Abrupt vessel closure complicating coronary angioplasty: Clinical, angiographic and therapeutic profile

AbstractTo assess the clinical, angiographic and procedural correlates of outcome after abrupt vessel closure during coronary angioplasty, results were analyzed of 109 patients (8.3%) who had abrupt vessel closure during 1,319 consecutive coronary angioplasty procedures performed between July 1, 1988 and June 30, 1990. These 109 patients had a mean age of 59 ± 11 years; 63% were male, 57% had had a prior myocardial infarction and 61% had multivessel disease. Coronary angioplasty was performed in the settings of acute myocardial infarction (14%), recent myocardial infarction (36%), unstable angina (34%) and stable ischemia (29%).Abrupt vessel closure occurred at a median of 27 min (range 0 min to 5 days) from the first balloon inflation. By angiographic criteria, thrombus or coronary dissection was identified in 20% and 28% of cases, respectively; both thrombus and dissection were present in 7% of closures, and 45% were due to indeterminate mechanisms. Successful reversal of abrupt vessel closure, defined as restoration of normal Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow without resultant Q wave myocardial infarction, emergency bypass surgery or death, was achieved in 47 patients (43%). By hierarchal analysis, the incidence of death, emergency coronary bypass surgery, Q wave and non-Q wave myocardial infarction was 8%, 20%, 9% and 11%, respectively.Univariate analysis using 23 clinical, morphologic and procedural variables demonstrated that successful outcome after abrupt closure was associated with prolonged balloon inflations (>120 s) (odds ratio = 6.87, p < 0.001), unstable angina (odds ratio = 2.37, p = 0.034) and placement of an intracoronary stent (odds ratio = 5.33, p = 0.062). By multivariate analysis, independent correlates of successful outcome were prolonged balloon inflations (odds ratio = 5.11, p = 0.001) and intracoronary stenting (odds ratio = 4.37, p = 0.049).Thus, although prolonged balloon inflations and intracoronary stents may improve outcome after abrupt vessel closure, the cumulative risk of morbidity or mortality remains significant and mandates investigation into improved strategies for its prevention and treatment

Paclitaxel-Eluting Coronary Stents in Patients With Diabetes Mellitus Pooled Analysis From 5 Randomized Trials

ObjectivesWe sought to examine the safety and efficacy of paclitaxel-eluting stents (PES) in patients with diabetes mellitus (DM).BackgroundCompared with patients without DM, patients with DM undergoing percutaneous coronary intervention are at increased risk for mortality and restenosis. The safety of drug-eluting stents in diabetic patients has recently been called into question by a published meta-analysis of randomized trials.MethodsPatient-level data were pooled from 5 prospective, double-blind, randomized trials of PES versus bare-metal stents (BMS) (n = 3,513). Safety and efficacy outcomes through 4 years of follow-up were assessed among the 827 randomized patients (23.6%) with DM.ResultsPatients treated with PES and BMS has similar baseline characteristics among both the diabetic and nondiabetic cohorts within these trials. At 4-year follow-up, there were no significant differences between PES and BMS among diabetic patients in the rates of death (8.4% vs. 10.3%, respectively, p = 0.61), myocardial infarction (6.9% vs. 8.9%, p = 0.17), or stent thrombosis (1.4% vs. 1.2%, p = 0.92). Treatment of diabetic patients with PES compared with treatment with BMS was associated with a significant and durable reduction in target lesion revascularization over the 4-year follow-up period (12.4% vs. 24.7%, p < 0.0001). The relative safety and efficacy of PES compared with the relative safety and efficacy of BMS in diabetic patients extended to both those requiring and not requiring insulin.ConclusionsIn these 5 randomized trials in which patients with single, primarily noncomplex lesions were enrolled, treatment with PES compared with treatment with BMS was safe and effective, resulting in markedly lower rates of target lesion revascularization at 4 years, with similar rates of death, myocardial infarction, and stent thrombosis

Sequential intravascular ultrasound of the mechanisms of rotational atherectomy and adjunct balloon angioplasty

AbstractObjectives. The purpose of this study was to use sequential intravascular ultrasound imaging before intervention, after rotational atherectomy and after adjunct balloon angioplasty to characterize the mechanisms of lumen enlargement after each.Background. Rotational atherectomy uses a high speed, rotating, diamond-tipped elliptic burr to abrade atherosclerotic plaque to increase lumen size. In vitro studies have shown that high speed rotational atherectomy selectively abrades hard, especially calcified, plaque elements. However, rotational atherectomy procedures usually require adjunct balloon angioplasty.Methods. Forty-eight lesions in 46 patients were treated with rotational atherectomy followed by adjunct balloon angioplasty in 44. Quantitative coronary arteriographic and intravascular ultrasound measurements of the target lesion were made before intervention, after rotational atherectomy and after balloon angioplasty.Results. Before intervention, target lesion external elastic membrane area measured 17.3 ± 5.9 mm2, lumen area measured 1.8 ± 0.9 mm2and plaque plus media area measured 15.7 ± 4.1 mm2. After rotational atherectomy, lumen area increased, plaque plus media area decreased, arc of target lesion calcium decreased and 26% of the target lesions had dissection planes After adjunct balloon angioplasty, external elastic membrane area increased, lumen area increased, plaque plus media area did not change and 77% of the target lesions had dissection planes. Arterial expansion was seen in 80% of lesions. The pattern of dissection plane location, which was predominantly within calcified plaque after rotational atherectomy, became predominantly adjacent to calcified plaque after adjunct balloon angioplasty (p = 0.008).Conclusions. Sequential intravascular ultrasound imaging shows that high speed rotational atherectomy causes lumen enlargement by selective ablation of hard, especially calcific, atherosclerotic plaque with little tissue disruption and rare arterial expansion. Adjunct balloon angioplasty further increased lumen area by a combination of arterial dissection and arterial expansion, especially of compliant, noncalcified plaque elements

Mechanism of benefit of combination thrombolytic therapy for acute myocardial infarction: A quantitative angiographic and hematologic study

AbstractObjectives. The goal of this study was to lend insight into the mechanisms responsible for the beneficial effects of combination thrombolytic therapy.Background. Combination thrombolytic therapy for acute myocardial infarction bas been associated with less reocclusion and fewer in-hospital clinical events than has monotherapy.Methods. Infarct-related quantitative coronary dimensions and hemostatic protein levels were evaluated in 287 patients with acute myocardial infarction during the early (90-min) and convalescent (7-day) phases after administration of recombinant tissue-type plasminogen activator (rt-PA), urokinase or combination rt-PA and urokinase.Results. Minimal lumen diameter was similar in the 90-min and 7-day phases after treatment with rt-PA, urokinase and combination rt-PA and urokinase (0.72 ± 0.45 mm, 0.62 ± 0.53 mm and 0.75 ± 0.58 mm, respectively, at 90 min, p = 0.16; and 1.05 ± 0.56 mm, 1.12 ± 0.72 mm and 0.94 ± 0.54 mm, respectively, at 7 days, p = 0.22). In-hospital clinical event and reocclusion rates were less frequent in patients receiving combination therapy than in those receiving monotherapy (25% vs. 38% and 32% for rt-PA and urokinase, respectively, p = 0.084; and 3% vs. 13% and 9% for rt-PA and urokinase, respectively, p = 0.03), but these events were unrelated to early or late coronary dimensions. Patients receiving combination therapy or urokinase monotherapy had significantly higher peak fibrin degradation products (1,307 ± 860 and 1,285 ± 898 μg/ml vs. 435 ± 717 μg/ml, respectively, p < 0.0001) and lower nadir fibrinogen levels (0.85 ± 1.00 and 0.75 ± 0.53 g/liter vs. 1.90 ± 0.86 g/liter, respectively, p < 0.0001) than did those receiving rt-PA monotherapy. Peak fibrinogen degradation products indirectly correlated (p = 0.004) and baseline (p = 0.026) and nadir (p = 0.089) fibrinogen levels directly correlated with reocclusion.Conclusions. Lower in-hospital clinical event and reocclusion rates observed with combination thrombolytic therapy may relate to systemic hematologic factors rather than to the residual lumen obstruction after thrombolysis

Atherectomy of right coronary ostial stenoses: Initial and long-term results, technical features and histologic findings

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29455/1/0000537.pd

In-hospital costs associated with new percutaneous coronary devices

To determine the relative economic impact of alternative methods of coronary revascularization, in-hospital patient accounts were reviewed in 149 patients undergoing elective coronary angioplasty (n = 50), coronary atherectomy (n = 72) or intracoronary stent placement (n = 27) over an 18-month period. Clinical and angiographic features were similar in the 3 groups, except that prior restenosis was seen more often in patients undergoing intracoronary stent placement. Procedural success, obtained in &gt;90% of patients, was independent of the treatment strategy. Total in-hospital stay was significantly longer in patients undergoing intracoronary stent placement than in patients undergoing coronary angioplasty and directional atherectomy (4.9 +/- 2.4 days vs 1.5 +/- 1.3 and 2.2 +/- 3.9 days, respectively; p &lt; 0.0001). Furthermore, the total in-hospital charges were significantly higher in patients undergoing intracoronary stent placement ($12,574 +/-$4,564 vs $6,220 +/-$5,716; p &lt; 0.001) and directional atherectomy ($8,329 +/-$8,588 vs $6,220 +/-$5,716; p &lt; 0.01) than in patients undergoing coronary angioplasty, reflecting overall differences in room costs, laboratory fees and pharmacy fees. The longer in-hospital stay in the intracoronary stent group was primarily attributed to the time required for anticoagulation with coumadin. It is concluded that a 102 and 34% increase in early hospital charges resulted with stenting or directional atherectomy, respectively, compared with coronary angioplasty. These increased in-hospital charges were chiefly due to the prolonged hospitalization time, device cost, laboratory fees and, in patients with intracoronary stents, the prolonged time needed to achieve systemic anticoagulation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29116/1/0000155.pd