Influence of coronary thrombus on outcome of percutaneous coronary angioplasty in the current era (the Mayo Clinic experience).

Earlier studies documented an increased risk of percutaneous coronary intervention (PCI) in patients with angiographic evidence of thrombus. With newer antiplatelet agents and stents, it is not known whether thrombus is a risk factor after PCI. This study examines whether outcome of PCI in patients with thrombus has improved, and whether thrombus is associated with adverse outcome after PCI in the current era. This single-institution retrospective analysis of PCI in 7,184 patients was divided into 2 periods: group I, 1990 to 1995 (n = 3,640), and group II, 1996 to 1999 (n = 3,544). The groups were subdivided according to the presence or absence of angiographic thrombus before PCI. We compared the outcome of PCI for patients with and without thrombus in group II. A comparison was made in the 2 groups in patients with angiographic thrombus. Procedural success improved in group II compared with group I patients with thrombus (93% vs 88%, p <0.001). There was significant reduction in abrupt closure in the recent era in patients with thrombus (4% vs 7%, p = 0.01). In group II, procedural success remained lower in patients with (93% vs 96%) than without thrombus (p <0.001). After adjusting for the significant univariate characteristics of group II patients, thrombus remained an independent predictor of Q-wave infarction (odds ratio 3.78; 95% confidence interval [CI], 1.8 to 8.0; p <0.0013) and the composite end point of death, Q-wave infarction, and emergency bypass surgery (odds ratio 2.37; 95% CI 1.4 to 4.1; p = 0.002). There was a trend toward increased in-hospital death among patients with thrombus (odds ratio 2.06; 95% CI 0.9 to 4.8; p = 0.09). The 1-year outcome after successful PCI was similar for those with and without thrombus. Despite improvement in the outcome of patients with thrombus undergoing PCI in recent years, thrombus is still an independent predictor of adverse in-hospital outcomes after PCI.

Toward an understanding of violence: neurobehavioral aspects of unwarranted physical aggression: Aspen Neurobehavioral Conference consensus statement.

OBJECTIVE: Violence is a global problem that poses a major challenge to individuals and society. This document is a consensus statement on neurobehavioral aspects of violence as one approach to its understanding and control. BACKGROUND: This consensus group was convened under the auspices of the Aspen Neurobehavioral Conference, an annual consensus conference devoted to the understanding of issues related to mind and brain. The conference is supported by the Brain Injury Association and by individual philanthropic contributions. Participants were selected by conference organizers to represent leading opinion in neurology, neuropsychology, psychiatry, trauma surgery, nursing, evolutionary psychology, medical ethics, and law. METHODS: A literature review of the role of the brain in violent behavior was conducted and combined with expert opinion from the group. The major goal was to survey this field so as to identify major areas of interest that could be targeted for further research. Additional review was secured from the other attendees at the Aspen Neurobehavioral Conference. RESULTS: The group met in the spring of 1998 and 1999 for two 5-day sessions, between which individual assignments were carried out. The consensus statement was prepared after the second meeting, and agreement on the statement was reached by participants after final review of the document. CONCLUSIONS: Violence can result from brain dysfunction, although social and evolutionary factors also contribute. Study of the neurobehavioral aspects of violence, particularly frontal lobe dysfunction, altered serotonin metabolism, and the influence of heredity, promises to lead to a deeper understanding of the causes and solution of this urgent problem.

Immediate and long-term outcome of intracoronary stent implantation for true bifurcation lesions.

OBJECTIVES: The aim of this study was to evaluate the immediate and long-term outcome of intracoronary stent implantation for the treatment of coronary artery bifurcation lesions. BACKGROUND: Balloon angioplasty of true coronary bifurcation lesions is associated with a lower success and higher complication rate than most other lesion types. METHODS: We treated 131 patients with bifurcation lesions with > or =1 stent. Patients were divided into two groups; Group (Gp) 1 included 77 patients treated with a stent in one branch and percutaneous transluminal coronary angioplasty (PTCA) (with or without atherectomy) in the side branch, and Gp 2 included 54 patients who underwent stent deployment in both branches. The Gp 2 patients were subsequently divided into two subgroups depending on the technique of stent deployment. The Gp 2a included 19 patients who underwent Y-stenting, and Gp 2b included 33 patients who underwent T-stenting. RESULTS: There were no significant differences between the groups in terms of age, gender, frequency of prior myocardial infarction (MI) or coronary artery bypass grafting (CABG), or vessels treated. Procedural success rates were excellent (89.5 to 97.4%). After one-year follow-up, no significant differences were seen in the frequency of major adverse events (death, MI, or repeat revascularization) between Gp 1 and Gp 2. Adverse cardiac events were higher with Y-stenting compared with T-stenting (86.3% vs. 30.4%, p = 0.004). CONCLUSIONS: Stenting of bifurcation lesions can be achieved with a high success rate. However, stenting of both branches offers no advantage over stenting one branch and performing balloon angioplasty of the other branch.

Immediate and late outcomes after direct stent implantation without balloon predilation.

OBJECTIVES: The aim of our study was to compare the in-hospital and long-term clinical outcomes of direct coronary stenting with balloon predilation followed by stent placement. BACKGROUND: With improvement in stent designs, the practice of direct stenting without balloon predilation has become more widespread. METHODS: We analyzed the Mayo Clinic Coronary Intervention data base between January 1, 1995 and March 5, 1999 and identified 777 patients who were treated with direct stenting (DS) and 3,176 patients treated with balloon angioplasty plus stenting (BA+S). RESULTS: The procedural success rates between the DS and BA+S groups were not significantly different (96.3% vs. 96.4%). The ability to deliver the stent in a subgroup of patients who had DS was 95%, with 5% requiring crossover to predilation. Multivariate analysis showed no significant differences with respect to in-hospital death (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.5 to 1.8), in-hospital myocardial infarction (OR 0.9, 95% CI 0.6 to 1.2) or revascularization (OR 0.7, 95% CI 0.4 to 1.5) in the DS compared with the BA+S group. Long-term outcomes were not significantly different between the DS and BA+S groups. The procedural duration was significantly shorter in the DS group, and there was a decreased utilization of contrast agent, balloons and wires. CONCLUSIONS: The in-hospital and long-term clinical outcomes in patients undergoing a coronary intervention are equivalent when comparing stenting without balloon predilation with balloon angioplasty followed by stenting. Direct stenting is associated with decreased utilization of contrast agent and equipment and shorter procedure times. A randomized study should be performed to better determine the impact of this technique on short- and long-term procedural outcomes.

Interventional cardiology and intracoronary stents--a changing practice: approved vs. nonapproved indications.

Our objective was to document change in stent usage in a single practice over time and to study "off-label" compared to Food and Drug Administration (FDA)-approved indications. Although only two intracoronary stents have been approved by the FDA, the relatively limited approved indications do not account for the dramatic increase in stent implantation. This increase has important implications for patient health care delivery. This study of stent usage in a single center over a 36-mo period included all patients treated with coronary stents at the Mayo Clinic from January 1993-December 1995, and evaluated the relative difference in frequency between "off-label" and FDA-approved indications for implantation. During the 36-mo period of study, 3,614 interventional procedures were done and one or more stents were placed in 25.4% of patients. The proportion of patients receiving stents increased throughout this time: during the first 6-mo period, stents were placed in 6.2% of procedures; during the last 6-mo period, stents were placed in 46.3% of procedures, an eightfold increase. During the final 6 mo, an unapproved device or an unapproved indication for an approved device constituted 59.4% of all stent procedures. In addition, use of the non-FDA-approved adjunctive treatment regimen without warfarin increased from 2.9% in the first 6-mo period of observation to 82.7% in the last 6 mo. The use of stents increased strikingly over a 36-mo period, from 6% to 46% of all procedures. The majority of implantations were performed either for an "off-label" unapproved indication or with an unapproved device.

Validation of a new UNIX-based quantitative coronary angiographic system for the measurement of coronary artery lesions.

We describe a method of validation of computerized quantitative coronary arteriography and report the results of a new UNIX-based quantitative coronary arteriography software program developed for rapid on-line (digital) and off-line (digital or cinefilm) analysis. The UNIX operating system is widely available in computer systems using very fast processors and has excellent graphics capabilities. The system is potentially compatible with any cardiac digital x-ray system for on-line analysis and has been designed to incorporate an integrated database, have on-line and immediate recall capabilities, and provide digital access to all data. The accuracy (mean signed differences of the observed minus the true dimensions) and precision (pooled standard deviations of the measurements) of the program were determined x-ray vessel phantoms. Intra- and interobserver variabilities were assessed from in vivo studies during routine clinical coronary arteriography. Precision from the x-ray phantom studies (6-In. field of view) for digital images was 0.066 mm and for digitized cine images was 0.060 mm. Accuracy was 0.076 mm (overestimation) for digital images compared to 0.008 mm for digitized cine images. Diagnostic coronary catheters were also used for calibration; accuracy.varied according to size of catheter and whether or not they were filled with iodinated contrast. Intra- and interobserver variabilities were excellent and indicated that coronary lesion measurements were relatively user-independent. Thus, this easy to use and very fast UNIX based program appears to be robust with optimal accuracy and precision for clinical and research applications.

"Rescue" directional coronary atherectomy after unsuccessful percutaneous transluminal coronary angioplasty.

OBJECTIVE: To evaluate the outcome in patients who underwent directional coronary atherectomy after unsuccessful balloon angioplasty. DESIGN: We conducted a retrospective computerized data bank search of patients in whom unsuccessful balloon angioplasty and subsequent "rescue" coronary atherectomy had been performed at the Mayo Clinic between Nov. 1, 1988, and May 1, 1993. MATERIAL AND METHODS: Among the 336 patients who underwent directional coronary atherectomy during the study period, in 16 the procedure was a rescue attempt. The mean age of these 16 study patients was 67 years. The following vessels were treated: left anterior descending coronary artery, six patients; right coronary artery, six; circumflex artery, two; and saphenous vein graft, two. Coronary angioplasty had failed because of dissection in eight patients, elastic recoil without evident dissection in seven, and recurrent thrombus without evident dissection in one. RESULTS: After coronary atherectomy, the mean stenosis was 41% (in comparison with 90% before coronary angioplasty and 71% after coronary angioplasty). Both angiographic success (20% or more decrease in stenosis after tissue removal and a final stenosis of less than 50%) and clinical success (angiographic success without in-hospital Q-wave myocardial infarction, bypass operation, or death) were achieved in 10 patients. Adventitia was obtained in two patients, both of whom underwent atherectomy for elastic recoil. In six patients, a stenosis of more than 50% remained after atherectomy; one patient suffered a Q-wave myocardial infarction, and one underwent emergent coronary artery bypass grafting. No deaths occurred in the study group. During follow-up (mean, 22 +/- 19 months), one patient suffered a non-Q-wave myocardial infarction, and two others underwent elective coronary artery bypass grafting. Eleven patients were asymptomatic at last contact. Repeated angiography, done in five patients a mean of 3.4 +/- 3.1 months after the procedure, showed restenosis in three. CONCLUSION: Rescue directional coronary atherectomy seems to be safe and effective in achieving angiographic and clinical successes in carefully selected patients after unsuccessful coronary angioplasty.

Immediate and long-term outcome after directional coronary atherectomy: analysis of gender differences.

OBJECTIVE: To compare the short-term and long-term outcomes of directional coronary atherectomy in women and men. DESIGN: We retrospectively analyzed 291 consecutive directional atherectomy procedures performed in 61 women and 230 men at the Mayo Clinic between October 1988 and November 1992. MATERIAL AND METHODS: The baseline clinical and angiographic characteristics, including extent of coronary artery disease and left ventricular ejection fraction, were compared for the male and female patients, and the short-term and long-term complications associated with atherectomy were summarized on the basis of gender. RESULTS: At baseline, women were older than men (67 +/- 12 versus 61 +/- 11 years; P = 0.001), and more women than men had class III or IV angina (90% versus 64%; P < 0.001); slightly more women than men had rest pain (64% versus 52%). Overall clinical success (improvement in luminal diameter of 40% or more and no death, Q-wave myocardial infarction, or emergency coronary bypass operation) was achieved in 89% of women and 95% of men (P = 0.054). In-hospital mortality was similar in women and men (1.6% and 1.7%, respectively), but acute myocardial infarction occurred more frequently in women than in men (4.9% versus 0.4%; P = 0.03). Significant peripheral vascular complications occurred in 6.6% of women versus 0.9% of men (P = 0.02). During long-term follow-up (mean, 2.9 years), survival and freedom from recurrent angina were similar among women and men. CONCLUSION: Directional coronary atherectomy is associated with slightly lower success and a higher frequency of myocardial infarction among women than among men. The higher postprocedural rate of myocardial infarction among women may reflect their worse clinical status at time of initial assessment. Despite these observations, women and men seem to have comparable survival and freedom from recurrence of angina during extended follow-up.

Percutaneous excimer laser coronary angioplasty: results in the first consecutive 3,000 patients. The ELCA Investigators.

OBJECTIVES: We report the comprehensive results of the first consecutive 3,000 patients treated in an excimer laser coronary angioplasty registry. BACKGROUND: Excimer laser coronary angioplasty involves the use of a pulsed, 308-nm ultraviolet laser transmitted by optical fibers to reduce coronary stenoses. Preliminary reports have described safety and efficacy profiles in small numbers of patients. METHODS: Patients were enrolled in a prospective, nonrandomized manner. The catheters used were 1.3, 1.6, 2.0, 2.2 and 2.4 mm in diameter, at energy densities up to 70 mJ/mm2. Procedures were performed by standard angioplasty technique with conventional guide catheters. RESULTS: Seventy-five percent of patients were male, 68% were in Canadian Cardiovascular Society functional class III or IV and the cohort included 3,592 lesions. Procedural success (final stenosis < or = 50% without in-hospital Q wave myocardial infarction, coronary artery bypass surgery or death) was 90% and did not differ between the first 2,000 and the last 1,000 patients treated. There was no significant difference in success or complication rates with respect to lesion length, nor were there differences between selected complex and simple lesions. Complications included in-hospital bypass surgery (3.8%), Q wave myocardial infarction (2.1%) and death (0.5%). Coronary artery perforation occurred in 1.2% of patients (1% of lesions) but significantly decreased to 0.4% in the last 1,000 patients (0.3% of lesions). Angiographic dissection occurred in 13% of lesions, transient occlusion in 3.4% and sustained occlusion in 3.1%. Comprehensive lesion morphologic data collected in the latter portion of the study showed the procedure predominantly limited to American College of Cardiology-American Heart Association type B2 and C lesions, with no significant difference in short-term outcome between groups. CONCLUSIONS: Excimer laser angioplasty can be safely and effectively applied, even in a variety of complex lesions not well suited for percutaneous transluminal coronary angioplasty. These types may include aorto-ostial, long lesions, total occlusions crossable with a wire, diffuse disease and vein grafts. Most recent data show a trend for the selection of predominantly complex lesions and a reduction in the incidence of perforation. This procedure may broaden the therapeutic window for the interventional treatment of selected complex coronary artery disease.

Coronary perforation after excimer laser coronary angioplasty: the Excimer Laser Coronary Angioplasty Registry experience.

OBJECTIVES: This study assessed the frequency of perforation with excimer coronary angioplasty. BACKGROUND: Coronary artery perforation after conventional percutaneous transluminal coronary angioplasty is extremely rare. Because laser coronary angioplasty involves actual tissue ablation, it has an increased potential for perforation. METHODS: All patients in the Excimer Laser Coronary Angioplasty Registry were included in this prospective study. Those who had a perforation related to the procedure were compared with those who did not have this complication. RESULTS: Of 2,759 consecutive patients in the Excimer Laser Coronary Angioplasty Registry, 36 (1.3%) had perforation. In these patients, the left anterior descending coronary artery was the most frequently treated vessel (53%). There were no differences in fiber sizes between patients with and those without perforation. Among the patients with perforation, 36.1% required coronary artery bypass surgery, 16.7% experienced an infarction and 5.6% had a fatal outcome. Among the patients without perforation, the rates were 3.1%, 3.8% and 0.6%, respectively. However, 41.7% of the patients with documented coronary artery perforation did not need coronary artery bypass surgery or experience myocardial infarction or death. No angiographic characteristics distinguished lesions with from those without perforation. The frequency of coronary artery perforation declined over time with increasing operator experience, from 1.6% in the first 1,888 patients to only 0.4% in the last 1,000 patients (p = 0.002). CONCLUSIONS: With increasing operator experience, the rate of perforation with excimer laser coronary angioplasty has decreased. When perforation occurs, subsequent event rates increase.

Significance of anterior ST depression in inferior wall acute myocardial infarction.

Early tomographic myocardial perfusion imaging with technetium-99m sestamibi was performed during inferior wall acute myocardial infarction to determine the relation between the amount and location of myocardium at risk and the presence or absence or anterior ST depression. The total size of the acute perfusion defect and its lateral and septal borders were measured in 29 consecutive patients who were admitted with > 30 minutes of chest pain and acute inferior ST elevation on their initial electrocardiogram. The 22 patients with anterior ST depression had significantly more left ventricular myocardium at risk than the 19 patients who did not have anterior ST depression (23 +/- 2% of the left ventricle vs 15 +/- 1%, p = 0.008). All 8 patients with > 25% of the left ventricle at risk had anterior ST depression. Patients with anterior ST depression had a significantly greater lateral extent of the acute perfusion defect (49 degrees +/- 8 degrees from the midinferior wall vs 23 degrees +/- 7 degrees, p = 0.002). There was no difference in the septal border of the perfusion defect between patients with and without anterior ST depression (-44 degrees +/- 4 degrees vs -46 degrees +/- 7 degrees, p = NS). No patient had a measurable anterior perfusion defect. Although there is considerable overlap between groups with and without anterior ST depression, anterior ST depression is a simple and readily available indicator of myocardium at risk in inferior wall acute myocardial infarction.

Chronic total obstruction and short-term outcome: the Excimer Laser Coronary Angioplasty Registry experience.

Percutaneous transluminal coronary angioplasty for chronic total obstructions is associated with significantly decreased success rates in comparison with those for dilation of subtotal stenoses. Failure usually results from inability to cross the occlusive lesion with a guidewire, although it may result from inability to pass the balloon catheter after the guidewire has been passed. In the Excimer Laser Coronary Angioplasty Registry, 172 chronic total obstructions were treated in 162 patients (10.3% of the 1,569 patients entered). For chronic total obstructions, passage of a guidewire is a prerequisite for laser angioplasty. Once a guidewire crossed an occlusion, the overall laser success rate for treatment of chronic total obstructions was 83%; the extent of stenosis decreased from 100% to 55 +/- 26%. Success was independent of length of the occlusive lesion. In 74% of patients, adjunctive percutaneous transluminal coronary angioplasty was used after laser angioplasty. A final procedural success, defined as residual stenosis of less than 50% and no major complication (coronary artery bypass grafting, myocardial infarction, or death), was achieved in 90%. Major complications were infrequent; 1.2% of patients required coronary artery bypass grafting, and 1.9% had a Q-wave myocardial infarction. Only one death occurred. The use of laser angioplasty may be of particular value when chronic total obstructions can be crossed with a guidewire but not with a conventional balloon catheter or when the occlusion is confirmed to be extremely long.

Relation of deep arterial resection and coronary artery aneurysms after directional coronary atherectomy.

OBJECTIVES: The aims of this study were to document the frequency of coronary artery aneurysm formation in patients undergoing directional coronary atherectomy and to determine the relation of such aneurysms to the depth of arterial resection. BACKGROUND: Deep arterial injury is relatively frequent with the use of directional coronary atherectomy, but the potential for subsequent coronary artery aneurysm formation is unknown. METHODS: Results in a consecutive series of 64 successfully treated patients (a total of 69 lesions; mean angiographic follow-up at 5 months) treated with directional coronary atherectomy were retrospectively analyzed with use of quantitative angiographic and histologic data. RESULTS: Coronary aneurysms (ratio of dilated vessel segment to the adjacent reference segment > 1.2:1) occurred in seven patients (10%). The only significant clinical correlate of aneurysm formation was a relatively shorter duration of angina. There were no significant preprocedural angiographic predictors of aneurysms, although 6 (86%) of the 7 aneurysmal lesions arose from restenosis lesions compared with 30 (48%) of 62 lesions with no subsequent aneurysm development (p = 0.06). Histopathologic examination of 414 specimens from 68 treated lesions showed no significant difference in the occurrence of subintimal resection (media +/- adventitia) between those with and without subsequent aneurysm (29% vs. 22%). Media alone was found in 14% of specimens from lesions that later became aneurysmal versus 15% of those that did not; adventitial resection was found in 14% and 7% of specimens, respectively (p = 0.08), with relatively more adventitia per specimen from those with aneurysm (55% vs. 30% without aneurysm, p = 0.08). CONCLUSIONS: Aneurysms occur relatively frequently after directional coronary atherectomy. Although there was no statistically significant correlation with the depth of arterial resection, the evidence from this study suggests that the role of adventitial resection in the occurrence of late aneurysm development should be explored further.

Results of directional atherectomy of primary atheromatous and restenosis lesions in coronary arteries and saphenous vein grafts.

Directional coronary atherectomy (DCA) was performed in 158 patients over a 2-year period at the Mayo Clinic. Primary atheromatous lesions were treated in 92 patients (group 1) and restenosis lesions were treated in 66 (group 2). Technical success (recovery of tissue and greater than or equal to 40% luminal enlargement with a residual stenosis of less than 50%) was achieved in 152 lesions (92%); clinical success (technical success and no in-hospital death, Q-wave myocardial infarction or coronary bypass surgery) was achieved in 143 patients (91%). Adjunctive balloon angioplasty was used in 41 patients. DCA was successful less often in group 1 than in group 2 (86 vs 97%; p = 0.038). A major complication occurred in 7% of patients; in-hospital death, Q-wave myocardial infarction and emergency coronary bypass surgery occurred in 3, 1 and 4% of patients, respectively. Major complications were more frequent in group 1 than in group 2 (10 vs 1; p = 0.02). During a follow-up period of 14 +/- 8 months, no difference between the groups was found in the incidence of late death (4%), Q-wave myocardial infarction (1%), recurrent severe angina (29%), bypass surgery (15%) or repeat interventional procedure of the same vascular segment (24%). Vein graft and restenosis lesions tended to have greater success and fewer complications. Angiographic restenosis (increase of greater than or equal to 30% in stenosis severity by visual assessment) occurred in 62% of patients and 58% of lesions with successful DCA, and was similar in the 2 groups; a tendency toward higher restenosis rates was seen in patients with vein graft DCA.(ABSTRACT TRUNCATED AT 250 WORDS)

Fistulous pseudoaneurysm complicating surgical accessory pathway interruption for Wolff-Parkinson-White syndrome.

Pseudoaneurysms of the left ventricle are unusual operative complications that have commonly been associated with replacement of the mitral valve. In this report, we describe a 31-year-old man who was referred to our institution because of atypical chest pain. He had previously undergone three operations for ablation of an accessory pathway because of Wolff-Parkinson-White syndrome. A pseudoaneurysm of the left ventricle was noted on transesophageal echocardiography, biplanar left ventriculography, and ultrafast cine computed tomography of the heart. Elective surgical repair was successful. Although rare, this case demonstrates an unusual but potentially serious complication of surgical treatment of Wolff-Parkinson-White syndrome.

Percutaneous transluminal coronary angioplasty in patients with cardiogenic shock.

In cardiogenic shock complicating acute myocardial infarction, percutaneous transluminal coronary angioplasty has been reported to significantly improve the modest survival benefits afforded by emergency surgical revascularization and thrombolytic therapy. The records of all patients who underwent angioplasty for acute myocardial infarction complicated by cardiogenic shock were retrospectively reviewed to determine whether coronary angioplasty improves survival. Of the 45 patients, 28 (group 1, 62%) had successful dilation of the infarct-related artery and 17 (group 2, 38%) had unsuccessful angioplasty. The groups were similar in extent of coronary artery disease, infarct location, incidence of multivessel disease and hemodynamic variables. The overall hospital survival rate was 56% (71% in group 1 and 29% in group 2). Group 1 patients had more left main coronary artery disease, and group 2 patients were older and had a higher incidence of prior myocardial infarction. Multivariate analysis showed that the survival advantage in patients with successful angioplasty was statistically significant (p = 0.014) when these factors were taken into account. At a mean follow-up interval of 2.3 years (range 1 month to 5.6 years), there were five deaths (four cardiac and one noncardiac), for a 2.3-year survival rate of 80% in patients surviving to hospital discharge. During the follow-up period, 36% of hospital survivors had repeat hospitalization for cardiac evaluation, 8% had myocardial infarction, 8% had coronary artery bypass surgery and 24% had angina.

Initial and long-term outcome of 354 patients after coronary balloon angioplasty of total coronary artery occlusions.

BACKGROUND: Coronary balloon angioplasty of chronic total occlusions is associated with relatively low success rates and a high incidence of restenosis. Whether there is long-term benefit in performing angioplasty of these lesions is unknown. The purpose of the present report was to analyze the long-term outcome of a large series of patients undergoing this procedure. METHODS AND RESULTS: A computerized database analysis of 354 consecutive patients (from 1979 to 1990) who underwent coronary angioplasty of a chronic total coronary occlusion was performed (mean age, 62.3 years). Initial technical success was achieved in 69%; in 66%, success was achieved without procedural death or need for coronary artery surgery. During hospitalization, six patients suffered myocardial infarction, nine required emergency bypass surgery, and nine patients died. During a mean follow-up period of 2.7 years, no difference was found in survival or freedom from myocardial infarction among 234 successfully dilated patients compared with 120 patients with a failed attempt. However, the use of coronary artery bypass surgery was significantly less after successful dilation (p less than 0.0001 versus failed attempt). No significant difference in the cumulative incidence of severe angina was observed between these two patient populations, with the majority remaining asymptomatic. Restenosis occurred in 59% of 69 patients who returned for follow-up angiography. CONCLUSIONS: Successful recanalization is achieved in the majority of patients undergoing angioplasty of chronic total occlusions and reduces the need for coronary artery bypass surgery. However, no major impact on either survival or incidence of myocardial infarction was noted after successful recanalization when patients with surgery were included.