Triple vessel coronary angioplasty: acute outcome and long-term results

Efficacy of coronary angioplasty for the treatment of hibernating myocardium

OBJECTIVES

To determine the efficacy of coronary angioplasty as the sole method of revascularisation in patients with coronary artery disease and chronically dysfunctional but viable myocardium (hibernating myocardium), and to assess the effect of restenosis on functional outcome.

DESIGN AND PATIENTS

24 consecutive patients with hibernating myocardium were studied. Positron emission tomography was used to assess myocardial viability, blood flow, and flow reserve. One patient refused angioplasty, one had bypass surgery, and one died while waiting for an elective procedure. The procedure failed in three patients. The remaining 18 patients had repeat echocardiography, 15 had repeat coronary angiography, and nine had repeat assessments of blood flow and flow reserve at mean (SD) 17 (2) weeks after angioplasty. In three patients restenosis was documented.

RESULTS

The wall motion score index in the revascularised territories improved from 1.71 (0.37) to 1.34 (0.47) (p = 0.008). Thirty of 51 dysfunctional segments improved in territories without restenosis compared with three of 14 in restenosed territories (p = 0.001). Hibernating and normal segments had comparable flows (0.82 (0.26) v 0.89 (0.24) ml/min/g; NS) while flow reserve was lower in hibernating segments (1.55 (0.68) v 2.07 (1.08); p = 0.03). In segments without restenosis flow reserve improved from 2.03 (1.25) to 2.33 (1.4) (p = 0.03). Sensitivity, specificity, and positive and negative predictive accuracy of the viability study were 97%, 77%, 82%, and 96%, respectively. After excluding patients with restenosis, specificity and positive predictive accuracy improved to 90% and 93%.

CONCLUSIONS

Angioplasty improves function in hibernating myocardium, and restenosis prevents recovery; hibernating myocardium is characterised by an impairment of flow reserve; restenosis affects the diagnostic accuracy of viability studies.

Clinical and angiographic follow-up after coronary angioplasty in patients with two-vessel disease: influence of completeness and adequacy of revascularization on long-term outcome

To assess the influence of the degree of revascularization on long-term results with angioplasty in multivessel disease, 151 consecutive patients with double-vessel disease and successful angioplasty in at least one vessel were prospectively followed up for a mean of 14 months (range 6 to 30 months) with clinical evaluation, an exercise stress test, and routine angiography. Patients were divided into three groups according to completeness and adequacy of revascularization: group 1--complete revascularization (no residual stenosis > or = 70%, 51 patients); group 2--incomplete but functionally adequate revascularization (residual stenosis > or = 70% in a vessel < 2 mm in diameter or supplying akinetic or dyskinetic segments of the left ventricle, 56 patients); group 3--incomplete and inadequate revascularization (residual stenosis > or = 70% in a vessel > or = 2 mm in diameter supplying normal or hypokinetic segments, 45 patients). There were no late deaths; one myocardial infarction occurred in group 1 patients, three in group 2, and two in group 3 patients (p = NS). Recurrence of angina was lower in group 1 (13 of 51 or 26%) and group 2 (16 of 56 or 28%) compared with group 3 (23 of 45 or 51%, p < 0.01). A positive stress test for ischemia was present in 20 patients (39%) of group 1, in 30 (54%) of group 2, and in 26 patients (58%) of group 3.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictive factors of restenosis after multivessel percutaneous transluminal coronary angioplasty

To evaluate the rate and predictive factors of restenosis after multivessel percutaneous transluminal coronary angioplasty (PTCA), 122 consecutive patients with multivessel PTCA performed in the same setting were included in a prospective study. Systematic angiographic control at 6 months was performed in 112 patients (92%). Restenosis (increase > 20% and stenosis > 50%) was found in 62 patients (55%) and 82 of 254 segments (32%) were dilated. Statistical analysis identified the number of successfully dilated segments as the only predictor of restenosis by patient (2.4 +/- 0.7 vs 2.0 +/- 0.7; p < 0.03), and the greater degree of residual stenosis as the only predictor of restenosis by lesion (30 +/- 14% vs 23 +/- 12%; p < 0.005). Twenty-two of 62 restenosed patients (35%) were asymptomatic (group 1). Baseline clinical and angiographic characteristics of these patients were similar to those with symptomatic restenosis (n = 40; group 2) and without restenosis (n = 50; group 3). Repeat revascularization for restenosis was used only in symptomatic patients (re-PTCA in 36; bypass surgery in 4). After a mean follow-up of 75 +/- 24 months, clinical status, and rates of cardiac death and myocardial infarction were similar in the 3 groups. Medical care was similar in groups 1 and 3, and higher in group 2. However, the rate of repeat revascularization for progression of disease was similar in the 3 groups (29%). In conclusion, restenosis is a frequent event after multivessel PTCA and is strongly related to the number of successfully dilated segments.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical applications of coronary sinus retroperfusion during high risk percutaneous transluminal coronary angioplasty

OBJECTIVES

This study was designed to determine the efficacy of synchronized coronary sinus retroperfusion of arterial blood in reducing myocardial ischemia associated with the performance of high risk coronary angioplasty.

BACKGROUND

Previous animal and clinical work has demonstrated the efficacy of this technique in supporting ischemic myocardium.

METHODS

Twenty-one patients were randomized to alternately receive coronary sinus retroperfusion support during either the second or the third coronary angioplasty balloon inflation, after an initial unsupported brief control inflation. Myocardial ischemia was assessed by the extent of echocardiographic left ventricular wall motion abnormality, quantified ST segment deviation and hemodynamic and anginal variables during balloon inflations performed with and without coronary sinus retroperfusion support. Regional wall motion score was defined as hyperkinesia (-1), normokinesia (0), hypokinesia (+1), akinesia (+2) and dyskinesia (+3).

RESULTS

A reduction in the echocardiographic left anterior descending regional wall motion score in retroperfusion-supported (1.7 +/- 2.1) versus unsupported (2.7 +/- 1.6) inflations (p < 0.05) was noted. Twelve-lead electrocardiographic monitoring revealed no additional ST segment deviation during supported (173 +/- 95 s) compared with unsupported (129 +/- 87 s) angioplasty inflations despite a significantly longer duration of supported inflations (p < 0.004). Mean and peak systolic coronary sinus pressures differed during supported inflations (21 +/- 6 and 44 +/- 13 mm Hg) versus unsupported inflations (10 +/- 4 and 16 +/- 5 mm Hg) (p < 0.001). There was no difference in hemodynamic or anginal variables.

CONCLUSIONS

A reduction in ischemia as defined by wall motion abnormality during retroperfusion-supported compared with unsupported angioplasty balloon inflations was documented. No additional ST segment deviation occurred during retroperfusion-supported compared with unsupported balloon inflations despite a significantly longer duration of supported inflations. No difference in hemodynamic or anginal variables was noted.

Five- to ten-year outcome after multivessel percutaneous transluminal coronary angioplasty

The early and late outcome of patients who underwent multivessel percutaneous transluminal coronary angioplasty (PTCA) in a 1-stage procedure are described, and the predictors for clinical event and new revascularization procedure are identified. Of 1,937 patients treated by PTCA between 1981 and 1986, 203 (10.4%) had multivessel PTCA in a 1-step procedure. A follow-up extending to 71 +/- 23 months was obtained in 195 patients (96%). Primary success was achieved in 91% of 494 attempted sites, and complete revascularization in 65% of 203 patients. There were no in-hospital deaths. Acute complications occurred in 13 patients (6.4%), including non-Q-wave (n = 8) and Q-wave (n = 5) infarction, and urgent coronary artery bypass surgery (n = 3). Before PTCA, 126 patients (62%) were in class III or IV of the Canadian Cardiovascular Society classification; at follow-up, 84% were angina-free or in class I. Death occurred in 14 patients and nonfatal myocardial infarction in 18. Angiographic restenosis was diagnosed in 37.2% of dilated lesions in 96 patients (60% of 159 restudied). A repeat revascularization procedure for restenosis or progression of disease, or both, was needed in 92 symptomatic patients (47%). The survival rate at 7 years without the need for surgery or PTCA was 53%, and cardiac survival without myocardial infarction was 85.5%. The only independent predictor of cardiac death was ejection fraction (p < 0.001). The rate of restenosis per patient was primarily determined by the number of segments dilated, whereas progression of disease was related to the number of nonsignificant coronary artery stenoses (< 50%) at baseline (p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term efficacy of triple-vessel angioplasty in patients with severe three-vessel coronary artery disease

Between May 1982 and December 1988, a total of 103 patients underwent angioplasty of all three major coronary arteries at a single institution. Angiographic success was achieved in 334 of 352 vessels (95%) and in 441 of 460 lesions (96%). No patients required urgent bypass surgery, and none died during the procedure; six had non-Q wave infarctions. The mean length of follow-up time was 49 +/- 15 months (range 28 to 107 months). There have been 11 deaths, and one patient has undergone cardiac transplantation. Thirty-six patients had a clinical recurrence; 30 had repeat angioplasty and five had bypass surgery. Another nine patients eventually had bypass surgery after the clinical recurrence. At 48 months actuarial event-free rates are myocardial infarction, 98%; bypass surgery, 88%; and death, 89%. Of 86 current survivors, 58 are in functional class O to I, 21 are in class II, and seven are in class III.

PTCA in patients with stable angina pectoris and multivessel disease: is incomplete revascularization acceptable?

Of all coronary angioplasties performed nowadays, 40% of the patients have multivessel disease. Angioplasty in patients with multivessel disease can be performed with a high immediate clinical success rate and an acceptable major complication rate. However, complete anatomic revascularization with coronary angioplasty is achieved in only 32 to 59%. This raises concern about the immediate and long-term outcome of patients in whom incomplete revascularization is achieved. This report reviews the literature and provides evidence that incomplete revascularization with coronary angioplasty is a safe and effective treatment in selected patients with multivessel disease, provided that adequate (functional) revascularization can be achieved. Adequate revascularization includes dilation of all significant lesions supplying large areas of viable myocardium.

The degree of revascularization and outcome after multivessel coronary angioplasty

Incomplete revascularization is a common occurrence following angioplasty (PTCA) in patients with multivessel disease. To determine the short-term and long-term consequences of incomplete revascularization and the influence of the functional nature of the incomplete revascularization, 139 consecutive patients with multivessel disease were analyzed: 72 were completely revascularized and 67 had incomplete revascularization. The former patients had a lower incidence of prior myocardial infarction (MI) and prior bypass surgery (CABG). All patients had at least one lesion successfully dilated. In-hospital complications were insignificantly greater in incompletely revascularized patients compared with completely vascularized patients (mortality 3% versus 1%, MI 11% versus 4%, and emergency surgery 5% versus 0%). After 1 year of follow-up, incompletely revascularized patients had similar outcomes (mortality 6% versus 3%, MI 13% versus 7%, CABG 18% versus 15%, and repeat PTCA 19% versus 31%). The degree of incomplete revascularization was categorized as functionally adequate if all stenoses in bypassable vessels supporting viable myocardium were successfully dilated. Significantly fewer adverse events (death, MI, or CABG) occurred in the functionally adequate group than in the functionally inadequate group (27% versus 6%, p less than 0.04). This study demonstrates that incompletely revascularized patients have a favorable 1-year outcome and that patients with incomplete but functionally adequate revascularization have long-term results comparable with those of patients with complete revascularization. This study emphasizes the need to assess the functional significance of a stenosis when considering incomplete revascularization in a patient with multivessel disease.

Initial and long-term outcome of 354 patients after coronary balloon angioplasty of total coronary artery occlusions

BACKGROUND

Coronary balloon angioplasty of chronic total occlusions is associated with relatively low success rates and a high incidence of restenosis. Whether there is long-term benefit in performing angioplasty of these lesions is unknown. The purpose of the present report was to analyze the long-term outcome of a large series of patients undergoing this procedure.

METHODS AND RESULTS

A computerized database analysis of 354 consecutive patients (from 1979 to 1990) who underwent coronary angioplasty of a chronic total coronary occlusion was performed (mean age, 62.3 years). Initial technical success was achieved in 69%; in 66%, success was achieved without procedural death or need for coronary artery surgery. During hospitalization, six patients suffered myocardial infarction, nine required emergency bypass surgery, and nine patients died. During a mean follow-up period of 2.7 years, no difference was found in survival or freedom from myocardial infarction among 234 successfully dilated patients compared with 120 patients with a failed attempt. However, the use of coronary artery bypass surgery was significantly less after successful dilation (p less than 0.0001 versus failed attempt). No significant difference in the cumulative incidence of severe angina was observed between these two patient populations, with the majority remaining asymptomatic. Restenosis occurred in 59% of 69 patients who returned for follow-up angiography.

CONCLUSIONS

Successful recanalization is achieved in the majority of patients undergoing angioplasty of chronic total occlusions and reduces the need for coronary artery bypass surgery. However, no major impact on either survival or incidence of myocardial infarction was noted after successful recanalization when patients with surgery were included.

Determinants of 2-year outcome after coronary angioplasty in patients with multivessel disease on the basis of comprehensive preprocedural evaluation. Implications for patient selection. The Multivessel Angioplasty Prognosis Study Group

BACKGROUND

To assess the likelihood of intermediate-term event-free survival (freedom from death, coronary artery bypass surgery, and myocardial infarction) in patients with multivessel coronary disease undergoing coronary angioplasty, 350 consecutive patients from four clinical sites were carefully evaluated and followed for 22 +/- 10 months.

METHODS AND RESULTS

Eight clinical variables were evaluated at the clinical sites, and 23 angiographic variables describing the number, morphology, and topography of coronary stenoses were evaluated at a core angiographic laboratory. Most patients had Canadian Cardiovascular Society class III or IV angina (72%), two-vessel coronary disease (68%), and well-preserved left ventricular function (mean ejection fraction, 58 +/- 12%; range, 18-85%). Follow-up was complete in 99% of patients. At 2 years, event-free survival was 72%, overall survival was 96%, freedom from bypass surgery was 82%, and freedom from nonfatal myocardial infarction without surgery was 96%. Sequential Cox proportional hazards regression analyses allowing stepwise entry of variables prospectively coded as simple, as of intermediate complexity, or as complex found event-free survival to be independently predicted by low Canadian Cardiovascular Society angina class, no diabetes, no proximal left anterior descending stenoses, and the sum of stenosis simplified risk-territory scores of 15 or less. In the absence of class IV angina and these risk factors, 2-year event-free survival was 87% and overall survival was 100%. In the presence of two or more of these risk factors, event-free survival was less than 50%.

CONCLUSIONS

Recognition of risk factors for poor long-term outcome in this setting may improve clinical decision making and provide a framework on which to base meaningful subgroup analyses in randomized trials assessing the efficacy of coronary angioplasty.

Coronary angioplasty of diffuse coronary artery disease

From January 1983 through December 1987, 98 patients underwent angioplasty of at least one diffusely diseased coronary artery. Diffuse coronary disease was described as: group I, narrowing greater than or equal to 50% that involved the entire vessel (40 patients), group II, long lesions greater than or equal to 2 cm in length (39 patients), group III, three or more lesions in the same vessel (19 patients). There were 65 men and 33 women, with a mean age of 60 years; 64 patients (65%) had unstable angina, 23 patients (23%) were diabetic, 31 (32%) had prior myocardial infarctions, and 12 had prior bypass surgery. Multivessel disease was present in 89% of patients. Angioplasty of only the diffusely diseased vessel was performed in 41 patients, and additional vessels were dilated in 57 patients. Overall, of 396 lesions (four per patient) and 197 vessels (two per patient) attempted, success was achieved in 382 lesions (96%) and 187 vessels (95%); angiographic success was achieved in 112 of 120 diffusely diseased vessels (93%). Clinical success was achieved in 91 patients (93%). The overall complication rate (death, myocardial infarction, urgent bypass surgery) was 8% (8 of 98): six patients (6%) had myocardial infarction (one Q wave, five non-Q wave), one patient (1%) had urgent bypass surgery, and two patients (2%) died (one during bypass surgery). The majority of complications (7 of 8 or 87%), including the two deaths, occurred in group I patients, with a 17.5% rate, versus 2.5% in group II and 0% in group III, p less than 0.002.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous coronary angioplasty in 1,001 multivessel coronary disease patients: an analysis of different patient subsets

The prospectively collected data of 1,001 multivessel coronary disease patients who underwent percutaneous transluminal angioplasty (PTCA) was analyzed after categorization into single vessel angioplasty (SVA; group I) and multiple vessel angioplasty (MVA; group II) PTCA groups, which were each compartmentalized into "simple" (group A) and "complex" (group B) cohorts. Patients were assigned to the SVA or MVA group according to the physician's pre-PTCA assessment of how many lesions would be attempted (intention to treat) and not the number of lesions actually attempted. A "simple" patient was more likely than a "complex" patient to be clinically improved after PTCA whether or not the patient had a single dilatation (90% vs 78%; P less than 0.05) or multiple dilatations (97% vs 94%; P<0.05). Similarly, a lesion(s) was more likely to be successfully dilated in the "simple" than in the "complex" group (SVA: 90% vs 82%, P less than 0.05; MVA: 97% vs 91%, P<0.05). In addition, occluded vessels in the MVA group were more likely to be recanalized than in the SVA group (73% vs 44%, P less than 0.05). Group I-A patients had a significantly increased (10%) incidence of emergency bypass surgery. Follow-up, at 84 months, showed that "simple" cohorts had a better survival than the "complex" cohorts (MVA: 95% vs 71%, P less than 0.05; SVA: 90% vs 72%, P less than 0.05); and, nearly two thirds of all successful PTCA patients were angina free.(ABSTRACT TRUNCATED AT 250 WORDS)

Precertification for percutaneous transluminal coronary angioplasty in Medicare beneficiaries: a melting pot or a need for better national standards?

The Health Care Financing Administration has contracted with state peer review organizations (PROs) in its effort to assure the quality of services and eliminate unreasonable and inappropriate care provided Medicare beneficiaries. By law, each state PRO must select 10 procedures for precertification. Coronary angioplasty has been chosen by 45 PROs for precertification and criteria in each state were developed with the advice of local physicians. This report describes the findings of a survey of these precertification criteria in an effort to determine their variability and to compare the PRO criteria to published national criteria created by expert panels. Current precertification criteria of Medicare beneficiaries show significant variability in the priorities and the clinical practice of cardiologists in performing coronary angioplasty, despite established and published guidelines for its safe and efficacious use. It is likely that the establishment of locally based criteria for coronary angioplasty will be geographically uneven and probably have a less than expected impact on the care provided to Medicare beneficiaries.

Coronary angioplasty in patients with severe left ventricular dysfunction

The applications for coronary angioplasty have greatly expanded and the procedure is now increasingly used in complex and potentially high risk conditions. This report describes the short- and long-term effects of coronary angioplasty in 61 patients with severely depressed left ventricular function (ejection fraction less than or equal to 35%) with unstable or refractory anginal symptoms, or both, in whom revascularization was necessary despite increased risk. In a retrospective analysis of 1,260 patients undergoing angioplasty between January 1985 through December 1987, 61 had an ejection fraction less than or equal to 35%. The common clinical presentation was unstable angina (70%) with or without recent myocardial infarction. Mean left ventricular ejection fraction was 27 +/- 6%. Forty-five patients (74%) had multivessel disease. Clinical success after angioplasty was achieved in 55 patients (90%). Major complications (death, infarction and emergency bypass surgery) occurred in five patients (8.2%), with death in two (3.2%). During long-term (mean 21 +/- 11 months) follow-up study of the 55 patients with successful angioplasty, 13 (23%) died, including 3 of noncardiac causes, and 11 (20%) had clinically symptomatic recurrence. Continued clinical success was present in 39 patients (71%), of whom 28 (51%) were event-free patients and 11 (20%) had clinical recurrence; a successful second angioplasty procedure was performed in 9 because of restenosis. Thus, in patients with depressed left ventricular function, coronary angioplasty can be performed with a short-term success rate comparable to that of routine angioplasty or surgical procedures. However, acute complications are more frequent and the late mortality rate is higher than in patients with less depressed function.

Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease. Implications for patient selection. Multivessel Angioplasty Prognosis Study Group

To assess the likelihood of procedural success in patients with multivessel coronary disease undergoing percutaneous coronary angioplasty, 350 consecutive patients (1,100 stenoses) from four clinical sites were evaluated. Eighteen variables characterizing the severity and morphology of each stenosis and 18 patient-related variables were assessed at a core angiographic laboratory and at the clinical sites. Most patients had Canadian Cardiovascular Society class III or IV angina (72%) and two-vessel coronary disease (78%). Left ventricular function was generally well preserved (mean ejection fraction, 58 +/- 12%; range, 18-85%) and 1.9 +/- 1.0 stenoses per patient had attempted percutaneous coronary angioplasty. Procedural success (less than or equal to 50% final diameter stenosis in one or more stenoses and no major ischemic complications) was achieved in 290 patients (82.8%), and an additional nine patients (2.6%) had a reduction in diameter stenosis by 20% or more with a final diameter stenosis 51-60% and were without major complications. Major ischemic complications (death, myocardial infarction, or emergency bypass surgery) occurred in 30 patients (8.6%). In-hospital mortality was 1.1%. Stepwise regression analysis determined that a modified American College of Cardiology/American Heart Association Task Force (ACC/AHA) classification of the primary target stenosis (with type B prospectively divided into type B1 [one type B characteristic] and type B2 [greater than or equal to two type B characteristics]) and the presence of diabetes mellitus were the only variables independently predictive of procedural outcome (target stenosis modified ACC/AHA score; p less than 0.001 for both success and complications; diabetes mellitus: p = 0.003 for success and p = 0.016 for complications). Analysis of success and complications on a per stenosis dilated basis showed, for type A stenoses, a 92% success and a 2% complication rate; for type B1 stenoses, an 84% success and a 4% complication rate; for type B2 stenoses, a 76% success and a 10% complication rate; and for type C stenoses, a 61% success and a 21% complication rate. The subdivision into types B1 and B2 provided significantly more information in this clinically important intermediate risk group than did the standard ACC/AHA scheme. The stenosis characteristics of chronic total occlusion, high grade (80-99% diameter) stenosis, stenosis bend of more than 60 degrees, and excessive tortuosity were particularly predictive of adverse procedural outcome. This improved scheme may improve clinical decision making and provide a framework on which to base meaningful subgroup analysis in randomized trials assessing the efficacy of percutaneous coronary angioplasty.

Percutaneous transluminal angioplasty in patients with multivessel coronary disease: how important is complete revascularization for cardiac event-free survival?

The relative influences of revascularization status and baseline characteristics on long-term outcome were examined in 867 patients with multivessel coronary disease who had undergone successful coronary angioplasty. These patients represented 83% of a total of 1,039 patients in whom angioplasty had been attempted with an in-hospital mortality and infarction rate of 2.5% and 4.8%, respectively. Emergency coronary bypass surgery was needed in 4.9%. Of the 867 patients, 41% (group 1) were considered to have complete revascularization and 59% (group 2) to have incomplete revascularization. Univariate analysis revealed major differences between these two groups with patients in group 2 characterized by advanced age, more severe angina, a greater likelihood of previous coronary surgery and infarction, more extensive disease and poorer left ventricular function. Over a mean follow-up period of 26 months, the probability of event-free survival was significantly lower for group 2 only with respect to the need for coronary artery surgery (p = 0.004) and occurrence of severe angina (p = 0.04). The difference in mortality was of borderline significance (p = 0.051) and there were no significant differences between groups 1 and 2 in either the incidence of myocardial infarction or the need for repeat angioplasty. Multivariate analysis identified independent baseline predictors of late cardiac events that were then used to adjust the probabilities of event-free survival. This adjustment effectively removed any significant influence of completeness of revascularization on event-free survival for any of the above end points including the combination of death, myocardial infarction and need for coronary artery surgery. Therefore, late outcome in these patients is not significantly influenced by revascularization status but depends more on baseline patient characteristics.

Multivessel coronary angioplasty early after acute myocardial infarction

Coronary angioplasty has been applied in patients with recent myocardial infarction, but results of angioplasty of multiple vessels early after myocardial infarction in patients with severe multivessel disease have not been reported. Coronary angioplasty of multiple vessels was performed in 105 patients 0 to 15 days (mean 5 +/- 4) after recent myocardial infarction. There were 77 men (73%) and 28 women (27%), with a mean age of 57 years. All patients had severe multivessel disease, 68% with two vessel and 32% with three vessel disease. Twenty-eight patients (27%) had successful thrombolysis before angioplasty and 70 (67%) had postinfarction angina. Mean left ventricular ejection fraction was 58 +/- 10% and was less than 45% in 13 patients (12%). Angioplasty was attempted in 319 lesions (mean 3 lesions per patient, range 2 to 9) and 252 vessels (mean 2.4 vessels per patient, range 2 to 4), with success in 302 lesions (95%) and 237 vessels (94%); angioplasty was done in two stages in 59 patients (56%). Clinical success was achieved in 102 patients (97%). Complications included myocardial infarction in six patients (5.7%) (one Q wave, five non-Q wave), urgent bypass surgery in two (1.9%) and death in one (0.9%); overall, seven patients (7%) had a major complication. All patients had a follow-up duration greater than 1 year (mean 31 months, range 12 to 73). Clinical recurrence developed in 24 patients (23%), of whom 21 had repeat angioplasty, 1 had bypass surgery and 2 were managed medically. Ten patients (9.8%) had a late infarction and 5 (4.9%) died of cardiac death during the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful multiple segment coronary angioplasty: effect of completeness of revascularization in single-vessel multilesions and multivessels

A long-term follow-up study was performed to evaluate the long-term value of performing multiple dilatations according to their procedural (single-vessel multilesion or mutltivessel dilatations) and anatomic types (single-vessel disease with multiple dilatations or multivessel disease dilatations with complete and incomplete revascularization). From 1980 until 1988, 248 patients met the following criteria: (1) at least two lesions dilated (range: 2 to 4) and (2) all attempted lesions successfully dilated. The mean length of follow-up was 33 months. The end points analyzed were death, myocardial infarction, redilatation, and bypass surgery. No differences were found for these events between the single-vessel multilesion group (144 patients) and the multivessel group (104 patients). The 4.5-year probability of event-free survival was 68% and 70%, respectively, for the multilesion group and the multivessel group. In the event-free patients, 57% versus 59% were asymptomatic and 45% versus 46% were not taking antianginal drugs. In the anatomic subgroups, there were less event-free patients in the cohort of incompletely revascularized multivessel disease patients (55% of 55 patients) when compared with the cohort of those who were completely revascularized (84% of 79 patients) or when compared with the single-vessel disease multiple dilatation patients (74% of 107 patients). The 4.5-year event-free survival probability for each group was 44%, 78%, and 74%, respectively. This difference was caused by more infarctions (9% versus 2% versus 4%, respectively) and bypass operations in the multivessel disease, incomplete revascularization group (20% versus 5% versus 10%, respectively). In event-free patients, improvement of angina was similar and was documented in over 85% of patients in each group. Furthermore, the number of asymptomatic patients at follow-up was similar in all groups except that within the incomplete revascularization group, less patients were free of antianginal drugs (21% versus 51% versus 48%). Finally, 48% of the entire cohort performed an exercise test 4.6 months (mean) after dilatation and no difference was found in any of the variables in any group. About 10% of the patients experienced angina and approximately 30% had a positive exercise test for ischemia by ST segment criteria. The functional performance in every group was over 90% of the predicted work load. These results suggest that completeness of revascularization in multivessel disease patients is an important prognostic variable. However, the symptomatic improvement after dilatation is very rewarding in all subsets of patients and argues in favor of the continued use of multiple dilatations as a treatment strategy.

Effect of pretreatment with aspirin versus aspirin plus dipyridamole on frequency and type of acute complications of percutaneous transluminal coronary angioplasty

It is unknown whether the addition of dipyridamole to aspirin as pretreatment for patients undergoing percutaneous transluminal coronary angioplasty (PTCA) decreases acute complications. In this study 232 patients were prospectively randomized to receive either aspirin 325 mg orally 3 times daily (group 1, n = 115) or aspirin 325 mg orally 3 times daily plus dipyridamole 75 mg orally 3 times daily (group 2, n = 117) before elective PTCA. All clinical, angiographic and PTCA-related variables were similar between groups. Angiographic success rate was 93% in both groups. Clinical success was achieved in 107 patients (92%) in group 1 and in 101 patients (88%) in group 2 (difference not significant). Q-wave myocardial infarction occurred in 2 patients (1.7%) in group 1 and 5 patients (4.3%) in group 2 (difference not significant). Emergency coronary artery bypass grafting was required in 3 patients (2.6%) in group 1 and 7 patients (6.1%) in group 2 (difference not significant). There was 1 in-hospital death (in group 2). In this study, the addition of dipyridamole to aspirin as pretreatment of patients undergoing PTCA did not significantly reduce acute complications compared to aspirin alone.

Recurrent ischemia more than 1 year after successful percutaneous transluminal coronary angioplasty. An analysis of the extent and anatomic pattern of coronary disease

Of 1,181 consecutive patients who underwent successful percutaneous transluminal coronary angioplasty (PTCA) as an initial revascularization procedure and who had at least 1 year of asymptomatic follow-up, 66 (6%) underwent repeat angiography because of recurrent symptoms or evidence of exercise-induced ischemia. Patients who had revascularization procedures within 1 year of PTCA were not included in the analysis. Mean time to recurrent ischemia was 30.8 +/- 17.4 months (range 12-89 months). At follow-up, 47 patients had angina, 13 had atypical chest pain, two had acute myocardial infarction, and four had positive exercise tests without symptoms. No patient showed spontaneous regression in the extent of coronary artery disease (CAD). As compared with the extent of CAD immediately after PTCA, the extent of CAD at follow-up did not change in 26 patients (39%); it increased by one vessel in 30 (45%), by two vessels in seven (11%), and by three vessels in three (5%). The pattern of CAD seen at follow-up compared with that seen after PTCA was as follows: 18 patients (27%), no change; seven (11%), restenosis only; 30 (45%), progression of CAD at other sites only; and 11 (17%), a combination of restenosis and progression of CAD at other sites. The time to recurrence of ischemia was significantly different between those with restenosis only versus those with progression only (20.1 +/- 9.2 vs. 38.3 +/- 18.5 months) (p less than 0.009). Progression of CAD was equally distributed between dilated and nondilated vessels; however, when progression occurred in the PTCA vessel, it was significantly more likely to be distal to the PTCA site (p less than 0.008).

Evolving applications of coronary angioplasty: technical and angiographic considerations

Coronary angioplasty (PTCA) is now applicable to selected patients with multiple vessel disease, total occlusions, tandem lesions and complex branch disease. Operator experience and skill contribute to a high success rate in complex anatomy, but equally important is appropriate case selection based on angiographic review of lesion morphology, branches, extent of coronary artery disease, and left ventricular function. Likewise, during and after the procedure similar angiographic assessment is important to determine resultant lesion morphology, branch anatomy, distal runoff, and adequacy of lesion dilatation. Thus, the outcome of angioplasty is dependent on the operator's ability to opacify the coronary arteries with minimal or no vessel/lesion overlap or foreshortening. Although coronary angiography has become more routine for many angiographers with the advent of angioplasty, the importance of high-quality angiography continues to be a major component for successful angioplasty.