1
|
Abstract
Percutaneous coronary interventions have been performed for 20 years. Despite the success and progress of these interventions, abrupt vessel closure has been a dramatic adverse event of coronary interventions. Closure has frequently led to the major complications of death, myocardial infarction, and emergency coronary artery bypass. Because of the fear of this adverse event and its subsequent complications, the applicability of coronary interventions is sometimes limited. The pathologic characteristics of abrupt vessel closure have been recognized as predominantly caused by dissection, with vessel recoil and thrombus formation playing important secondary roles. The recognition of the lesions at risk for abrupt vessel closure has led to a strategy of lesion-specific device therapy to reduce complications. Similarly the role of antiplatelet and antithrombotic therapies have reduced complications. The earliest methods of dealing with abrupt closure was emergency coronary artery bypass surgery with significant rates of morbidity and mortality. With the advent of second-generation devices and techniques, particularly stents, the management of abrupt vessel closure has been simplified and alternatives to emergency coronary bypass are more available. This article will review the history and current status of the prevention and management of abrupt vessel closure and demonstrate that anticipation and management of this complication have been facilitated with reduction of subsequent complications and increased applicability of coronary interventions.
Collapse
Affiliation(s)
- B A Bergelson
- Department of Medicine, Veterans Administrative Lakeside Medical Center, Northwestern University Medical School, IL, USA
| | | | | |
Collapse
|
2
|
Dean LS, George CJ, Roubin GS, Kennard ED, Holmes DR, King SB, Vlietstra RE, Moses JW, Kereiakes D, Carrozza JP, Ellis SG, Margolis JR, Detre KM. Bailout and corrective use of Gianturco-Roubin flex stents after percutaneous transluminal coronary angioplasty: operator reports and angiographic core laboratory verification from the National Heart, Lung, and Blood Institute/New Approaches to Coronary Intervention Registry. J Am Coll Cardiol 1997; 29:934-40. [PMID: 9120178 DOI: 10.1016/s0735-1097(97)00013-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES We sought to determine the in-hospital clinical outcome and angiographic results of patients prospectively entered into the National Heart, Lung, and Blood Institute/New Approaches to Coronary Intervention (NHLBI/NACI) Registry who received Gianturco-Roubin stents as an unplanned new device. BACKGROUND Between August 1990 and March 1994, nine centers implanted Gianturco-Roubin flex stents as an unplanned new device in the initial treatment of 350 patients (389 lesions) who were prospectively enrolled in the NHLBI/NACI Registry. METHODS Patients undergoing implantation of the Gianturco-Roubin flex stent were prospectively entered into the Gianturco-Roubin stent portion of the NHLBI/NACI Registry. Only subjects receiving the Gianturco-Roubin stent as a new device in an unplanned fashion are included. RESULTS The mean age of the patient group was 61.8 years, and the majority of the patients were men. A history of percutaneous transluminal coronary angioplasty (PTCA) was present in 35.4% of the group, and 16.9% had previous coronary artery bypass graft surgery. Unstable angina was present in 67.7%. Double- or triple-vessel coronary artery disease was present in 55.4%, and the average ejection fraction was 58%. The presence of thrombus was noted in 7.3%, and 7.2% had moderate to severe tortuosity of the lesion. The angiographic success rate was 92%. Individual clinical sites reported that 66.3% of the stents were placed after suboptimal PTCA, 20.3% for abrupt closure and 13.4% for some other technical PTCA failure. Major in-hospital events occurred in 9.7% of patients, including death in 1.7%, Q wave myocardial infarction in 3.1% and emergency bypass surgery in 6%. Abrupt closure of a stented segment occurred in 3.1% of patients at a mean of 3.9 days. Cerebrovascular accident occurred in 0.3%, and transfusion was required in 10.6%. Vascular events with surgical repair occurred in 8.6% of patients. CONCLUSIONS Despite these complications, the use of this device for the treatment of a failed or suboptimal PTCA result remains promising given the adverse outcome of abrupt closure with conventional (nonstent) treatment.
Collapse
Affiliation(s)
- L S Dean
- Department of Medicine, University of Alabama at Birmingham, 35294-0012, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Waller BF, Fry ET, Peters TF, Hermiller JB, Orr CM, VanTassel J, Pinkerton CA. Abrupt (< 1 day), acute (< 1 week), and early (< 1 month) vessel closure at the angioplasty site. Morphologic observations and causes of closure in 130 necropsy patients undergoing coronary angioplasty. Clin Cardiol 1996; 19:857-68. [PMID: 8914779 DOI: 10.1002/clc.4960191105] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
While abundant clinical and angiographic data are available regarding features of acute or abrupt closure at the site of balloon angioplasty, little morphologic information is available. This study discusses morphologic-histologic causes for acute closure after angioplasty in 130 necropsy patients. Intimal-medial flaps, elastic recoil, and primary thrombosis were the three leading morphologic causes for closure. Data were subdivided into time categories: abrupt (< 1 day), acute (< 1 week), and early (< 1 month). Intimal-medial flaps remained the most common cause for angioplasty closure despite time from angioplasty to documented occlusion. Morphologic recognition of types and frequencies of angioplasty closure are discussed, and specific mechanical, pharmacologic, or combined treatments are reviewed.
Collapse
Affiliation(s)
- B F Waller
- Cardiovascular Pathology Registry, St. Vincent Hospital, USA
| | | | | | | | | | | | | |
Collapse
|
4
|
BERGER PETERB. The Cook Inc. Gianturco-Roubin Flex-Stent. J Interv Cardiol 1996. [DOI: 10.1111/j.1540-8183.1996.tb00609.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
5
|
de Muinck ED, den Heijer P, van Dijk RB, Crijns HJ, Hillige HL, Lie KI. Distal coronary hemoperfusion during percutaneous transluminal coronary angioplasty. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 37:233-40; discussion 241-2. [PMID: 8974796 DOI: 10.1002/(sici)1097-0304(199603)37:3<233::aid-ccd1>3.0.co;2-d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Distal coronary hemoperfusion during percutaneous transluminal coronary angioplasty (PTCA)-with an autoperfusion balloon or active system-facilitates prolonged balloon inflation. Prolonged inflations may tack up intimal dissections and improve the primary angioplasty result in complex lesions. Additionally, distal perfusion may reduce the likelihood of cardiogenic shock during high-risk PTCA. Autoperfusion balloons are most frequently used to treat acute or threatened closure. There currently is no prospective clinical study showing that stent implantation for this complication is more successful and more cost-effective. The blood flow rates through autoperfusion balloons may not abolish myocardial ischemia, and higher flow rates can often be achieved with pumps. Therefore, during high-risk PTCA, pumps may be preferred to prevent hemodynamic collapse. Clinical application of perfusion pumps is hampered by the risk for mechanical hemolysis during prolonged perfusion and the high velocity of the bloodstream that exits the PTCA catheter, causing distal vessel wall trauma.
Collapse
Affiliation(s)
- E D de Muinck
- Catheterization Laboratory, University Hospital, Groningen, The Netherlands
| | | | | | | | | | | |
Collapse
|
6
|
Antoniucci D, Santoro GM, Bolognese L, Leoncini M, Buonamici P, Fazzini PF. Bailout Palmaz-Schatz coronary stenting in 39 patients with occlusive dissection complicating conventional angioplasty. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1995; 35:204-9. [PMID: 7553823 DOI: 10.1002/ccd.1810350308] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The purpose of this study was to evaluate feasibility, safety, and efficacy of bailout Palmaz-Schatz stenting in a series of 39 patients with coronary dissection associated with acute or unequivocal threatened closure complicating conventional angioplasty. No anatomical characteristics other than reference vessel diameter < 3 mm were considered as contraindications for bailout coronary stenting. Stringent criteria were adopted in defining optimal results (< 10% residual stenosis, no angiographic evidence of residual dissection), suboptimal results (> 10% residual stenosis or angiographic evidence of residual dissection), deployment failure (failure to deploy the stent because of poor trackability or persistent occlusion despite stent deployment). A total of 49 stents and 7 half-stents were implanted in 36 patients (range 1-5; mean 1.45 +/- 0.84). Successful stenting without in-hospital death, urgent or semielective coronary surgery, stent thrombosis, or Q-wave myocardial infarction was achieved in 33/39 patients (85%). A suboptimal result was associated with an increased risk of in-hospital recurrence of ischemia and other related major adverse events (2/5 patients with suboptimal results vs. 1/31 patients with complete deployment success; P < 0.05). Multiple stents implantation did not carry a significant risk of major cardiac adverse events. The results of this study suggest that bailout Palmaz-Schatz stenting may be considered a stand-alone treatment of coronary dissection if an optimal acute angiographic result is achieved.
Collapse
Affiliation(s)
- D Antoniucci
- Division of Cardiology, Careggi Hospital, Florence, Italy
| | | | | | | | | | | |
Collapse
|
7
|
Alfonso F, Hernandez R, Goicolea J, Segovia J, Perez-Vizcayno MJ, Bañuelos C, Silva JC, Zarco P, Macaya C. Coronary stenting for acute coronary dissection after coronary angioplasty: implications of residual dissection. J Am Coll Cardiol 1994; 24:989-95. [PMID: 7930235 DOI: 10.1016/0735-1097(94)90860-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The aim of this study was to assess the implications of residual coronary dissections after stenting. BACKGROUND Coronary stenting is currently used in selected patients with coronary dissection after angioplasty. However, in some patients the total length of the dissection may not be completely covered with the device. METHODS Forty-two consecutive patients (mean [+/- SD] age 58 +/- 11 years; 39 men, 3 women) undergoing stenting for a major coronary dissection after angioplasty were studied. RESULTS Thirty (67%) coronary dissections were small (< or = 15 mm), and 29 (64%) were occlusive (Thrombolysis in Myocardial Infarction [TIMI] flow grade < or = 2). In 3 patients, coronary stenting was unable to open large occlusive dissections, but a good angiographic result was obtained in 39 patients (93%). After stenting, 22 of these patients (56%) had no visible residual dissections, and 13 (33%) had small and 4 (10%) had large residual dissections. These residual dissections were stable and did not compromise coronary flow. In a repeat angiogram (24 h later) the stent was patent in all 39 patients. However, two patients experienced a subacute stent occlusion. Of the remaining 37 patients, 36 (97%) had a late angiogram after stenting. Quantitative angiography revealed a reduction in minimal lumen diameter at the stent site (2.6 +/- 0.4 vs. 2 +/- 0.7 mm, p < 0.05) and a trend toward improvement in vessel diameter at the site of the previous residual dissection (1.7 +/- 0.6 vs. 1.9 +/- 0.5 mm, p < 0.1). The angiographic image of residual dissection disappeared in all patients. These factors provided a rather smooth angiographic appearance at follow-up. The four patients with large residual dissections after stenting did not have restenosis and were asymptomatic at last visit. CONCLUSIONS Coronary stenting is effective in the management of acute coronary dissections after angioplasty. In this setting, small residual dissections are frequently seen but have a good outcome and disappear at follow-up. Large residual dissections may have a good outcome if coronary flow is not impaired and no residual stenosis is visualized.
Collapse
Affiliation(s)
- F Alfonso
- Cardiopulmonary Department, Hospital Universitario San Carlos, Madrid, Spain
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Foley JB, Sridhar K, Dawdy J, Konstantinou C, Brown RI, Penn IM. Pros and cons of perfusion balloons in failed angioplasty. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 31:264-9. [PMID: 8055564 DOI: 10.1002/ccd.1810310404] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Prolonged inflation with perfusion balloons is commonly used in failed angioplasty. The objective of this study was to determine the angiographic outcome of 59 consecutive patients treated with prolonged inflation with perfusion balloons as the primary treatment for failed angioplasty. Angiographic success (< 50% stenosis and normal flow) was achieved in 41%. Angiographic success was greater in the left anterior descending coronary artery (67% versus 33% for non-left anterior descending involvement, P = .044) and was less in complex dissections (25% versus 75% for no dissection or simple dissections, P = .025). Angiographic deterioration occurred in 37.5% of the successful group and 77% of the unsuccessful group (P = .002) and was more frequent in the right coronary artery (88% versus 50% for non-right coronary involvement, P = .007) and complex dissections (92% versus 38% for no dissection or simple dissections, P = .0001). Thus, in a group of patients with unsuccessful outcome following conventional balloon angioplasty, success with the perfusion balloon was modest. Furthermore, angiographic deterioration was frequently observed following unsuccessful prolonged inflation.
Collapse
Affiliation(s)
- J B Foley
- Victoria Hospital, University of Western Ontario, London, Ontario, Canada
| | | | | | | | | | | |
Collapse
|
9
|
Carey L, Cameron J, Aroney C, Bett N, Holt G, Mahononda N, McEniery P. Experience with the Gianturco-Roubin stent for abrupt vessel closure complicating percutaneous transluminal coronary angioplasty. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1994; 24:31-5. [PMID: 8002855 DOI: 10.1111/j.1445-5994.1994.tb04422.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Emergency coronary artery bypass grafting (CABG) has previously been the only option in the treatment of refractory abrupt vessel closure complicating percutaneous transluminal coronary angioplasty (PTCA), and has been associated with high rates of morbidity and mortality. Intracoronary stenting now provides an alternative to emergency CABG. AIM To assess our initial experience with emergency coronary artery stenting as a new technique. METHODS Retrospective case study review with clinical and angiographic follow-up. RESULTS The Gianturco-Roubin (GR) stent was deployed in 13 patients in whom PTCA was complicated by abrupt vessel closure refractory to standard balloon techniques. Indications for PTCA were unstable angina (six), stable angina (six) and acute myocardial infarction (MI) (one). The arteries stented included left anterior descending (LAD) artery lesions (eight) and right coronary artery lesions (five). Two patients required urgent CABG, one due to failed stent deployment and one for inadequate control of vessel dissection. In seven of the stented patients the creatine kinase rose to greater than twice the upper limit or normal. Three patients had subacute thrombotic occlusion at seven to 19 days post stent deployment, managed with intravenous thrombolysis or repeat PTCA. At seven months follow-up, 11 patients were free of angina, two patients had Canadian Heart Association class II angina and there were no deaths. Eleven patients had repeat angiography at mean six months post stent. Five patients had evidence of restenosis managed with repeat PTCA in four and CABG in one. CONCLUSIONS The GR stent is an effective alternative to urgent CABG in the treatment of refractory abrupt vessel closure complicating PTCA.
Collapse
Affiliation(s)
- L Carey
- Department of Cardiology, Prince Charles Hospital, Brisbane, Qld
| | | | | | | | | | | | | |
Collapse
|
10
|
Timmis GC. Interventional Cardiology: A Comprehensive Bibliography. J Interv Cardiol 1993. [DOI: 10.1111/j.1540-8183.1993.tb00864.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
11
|
Maiello L, Colombo A, Gianrossi R, McCanny R, Finci L. Coronary stenting for treatment of acute or threatened closure following dissection after coronary balloon angioplasty. Am Heart J 1993; 125:1570-5. [PMID: 8498295 DOI: 10.1016/0002-8703(93)90742-r] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We studied 32 patients (age 58 +/- 9 years) who had been treated with a Palmaz-Schatz stent after significant dissection complicating percutaneous transluminal coronary angioplasty (PTCA). We attempted to cover the entire site of dissection with prosthesis. The presence of dissection after PTCA was associated with Thrombolysis in Myocardial Infarction grade 0 to 1 flow in 19 patients and grade 2 flow in 13. The stented arteries were: left anterior descending artery in 19 patients, right coronary artery in seven, and left circumflex artery in five. A single stent was implanted in 11 and multiple stents in 21 patients. Angiographic success was achieved in 30 patients (94%). Two patients (6%) had urgent coronary artery bypass graft surgery, two (6%) had a myocardial infarction, and one (3%) patient died. Subacute occlusion occurred in one patient (3%). Angiographic restenosis was found in three of nine patients (33%) with a single stent and 11 of 17 (65%) with multiple stents. Clinical follow-up at 11 +/- 3 months showed the necessity of coronary artery bypass graft surgery in two patients and repeat PTCA in nine (31%). We conclude that coronary stenting is an effective treatment for significant coronary dissection after PTCA with an acceptable incidence of major cardiac events at follow-up.
Collapse
Affiliation(s)
- L Maiello
- Catheterization Laboratory, Centro Cuore Columbus, Milan, Italy
| | | | | | | | | |
Collapse
|
12
|
Thoolen MJ, Rasbach DE, Shaw JH, Raynolds S, Timmermans PB. Preservation of regional and global left ventricular function by intracoronary infusion with oxygenated fluorocarbon emulsion Therox in dogs. BIOMATERIALS, ARTIFICIAL CELLS, AND IMMOBILIZATION BIOTECHNOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR ARTIFICIAL CELLS AND IMMOBILIZATION BIOTECHNOLOGY 1993; 21:53-62. [PMID: 8461436 DOI: 10.3109/10731199309118296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We tested the oxygen transport and delivery capacity of the novel perfluorocarbon emulsion, Therox (F44E, 1,2-bis-perfluorobutyl-ethylene) by comparing left ventricular regional and global function in dogs during perfusion of the left anterior descending coronary artery (LAD) with oxygenated Krebs buffer and oxygenated Therox emulsion (20% w/v) at 20 ml/min for two separate 3 min periods. During LAD perfusion with oxygenated Krebs buffer, complete loss of systolic wall thickening in the LAD perfusion area was observed, dP/dt was significantly reduced and left ventricular end-diastolic pressure (LVEDP) was increased. In contrast, LAD perfusion with oxygenated Therox maintained regional wall thickening at 60-70% of control and completely preserved global function as measured by dP/dt and LVEDP. Thus, Therox is an effective oxygen carrier in this animal model.
Collapse
Affiliation(s)
- M J Thoolen
- Du Pont Merck Pharmaceutical Company, Wilmington, DE 19898
| | | | | | | | | |
Collapse
|
13
|
Colle JP, Delarche N. PTCA with side-by-side balloon using fixed guide wire systems: a potential alternative autoperfusion device--an in vitro study. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1992; 27:303-8. [PMID: 1458527 DOI: 10.1002/ccd.1810270412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The use of "hugging balloons" for the implementation of a coronary angioplasty is a well-known and much-written-about technique. It has not, on the other hand, ever been stressed that two inflated hugging balloons are not totally obstructive, leaving enough space, between the balloons and the arterial wall, for perfusion. The cross section of this free area can be as much as 12% of the total arterial cross section, when the side-by-side balloons are of a relatively similar size. Calculations show that similar total conduit cross sections are achieved when inflating either a 3.0 balloon or two 2.0 side-by-side balloons. An in vitro experiment compares how systems using 2.0 double balloons and a 3.0 autoperfusion balloon affect the distal flow of a 3 mm internal diameter conduit. A semi-rigid silastic tubing is perfused with a 5% glucose isotonic solution at various predetermined proximal pressure levels. Distal pressures and flows are measured at different stages: with no balloon, with deflated balloons, and with inflated balloons. Comparison shows that 1) the double balloon system offers little resistance to flow compared to the autoperfusion balloon; 2) this system's rate of perfusion run-off is hardly affected and is constantly better than with the autoperfusion balloon; 3) this difference is all the more marked, the lower the proximal perfusion. These results suggest that the use of a double balloon could, in some cases, provide an alternative solution to autoperfusion equipment. Further clinical studies are needed to test this hypothesis.
Collapse
Affiliation(s)
- J P Colle
- Laboratoire d'Hémodynamique, Clinique Saint-Martin, Pessac, France
| | | |
Collapse
|
14
|
de Muinck ED, van Dijk RB, den Heijer P, Meeder JG, Lie KI. Autoperfusion balloon catheter for complicated coronary angioplasty: a prospective study with retrospective controls. Int J Cardiol 1992; 37:317-27. [PMID: 1468815 DOI: 10.1016/0167-5273(92)90261-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Prolonged angioplasty balloon inflation with an autoperfusion balloon for failed conventional coronary angioplasty, was compared with emergency surgery for this condition. Restenosis was assessed 6 weeks after successful intervention with the autoperfusion balloon. Forty consecutive patients with persistent acute occlusion and/or severe intimal dissection during conventional angioplasty, were treated with the autoperfusion balloon. They were candidates for emergency surgery if it failed. Total inflation time was significantly longer (p < 0.001) with the autoperfusion balloon (27.5; 10-180 min) than with the standard balloon (10; 1-20 min) (median; range). The number of inflations was significantly lower (p < 0.001) with the autoperfusion balloon (2; 1-5 times) than with the standard balloon (5; 2-14 times) (median; range). Two patients died, one before surgery could be performed. The autoperfusion balloon was successful in 26 patients (65%). After 6 weeks, 16 (62%) were asymptomatic without anti-anginal medication, 24 underwent repeat angiography, 10 (42%) had restenosis, 7 (27%) underwent elective bypass surgery. Emergency surgery remained necessary in 13 patients (33%), 9 received arterial grafts. In 31 retrospective controls, who had undergone immediate surgery for the same indication, only venous grafts could be used. Thus, prolonged autoperfusion balloon inflation was successful in 65% of the cases of failed, conventional angioplasty. The angiographic restenosis rate after 6 weeks was 42%. If emergency surgery remained necessary, the autoperfusion balloon facilitated the use of arterial bypass grafts.
Collapse
Affiliation(s)
- E D de Muinck
- Department of Cardiology, University Hospital Groningen, Netherlands
| | | | | | | | | |
Collapse
|
15
|
Heuser RR, Mehta S, Strumpf RK. ACS RX flow support catheter as a temporary stent for dissection or occlusion during balloon angioplasty: initial experience. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1992; 27:66-74. [PMID: 1525814 DOI: 10.1002/ccd.1810270115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The ACS RX flow support catheter, which functions as a temporary stent, was placed successfully during four procedures in three patients who had suboptimal results following angioplasty. This investigational device allowed prolonged perfusion and supported the vessel wall when coronary blood flow was compromised, avoiding emergent coronary artery bypass graft surgery during two procedures. In the remaining procedures the device was used as a bridge to surgery. These early applications of the flow support catheter following failed balloon angioplasty suggest a rapid, effective alternative to the autoperfusion balloon when it fails or is contraindicated because of the lesion location.
Collapse
Affiliation(s)
- R R Heuser
- Department of Cardiology, Arizona Heart Institute & Foundation, Phoenix 85064
| | | | | |
Collapse
|
16
|
Van Lierde JM, Glazier JJ, Stammen FJ, Vrolix MC, Sionis D, De Geest H, Piessens JH. Use of an autoperfusion catheter in the treatment of acute refractory vessel closure after coronary balloon angioplasty: immediate and six month follow up results. BRITISH HEART JOURNAL 1992; 68:51-4. [PMID: 1515292 PMCID: PMC1024970 DOI: 10.1136/hrt.68.7.51] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the usefulness of the Stack autopersion dilatation catheter in patients with acute recurrent vessel closure during coronary angioplasty. DESIGN Prospective data collection. SETTING University hospital. PATIENTS In 37 of 1003 consecutive patients undergoing angioplasty between November 1989 and December 1990 acute vessel closure developed that could not be redilated by a conventional balloon catheter. 13 (35%) of these 37 patients were sent immediately for emergency bypass surgery. INTERVENTION In the remaining 24 patients an attempt was made to reopen the vessel with a Stack catheter. MAIN OUTCOME MEASURE Successful reopening of the vessel. All successfully treated patients were followed for at least six months to detect recurrent ischaemia. RESULTS In 16 patients (67%) the Stack procedure was successful. Of the eight patients in whom reopening of the occluded vessel was not achieved, seven were sent for bypass surgery and one was successfully treated by emergency stent implantation. The 16 patients successfully treated with the Stack autoperfusion system were followed up for a mean (SD) of 6.7 (2.6) (range 2 to 11) months. Ten patients remained symptom free but early clinical restenosis developed in four (25%). Overall, only three (19%) of 16 patients experienced recurrence of severe (class III-IV) symptoms and required further mechanical revascularisation. CONCLUSION These data support the use of the Stack autoperfusion catheter system in selected patients with acute vessel closure not responsive to attempted redilatation with conventional balloon catheters. The short-term outcome seen in this series of patients who were successfully treated with this coronary autoperfusion system is encouraging.
Collapse
Affiliation(s)
- J M Van Lierde
- Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
| | | | | | | | | | | | | |
Collapse
|
17
|
Roubin GS, Cannon AD, Agrawal SK, Macander PJ, Dean LS, Baxley WA, Breland J. Intracoronary stenting for acute and threatened closure complicating percutaneous transluminal coronary angioplasty. Circulation 1992; 85:916-27. [PMID: 1537128 DOI: 10.1161/01.cir.85.3.916] [Citation(s) in RCA: 448] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND. Acute closure remains a significant limitation of percutaneous transluminal coronary angioplasty (PTCA) and underlies the majority of ischemic complications. This study details the clinical and angiographic characteristics of a series of patients receiving an intracoronary stent device to manage acute and threatened closure and presents the early clinical results. METHODS AND RESULTS. From October 1989 through June 1991, 115 patients undergoing PTCA received intracoronary stents to treat acute or threatened closure in 119 vessels. Sixty-three percent had multivessel coronary disease, 33 (29%) had undergone prior coronary artery bypass grafting (CABG), and 52 (45%) had had previous PTCA. Using the American College of Cardiology/American Heart Association (ACC/AHA) classification, 15% of lesions were class A, 55% were class B, and 30% were class C. Eight patients were referred with severe coronary dissection and unstable angina after PTCA at other institutions. Acute closure was defined as occlusion of the vessel with TIMI (Thrombolysis in Myocardial Infarction) 0 or 1 flow immediately before stent placement. Threatened closure required two or more of the following criteria: 1) a residual stenosis greater than 50%, 2) TIMI grade 2 flow, 3) angiographic dissection comprising extraluminal dye extravasation and/or a length of greater than 15 mm, 4) evidence of clinical ischemia (either typical angina or ECG changes). Twelve vessels (10%) met the criteria for acute closure, and 87 vessels (73%) satisfied the criteria for threatened closure. Twenty vessels (17%) failed to meet two criteria. Stenting produced optimal angiographic results in 111 vessels (93%), with mean diameter stenosis (+/- 1 SD) reduced from 83 +/- 12% before to 18 +/- 29% after stenting. Overall, in-hospital mortality was 1.7% and CABG was required in 4.2%; Q wave myocardial infarction (MI) occurred in 7% and non-Q wave MI in 9%. Stent thrombosis occurred in nine patients (7.6%). For the 108 patients who presented to the catheterization laboratory without evolving MI, Q wave MI occurred in 4% and non-Q wave MI occurred in 7%. Angiographic follow-up has been performed in 81 eligible patients (76%), and 34 patients (41%) had a lesion of greater than or equal to 50%. CONCLUSIONS. This stent may be a useful adjunct to balloon dilatation in acute or threatened closure. Randomized studies comparing this stent with alternative technologies are required.
Collapse
Affiliation(s)
- G S Roubin
- Division of Cardiovascular Disease, University of Alabama, Birmingham 35294
| | | | | | | | | | | | | |
Collapse
|
18
|
Zapolanski A, Rosenblum J, Myler RK, Shaw RE, Stertzer SH, Millhouse FG, Zatzkis M, Wulff C, Schechtmann NS, Siegel S. Emergency coronary artery bypass surgery following failed balloon angioplasty: role of the internal mammary artery graft. J Card Surg 1991; 6:439-48. [PMID: 1815767 DOI: 10.1111/j.1540-8191.1991.tb00343.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
During a 4-year period (1986-1989), 3,502 patients had percutaneous transluminal coronary angioplasty (PTCA) in our institution. One hundred nineteen (3.4%) patients required emergency coronary artery bypass graft surgery (CABG) because of abrupt vessel closure following PTCA. Factors associated with vessel closure included lesion angulation greater than or equal to 90 degrees (p less than 0.007), the presence of thrombus (p less than 0.02), or a long (greater than or equal to 2 cm) lesion (p less than 0.03). Of these 119 emergency CABG patients, 108 (91%) arrived in the operating room in a stable condition (group I) and 11 (9%) were in cardiogenic shock (group II). Five (45%) of the group II patients were admitted to the hospital with an acute myocardial infarction and all 11 patients had a higher incidence of multivessel disease (p less than 0.05) and lower left ventricular ejection fraction (p less than 0.001) than group I patients. The overall surgical mortality was 10.1%; however, in group I the mortality was 5.6% and in group II it was 54.5% (p less than 0.001). The vessel that abruptly closed ("culprit vessel") was the left anterior descending (LAD) in 60%, the right coronary artery in 27%, and the left circumflex in 13%. The internal mammary artery was utilized to bypass the culprit artery in 51 (43%) patients, including 50% of the culprit LADs. With group I culprit LAD patients, when the left IMA was the bypass conduit, there were no hospital deaths nor strokes and there was a 6.3% incidence of perioperative infarction.
Collapse
Affiliation(s)
- A Zapolanski
- Department of Cardiovascular Surgery, San Francisco Heart Institute, Seton Medical Center, Daly City, California 94015
| | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
This review updates and extends observations made in this journal in March 1988. The focus then was on percutaneous transluminal coronary angioplasty and the clinical results of its practical application. A concern was expressed that science lagged in solving the major problems of rethrombosis and restenosis. The NHLBI Bypass Angioplasty Revascularization Investigation (BARI) study was still in the planning phase. In 1991, the scene has changed. Interventional cardiology now embraces a multitude of different catheter devices--angioplasty, atherectomy, laser, stents. Basic scientists are increasingly involved in addressing the restenosis issue. Our national heart meetings are increasingly oriented towards molecular biology approaches to solving the remaining problems. The BARI trial has nearly completed patient entry, and we eagerly await its results. The cardiologist and surgeon are faced with increasingly complex decisions with respect to interventional technologies, involving not only whether to use them, but which ones.
Collapse
Affiliation(s)
- R E Vlietstra
- Cardiology Section, Watson Clinic, Lakeland, Florida 33804-5000
| | | | | |
Collapse
|
20
|
Brenner AS, Browne KF. Five-hour balloon inflation to resolve recurrent reocclusion during coronary angioplasty. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1991; 22:107-11. [PMID: 1901243 DOI: 10.1002/ccd.1810220207] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A 63-year-old male presented with an acute inferior myocardial infarction with initial clinical reperfusion following thrombolysis. Due to recurrent reocclusion, emergency catheterization was performed, demonstrating a 90% stenosis in the mid right coronary artery. Angioplasty was complicated by multiple reocclusions, ultimately requiring 5-h autoperfusion balloon inflation to maintain patency.
Collapse
Affiliation(s)
- A S Brenner
- Department of Cardiology, Watson Clinic, Lakeland, Florida 33804-5000
| | | |
Collapse
|