Angioplasty in the stent era: results of a consecutive series of patients undergoing coronary angioplasty without surgical backup

Staged revascularization in critically ill patients with coronary artery disease

BACKGROUND

Critically ill patients undergoing bypass surgery experience a higher mortality and morbidity.

HYPOTHESIS

The study was undertaken to evaluate the efficacy and value of percutaneous transluminal coronary angioplasty (PTCA) as a bridge to coronary artery bypass graft surgery (CABG) in high-risk patients with refractory unstable angina or cardiogenic shock.

METHODS

We present 11 seriously unstable patients with severe multivessel coronary artery disease undergoing culprit vessel PTCA. Angioplasty was performed not as a definitive procedure but rather as a bridge to surgical revascularization. All the patients had sustained at least one myocardial infarction prior to catheterization, all had refractory unstable angina, eight patients had only a single patent coronary artery, and five patients were in cardiogenic shock.

RESULTS

Following PTCA, all patients enjoyed a stable in-hospital period. One patient died 12 weeks after successful PTCA while awaiting second CABG. Seven patients subsequently underwent CABG and are doing well. The remaining three patients were also advised to undergo CABG, but elected to continue medical management.

CONCLUSIONS

Coronary angioplasty of the culprit vessel may play a role as a bridge to surgery in critically ill patients.

Three years of experience with a mobile angiograph in a center without on-site surgical back-up

BACKGROUND

The safety of percutaneous coronary interventions (PCI) performed in centers without surgical back-up is controversial, but data from several western countries indicates that this approach can be extended to a larger number of hospitals. We assessed the safety and efficacy of performing angiography and PCI with a mobile C-arm angiograph in a center without on-site surgical back-up, and compared our data with that reported in the literature.

METHODS

We retrospectively analyzed 1485 coronary angiograms and 172 PCI procedures performed in our center from January 2001 to May 2003 using a mobile angiograph. Half of the patients that have undergone PCI had refractory unstable angina and one-third had acute myocardial infarction (AMI). The safety of PCI was assessed by the analysis of in-hospital complications (death, urgent need for repeated revascularization, AMI with or without ST elevation and stroke). The PCI procedures were considered effective when the post-PCI residual stenosis did not exceed 50% with distal Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow.

RESULTS

In patients who underwent diagnostic coronary angiography there were no deaths, anaphylatic shock, acute renal failure or major ischemic complications. In patients who underwent PCI, the mortality rate was 1.1% (2 deaths), two patients (1.1%) developed acute MI with ST segment elevation, one patient (0.5%) underwent repeated PCI and three patients (1.7%) were referred for urgent by-pass surgery.

CONCLUSIONS

Diagnostic and PCI procedures can be safely performed using a mobile angiograph. The efficacy and safety requirements of PCI, performed in a center without an on-site surgical back-up facility using a mobile angiograph were similar to other data reported in the literature.

Coronary artery disease among diabetic and non-diabetic patients with end stage renal disease

Cardiovascular disease is the major cause of death among patients with end stage renal disease and accounts for about half the deaths among the dialysis population. Several researchers have reported a high prevalence of coronary artery disease among diabetic patients with renal failure and coronary arteriography is often considered an integral part of the pre-transplant evaluation of diabetic patients with end stage renal disease. However, very few reports have addressed the question of coronary disease in non-diabetic patients, and the pattern and prevalence of coronary artery disease in non-diabetic patients with end stage renal disease are not well defined. We evaluated the clinical and coronary angiographic findings in 158 consecutive patients (84 diabetic and 74 non-diabetic) with end stage renal disease. The coronary arteries were divided into 16 segments and each segment was analyzed for the presence of coronary disease, which was defined as the presence of > or = 50% luminal diameter stenosis. Diabetic patients had more adverse risk factors for coronary artery disease, yet there was no significant difference in the prevalence of coronary artery disease between the diabetic and non-diabetic patients (67% vs. 55%, p = 0.15), or in the number of affected coronary artery segments (2.0 vs. 1.4, p = 0.05). Triple vessel coronary artery disease was however, significantly more common among the diabetic subjects (27% vs. 12%, p = 0.005). Non-diabetic patients with end stage renal disease also have a high prevalence of coronary artery disease and may merit as careful investigation of their coronary status as their diabetic counterparts.

Ostial left anterior descending coronary artery stent positioning: partial preinflation prevents stent oscillation and facilitates accurate deployment

Ostial intracoronary stent deployment is complicated by the influence of cardiac motion, which causes the stent to oscillate back and forth during the cardiac cycle. Accurate deployment can be facilitated by initial low pressure inflation of the balloon on which the stent is mounted. This stabilizes the stent within the stenosis, while still allowing adjustment of the exact stent location prior to deployment.