternative to repeat coronary bypass graft surgery in patients with medically refractory unstable angina, previous coronary bypass graft surgery and saphenous vein narrowing.
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Affiliation(s)
- D A Morrison
- Cardiology Section, Denver Department of Veterans Affairs Medical Center, Colorado
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Gershony G, Glass PR. Coronary thrombus: a novel catheter-based approach to treatment. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 31:147-9. [PMID: 8149429 DOI: 10.1002/ccd.1810310212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The presence of coronary thrombus during intracoronary interventions increases the risk of complications during the procedure. We describe a novel approach to infusing thrombolytic agents selectively into a coronary artery utilizing a new low-profile perfusion balloon. This approach may add a useful new treatment for resistant intracoronary thrombi.
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Affiliation(s)
- G Gershony
- Tulsa Heart Center, University of Oklahoma College of Medicine, Tulsa Hillcrest Medical Center
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Blankenship JC, Modesto TA, Madigan NP. Acute myocardial infarction complicating urokinase infusion for total saphenous vein graft occlusion. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1993; 28:39-43. [PMID: 8416330 DOI: 10.1002/ccd.1810280108] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Saphenous vein graft occlusions have been successfully treated with extended urokinase infusions. We report a case of myocardial infarction complicating this treatment. A review of reported cases suggests that this complication may not be uncommon. The optional drug, dose, and infusion technique for intra-graft lytic therapy has not been determined. The costs, risks, and difficulty of this technique may limit its application.
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Affiliation(s)
- J C Blankenship
- Department of Cardiology, Geisinger Medical Center, Danville, PA 17822
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10
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Cospito PD, Popma JJ, Satler LF, Leon MB, Kent KM, Pichard AD. Prolonged intravenous urokinase infusion: an alternative pharmacologic approach in the treatment of thrombus-containing saphenous vein graft stenoses. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1992; 26:291-4. [PMID: 1394416 DOI: 10.1002/ccd.1810260409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A subtotally occlusive saphenous vein graft stenosis resolved after rapid intracoronary and prolonged intravenous urokinase infusion. Additional therapy was unnecessary, avoiding the attendant risks of saphenous vein graft angioplasty. Combined intracoronary and intravenous urokinase infusion should be considered prior to coronary angioplasty of saphenous vein graft stenoses, particularly when diffuse degeneration is present or the risk of underlying thrombus is high.
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Affiliation(s)
- P D Cospito
- Angiographic Core Laboratory, Washington Cardiology Center, Washington, D.C. 20010
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11
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Bedotto JB, Rutherford BD, Hartzler GO. Intramyocardial hemorrhage due to prolonged intracoronary infusion of urokinase into a totally occluded saphenous vein bypass graft. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1992; 25:52-6. [PMID: 1555226 DOI: 10.1002/ccd.1810250111] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A 0.038 inch perfusion wire was used to selectively administer a 24-hr infusion of urokinase into the occluded saphenous vein bypass graft of a 69-yr-old woman. Immediately following subsequent reperfusion by balloon angioplasty, she developed a hemorrhagic myocardial infarction.
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Affiliation(s)
- J B Bedotto
- Mid America Heart Institute, Kansas City, Missouri
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12
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Goudreau E, DiSciascio G, Vetrovec GW, Chami Y, Kohli R, Warner M, Sabri N, Cowley MJ. Intracoronary urokinase as an adjunct to percutaneous transluminal coronary angioplasty in patients with complex coronary narrowings or angioplasty-induced complications. Am J Cardiol 1992; 69:57-62. [PMID: 1729868 DOI: 10.1016/0002-9149(92)90676-p] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The effectiveness of intracoronary urokinase infusion as an adjunct to percutaneous transluminal coronary angioplasty (PTCA) was studied in 50 patients who underwent angioplasty for complex coronary narrowings or had thromboembolic complications during PTCA (29 [58%] men, 3 [6%] stable and 37 [74%] unstable angina, and 16 [32%] prior coronary bypass surgery). The primary indications for intracoronary urokinase infusion were intracoronary thrombus in 27 patients (54%), distal coronary embolization in 9 (18%), and abrupt reclosure in 14 (28%). Urokinase was infused in a mean (+/- standard deviation) dosage of 399,000 +/- 194,000 IU (range 150,000 to 1,000,000) at an average rate of 5,000 to 20,000 IU/min. Angiographic success was achieved in 43 patients (86%). Complications included the need for urgent bypass surgery in 3 patients, Q-wave myocardial infarction in 2, and non-Q-wave myocardial infarction in 12 (8 of whom had peak creatine kinase less than twice the upper normal limit). The incidence of myocardial infarction was significantly higher in patients with vein grafts (69%) than in those with PTCA of native vessels (14%). Two patients died (1 massive gastrointestinal necrosis 24 hours after angioplasty, and 1 after urgent bypass surgery). Mean (+/- standard deviation) fibrinogen levels were 355 +/- 73 mg/dl before urokinase infusion, and 361 +/- 70, twelve hours afterward. Three patients had local bleeding, but no transfusions were needed. It is concluded that intracoronary urokinase is a safe and effective adjunct to PTCA in patients with associated thrombi and may improve the success rate in angioplasty complicated by thrombus formation.
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Affiliation(s)
- E Goudreau
- Department of Medicine, Medical College of Virginia, Richmond 23298
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Hartmann JR, McKeever LS, Stamato NJ, Bufalino VJ, Marek JC, Brown AS, Goodwin MJ, Cahill JM, Enger EL. Recanalization of chronically occluded aortocoronary saphenous vein bypass grafts by extended infusion of urokinase: initial results and short-term clinical follow-up. J Am Coll Cardiol 1991; 18:1517-23. [PMID: 1939955 DOI: 10.1016/0735-1097(91)90684-2] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Chronic occlusion of saphenous vein aortocoronary bypass grafts is a common problem. Although percutaneous transluminal angioplasty of a saphenous vein with a stenotic lesion is feasible, angioplasty alone of a totally occluded vein graft yields uniformly poor results. Patients with such occlusion are often subjected to repeat aortocoronary bypass surgery. Experience with a new technique that allows angioplasty to be performed in a totally occluded saphenous vein bypass graft is reported. This technique utilizes infusion of prolonged low dose urokinase directly into the proximal portion of the occluded graft. Forty-six consecutive patients with 47 totally occluded grafts were studied. Patients had undergone end to side saphenous vein bypass grafting 1 to 13 (mean 7) years previously. All patients presented with new or worsening angina pectoris with ST-T changes or non-Q wave acute myocardial infarction and all had a totally occluded saphenous vein bypass graft. The new technique entailed the positioning of an angiographic catheter into the stub of the occluded graft and the advancement of an infusion wire into the graft. Patients were returned to the coronary care unit, where urokinase was delivered at a dose of 100,000 to 250,000 U/h. The total dose of urokinase ranged from 0.7 to 9.8 million U over 7.5 to 77 h (mean 31). After therapy, recanalization was seen in 37 (79%) of the 47 grafts. In 20 successfully treated patients, angiography was performed 1 to 24 (mean 11) months after treatment; 13 (65%) of these grafts were patent.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J R Hartmann
- Midwest Cardiovascular Institute, Downers Grove, Illinois
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Doorey AJ, Rosenbloom MA, Zolnick MR. Successful angioplasty of a chronically occluded saphenous vein graft using a prolonged urokinase infusion from the brachial route. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1991; 23:127-9. [PMID: 2070399 DOI: 10.1002/ccd.1810230214] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A 68-year-old man who presented with unstable angina had had cardiac bypass surgery 12 years earlier and successful angioplasty of a native circumflex lesion 18 months previously. Repeat catheterization showed a widely patent angioplasty site but interval closure of a saphenous vein graft to a large marginal branch that was totally occluded proximally. A stress test revealed significant myocardial ischemia. Severe peripheral peripheral vascular disease with known bilateral iliac artery occlusions mandated a brachial approach. Because of his high risk for repeat cardiac surgery, it was elected to attempt saphenous graft angioplasty following a prolonged urokinase infusion. After an infusion of urokinase for 36 hr, antegrade flow was restored and angioplasty was carried out successfully on a discrete mid-graft legion. Subsequent stress testing showed resolution of the ischemia. There were no vascular complications.
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Affiliation(s)
- A J Doorey
- Department of Medicine, Medical Center of Delaware, Newark 19713
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