Extraluminal contrast pooling on coronary angiography as an expression of ruptured atheromatous plaque

Coronary angiographic findings in infarct-related arteries following 1 month of medical treatment

PURPOSE

We undertook the present study to determine first whether coronary angiographic (CAG) features, suggestive of ruptured atherosclerotic plaque, develop in infarct-related arteries of patients receiving conventional medical therapy without thrombolytic agents, and if they develop, what the incidence is, and second whether the sites where the CAG features develop are specific to infarct-related lesions.

METHODS

We reviewed the CAG findings of 127 consecutive patients one month after myocardial infarction (MI), including 72 consecutive patients who received medical therapy (Group I) and 55 patients who underwent intracoronary urokinase infusion (Group II).

RESULTS

Angiographic evidence of ruptured plaque was present in 24/44 (54.5%) patent infarct-related arteries in Group I and in 27/43 (62.8%) in Group II. Similar findings were only noted in 2/52 (3.8%) patent non-infarct-related arteries with significant stenosis in Group I, and in 0/45 (0.0%) in Group II.

CONCLUSION

On angiography, ruptured plaque was commonly found in patent infarct-related arteries in both groups, and was highly specific for the site of infarction. Thrombolytic therapy seemed to have no apparent effect on lesion morphology 1 month after MI.

Angioplasty in ulcerative coronary artery disease: acute results and early follow-up

The safety and efficacy of percutaneous transluminal coronary angioplasty (PTCA) for stenoses involving ulcerative lesions were retrospectively studied. Seventy-seven patients (62 men and 15 women, mean age 62 +/- 10 years) representing 3.4% of 2,250 patients treated with PTCA during the period January 1, 1988 and June 30, 1990, had pre-PTCA stenoses defined as ulcerated. Twenty-eight (36%) of the stenoses were localized in the left anterior descending coronary artery, 9 (12%) in the left circumflex and 40 (52%) in the right coronary artery. During angioplasty, percent diameter stenosis was reduced from 73 +/- 14% to 22 +/- 13% and transstenotic gradient decreased from 48 +/- 18 to 12 +/- 6 mm Hg. Clinical success (freedom from angina at discharge without coronary bypass surgery, infarction or death) was achieved in 70 patients (90.9%). There were seven unsuccessful cases: three underwent elective coronary bypass surgery, one was managed medically, and three developed a major flow interrupting dissection during the procedure requiring emergency coronary bypass surgery. There were no deaths. At mean follow-up of 7.6 months, 45 of 61 patients (73.7%) remained asymptomatic. One patient needed an elective coronary bypass surgery and five patients had a successful repeat PTCA. In conclusion, PTCA for an ulcerated stenosis can be performed safely with a high primary success rate and a favorable early clinical course.

The origin and fate of complex coronary lesions

Complex irregular coronary artery stenoses, representing plaque rupture/thrombosis, are associated with the acute coronary syndromes. However, the natural history (origin and fate) of these lesions is not known. To examine this issue we studied 255 patients who had had two to four arteriograms within a mean interval of 2.6 +/- 1.7 years. Of 53 irregular lesions that had progressed on a later arteriogram, 35 (66%) originated from areas that were smooth and less than 50% in stenosis diameter. Of 44 irregular lesions on an earlier study, 10 (23%) became totally occluded, five (11%) progressed in severity (all remained irregular), 25 (57%) showed no change in severity (all remained irregular), and four (9%) regressed (two became smooth). Nine of the 10 lesions progressing to occlusion were greater than or equal to 95% stenosed on the earlier study. Only 2 of 44 lesions (5%) showed smoothing. These findings are in agreement with the concept that irregular lesions represent ruptured atherosclerotic plaques and demonstrate that they usually originate from mildly occlusive smooth plaques. Markedly narrowed irregular lesions (greater than or equal to 95% stenosis) frequently progress to occlusion. Irregular lesions less than 90% narrowed commonly remain angiographically stable, and irregular over several years. They were found rarely to evolve into smooth-walled plaques.

Coronary angiographic ruptured atheromatous plaque as a predictor of future progression of stenosis

To determine whether or not angiographic coronary morphology can predict future development/progression of narrowing, we reviewed coronary angiograms (CAGs) from 29 patients who underwent CAG studies twice but who had no myocardial revascularization during the period of the studies. The mean age of the patients was 52.9 +/- 8.5 years, and the mean interval between the studies was 25.4 +/- 22.6 months. Mean luminal diameter stenosis of 77 lesions that reduced the diameter by 50% or more on either CAG, but were not totally occluded on the initial CAG, increased from 62% to 79% (p less than 0.01). Progression of stenosis developed in 35 lesions (45%); the progression in 13 lesions of the 35 (37%) was on sites associated with no stenosis or mild stenosis on the initial CAG. No relation was found between the development/progression of stenosis and either its initial severity or elapsed time; however, the prevalence of the development/progression of stenosis was more frequent on sites with possible or probable ruptured atheromatous plaque on the initial CAG than on sites without such plaque (p less than 0.05). The evidence suggests that there is no apparent relation between the future development/progression of coronary narrowing and either the severity of stenosis on the initial CAG or elapsed time but that some of the development/progression can be predicted on the basis of certain specific coronary morphology.