Autoperfusion balloon catheter for complicated coronary angioplasty: a prospective study with retrospective controls

Abrupt vessel closure: changing importance, management, and consequences

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.

Distal coronary hemoperfusion during percutaneous transluminal coronary angioplasty

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.

Autoperfusion balloon versus stent for acute or threatened closure during percutaneous transluminal coronary angioplasty

Efficacy and major clinical end points were compared in 61 patients treated with a Stack autoperfusion balloon versus 36 patients who received a Palmaz-Schatz stent for acute or threatened closure during coronary angioplasty. The groups were comparable regarding baseline clinical characteristics. Procedural success was achieved in 43 patients (70%) treated with an autoperfusion balloon versus 34 patients (94%) who received a stent (p < 0.02). Emergency bypass surgery was performed in 13 patients (21%) with the autoperfusion balloon versus none of the patients with a stent (p < 0.001). In the stent group, 3 patients (8%) died (p < 0.05); 2 deaths were caused by thrombotic reclosure, and 1 patient died after unsuccessful stent delivery. Subacute reclosure during hospitalization occurred in none of the patients with autoperfusion versus 8 patients with the stent (22%) (p < 0.0002). Therefore, the number of patients with successful stent implantation at discharge decreased to 26 (72%). At 3-month follow-up in all patients with a successful intervention, reclosure or angiographic restenosis (> 50%) occurred in 13 patients with autoperfusion (30%) versus 3 patients with stents (12%) (p = NS). There was no difference in event-free survival during follow-up. Thus, both interventions were equally successful in the treatment of acute and threatened closure. More emergency surgery was performed in the autoperfusion balloon group, whereas a higher subacute reclosure rate was seen in the stent group. At 3-month follow-up, there were no significant differences regarding reclosure, restenosis, and event-free survival.