Finci, L.

Meier, B.

Rutishauser, W.

Steffenino, G.

Urban, P.

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European Heart Journal (1988) 9 {Supplement Q, 11-13Restenosis and repeat coronary angioplasty in GenevaL. FINCI, B. MEIER, G. STEFFENINO, P. URBAN AND W. RUTISHAUSERCardiology Centre, University Hospital, 1211 Geneva 4, SwitzerlandKEY WORDS: Coronary angioplasty, restenosis after angioplasty.MethodsBetween July 1983 and August 1985, a total of400 patients underwent coronary angioplasty on488 vessels at the Cardiology Centre. There were358 men (89%) and 42 women (11 %) with a meanage (±SD) of 55 ±9 years. There were 83 multi-vessel angioplasties, 56 angioplasties for chronictotal occlusion, and 27 angioplasties for evolvingmyocardial infarction. Clinical follow-up was avail-able in 318 of 400 patients (80%). Of these, 230patients also underwent control angiography.The technique of angioplasty which was used hasbeen described previously*'1. The degree of stenosiswas estimated and averaged by two experiencedangiographers in at least two projections. Primarysuccess was considered to be present if the followingconditions were fulfilled: angiographically im-proved stenosis, improvement of transstenoticpressure gradient, absence of electrocardiographicor enzymatic evidence of myocardial infarction orneed for bypass surgery, and improvement ofNYHA functional class and/or stress test. In multi-vessel coronary angioplasty, angiographic successwas considered to be present if at least the dilatationof the strategic lesions was successful. Restenosiswas defined as a > 50% narrowing of the site ofangioplasty. All patients received aspirin beforeangioplasty, most of them were given intracoronarynifedipine and/or nitrates immediately beforeangioplasty and aspirin 100 mg day" l after the pro-cedure. The pressure used for balloon inflationsranged from 4 to 14 bar, and the inflation time from30 to 90 s. Repeat inflations were performed untilthe transstenotic pressure gradient had diminished,and the angiographic aspect of the lesion appearedsatisfactory.Clinical follow-up consisted of an interview and/or exercise stress test. A small number of patientswere followed by a questionnaire. Control angio-graphy was solicited in all patients. Repeat angio-0195-668X/88/09C011 +03 $02.00/0graphy was performed promptly in any patient whoreferred for recurrence of angina or deterioration infunctional class.ResultsPrimary success was obtained in 348 of 400patients (87%). Major complications were encoun-tered in 20 patients (5%): one death, 17 (4%) myo-cardial infarctions, 11 (3%) emergency operations.Clinical follow-up was available in 318 of 348patients (91%) with primary success at 10 ±6months (Fig. 1). Including repeat angioplasty, 80%of the patients (253/318) with primary success wereimproved by at least one NYHA functional classand/or had an improved exercise test: 19% (61)were improved by three classes, 31% (97) by twoclasses, and 30% (95) by one class. Among the 65patients with no improvement, there was onesudden death at 7 months, one patient had a myo-cardial infarction at 4 months, 16 patients hadbypass surgery, and 47 patients were treatedmedically.Seventy patients had repeat angioplasty at 6±4months (range 3-24 months) after the first pro-cedure. At the time of their second procedure, 61 %(43) were still clinically improved by at least onefunctional class: 3% (2) were improved by threeclasses, 17% (12) by two classes, and 41% (29) byone class. Among the other patients 24% (17) wereagain in the same class as before angioplasty and14% (10) were worse than before angioplasty. The61% with clinical improvement have to be com-pared to the 88% with clinical improvement amongthe 146 patients without recurrence (P<00l).Angiographic follow-up in 230 patients withprimary success revealed a recurrence in 84 patients(37%) at 12 ± 6 months. In the subgroup with multi-vessel angioplasty, recurrence was found in 21 ofthe 45 patients (47%) restudied. Recurrence perartery was 40% (56/140) for the left anterior© 1988 The European Society of Cardiology12 L. Find etal.400 consecutive patient*PRIMARY 8UCCESS87 % (848/400)CLINICAL FOLLOW-UP01 % (318/348)1CONTROL ANQIOQRAPHY66 % (230/348)1st RECURRENCE37 % (84/230)SECOND PTCASUCCESS 80 % (63/70)CONTROL ANQIOQRAPHY37 % (23/63)12nd RECURRENCE48 % (11/23)THIRD PTCASUCCE88 100 % (S/8)PTCA FAILURE8 62NO FOLLOW-UP 30NO CONTROLANQIOGRAPHY 118BYPA8S 8UR0ERY 12MEDICAL TREATMENT 2PTCA FAILURE 7NO CONTROLANQIOQRAPHY 40BYPASS SURGERY 4-B»~| MEDICAL TREATMENT 14Figure I Follow-up after successful coronary angioplasty.descending artery, 33% (24/73) for the right coron-ary artery, 30% (18/61) for the left circumflexartery, and 29% (4/14) for diagonal branches. Ofthese, 70 patients underwent repeat angioplasty, 65on one vessel, and five on two vessels (Fig. 1).Primary success was 90% (63/70). There was onemyocardial infarction, and no emergency surgery.Figure 2 depicts the interval between the first andthe second angioplasty. A control angiographywas performed in 23 of 63 patients with successfulrepeat angioplasty. Recurrence was found in 11patients, representing 17% of the patients with pri-mary success of repeat angioplasty or 48% of thepatients with angiographic follow-up. In five ofthese patients, a third angioplasty was performedafter 7 ± 3 months. It was successful and withoutcomplications in all patients. Medium-term clinicalfollow-up (8 ± 6 months) after the last procedure,available for all 59 patients with repeat angioplastywho did not undergo surgical revascularization,showed improvement of at least one NYHA func-tional class in 84% (50/59). This percentage isidentical to that of the whole group with initial pri-mary success without subsequent bypass surgerywhere long-term clinical improvement was presentin 84% of patients (253/302) after 10 ±6 months.DiscussionThe accuracy of recurrence rates is subject to thecompleteness of follow-up angiography. In ourstudy, as in most others'21, control angiography wasdone in only 2/3 of the population studied, showingrecurrence in 37%. One might speculate that mostof the symptomatic patients were restudied andtherefore the real recurrence rate would be less if theRestenosis and repeat coronary angioplasty 136.3 ± 4.114128H1 2 3 4 9 6 7 8 S 10 11 12 13 14 > 15Figure 2 Distribution of intervals between first and second coronaryangioplasty in 70 patients.entire population had been subjected to controlangiography.In patients with angiographically documentedrecurrence, there was still a clinical improvement in61% as compared to the pre-angioplasty status.This indicates that recurrences in general cause lesssymptoms than the initial lesions. Even thoughrecurrences may be only partial and may be treatedby repeat angioplasty at a low risk, they are fre-quent and represent a serious problem. This factjustifies control angiography as well as any efforttowards a better understanding of their pathophy-siologic mechanism and new methods to diminishrestenosis.References[1] Meier B, Rutishauser W. Transluminal coronary angio-plasty—state of the art 1984. Ada Med Scand 1985; 701(Suppl): 142-7.[2] Hollman J, Ischinger T. The problem of restenosis. In:Ischinger T, ed. Practice of coronary angioplastv. Berlin,Heidelberg: Springer-Verlag, 1986: 211-22.

Restenosis and repeat coronary angioplasty in Geneva

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