[Results of the French register of renal stenting: the Esternal study]. / Résultats du registre français du stenting rénal: étude Esternal.

Renal artery angioplasty using the same techniques employed for coronary arteries has developed considerably. A register was set up in France to evaluate the efficacy of this treatment for improving renal function and lowering blood pressure in cardiac patients. Between 2001 and 2005, 205 patients (234 lesions) were treated in 14 centres (mean age: 69.2 +/- 10.4 years, 59% male). All of the patients had hypertension and the majority of them (171) had renal failure (creatinine clearance<90 ml/min). Direct implantation of a stent was performed in 75.2% of the cases, successfully in 196 patients (96%) with 220 lesions (95.2%). The complications encountered were segmental renal infarction in two patients (0.9%), and four cases of minor vascular complications at the puncture site (2%). The mean value for pre-implantation creatinine clearance was 54.6 +/- 32.8 ml/min and 58.1 +/- 36.0 post- implantations. The duration of follow up was 5.9 +/- 2.7 months. Mortality was 3.5% (seven patients, of whom two died from renal causes). The mean systolic and diastolic blood pressure was 142.2 +/- 16.2 and 78.9 +/- 9.5 respectively versus 164.9 +/- 25.2 and 89.1 +/- 14.8 before treatment (p<0.0001). A non-significant improvement in creatinine clearance at six months was also observed in patients with renal failure prior to treatment: 48.7 +/- 17.1 ml/min vs. 69.2 +/- 160.3. Renal artery stenting in cardiac patients with renal artery stenosis is associated with a very high success rate, with few complications and an improvement in hypertension and renal function.

Indications of coronary angioplasty and stenting in 2003: what is left to surgery?

UNLABELLED: For many years, coronary artery by-pass graft (CABG) remained the only effective treatment of multivessel disease compared to medical treatment. The first technical revolution was in 1977 when Gruentzig introduced balloon percutaneous transluminal coronary angioplasty (PTCA), the 2nd in the 90's with the developments of stents and antiaggregant protocols. The equipment for PTCA became more and more sophisticated, and the skill of cardiologists greater. In the 90's, interventional cardiology played a predominant role in revascularization as the number of CABG decreased at the same time, and emergency CABG for bail out almost disappeared (0% to 0.5%). Systematic stenting decreased the need for repeat revascularization to about 18-20% nowadays in the majority of centers, except in diabetic patients. Despite this fact restenosis remains the pitfall of angioplasty, mostly in diabetic patients presenting multivessel disease in which surgery with "all arterial grafts" gives good long term RESULTS: The first studies comparing PTCA and CABG are favourable to surgery (BARI), then late ones using stents (ARTS, ERACI 2) showed that stenting was at least equivalent to CABG, in terms of mortality or serious complications (major acute coronary events, MACE), despite a higher target vessel revascularisation (TVR) mainly due to restenosis in the angioplasty cohort. The same results are observed by stenting a high risk lesion as the unprotected left main stenosis can be, until then treated surgically. However, high volume centers studies treating by PTCA+stent the unprotected left main artery (LMA) shows that the 1 year survival rate is similar to surgery, but always related to a restenosis rate of 20% at 6 months in the stent group, which represents the only significant difference in terms of MACE; the new drug eluting stents lead us to expect, according to SIRIUS and TAXUS II studies, to reduce the restenosis rate, and by the way, the MACE could be dramatically lowered from 50% to 60%. Randomised studies would be necessary, but the extrapolation of the actual data, more particularly results of subgroups with a high risk of restenosis, diabetic patients and small vessels, lead us to think that stenting could come in first intention before surgery if TVR is significantly reduced. A complex anatomy, failed attempted chronic occlusion, several lesions on tortuous vessels, would remain the last surgical indication if CABG provides a more complete revascularization. The impact of these new drugs seems promising. However, we should await early results of studies in diabetic patients and bifurcations. But in high volume experienced centers, CABG indications would be reduced in the future to the technical pitfalls of stenting (complex or tortuous anatomy, chronic occlusions) or to the adverse additional cost of this device, unless reduction of restenosis or TVR could also cancel this extra cost. We expect randomised studies CABG versus stented angioplasty using drug eluting stents to confirm these preliminary data.

[Complete revascularisation of multivessel coronary artery disease during acute myocardial infarction. Results following hospitalization and after 30 months. Series of 86 interventions carried out with 167 multivessel disease patients; causes of failure]. / Revascularisation complète des patients multitronculaires en phase aiguë d'infarctus du myocarde. Résultats en fin de période hospitaliere et à 30 mois. Série de 86 cas effectués sur 167 patients multitronculaires consécutifs; causes d'échec.

This series studied 167 patients with multivessel disease, admitted consecutively for acute myocardial infarction (excluding cardiogenic shock), who underwent systematic angioplasty and stenting before the 12th hour of the culprit artery and the other vessels with >70% (QCA) angiographic stenosis, and followed up for a period of 8 to 68 months with an average follow-up of 2.5 years. The criteria of evaluation were: numbers of asymptomatic patients, deaths, new infarctions, residual ischaemias, cardiac failure, angioplasties or bypass surgeries. On admission, 43.1% of infarcts were anterior, 48.5% inferior or postero-inferior and 8.3% lateral wall infarcts. One hundred and twenty-two consecutive patients had double vessel disease and 45 has triple vessel disease. The failures of revascularisation of the culprit artery were excluded from the study. The feasibility rate of complete multivessel revascularisation in a single procedure was over half the cases (86 out of 167, 51.5%): 60.6% of double vessel disease and 26.9% of triple vessel disease, a simple favorable anatomical presentation being necessary to accomplish this objective. During the hospital period (30 days), 95.3% of patients who were completely revascularised remained totally asymptomatic, 2 (2.3%) had recurrent infarction, 1 (1%) had cardiac failure and 1 (1%) died of a non-cardiac cause. No cardiac deaths were observed in this series. Of the multivessel disease patients who could not be completely revascularised (N=81) (poor clinical state or complicated anatomical presentation), 83.6% were asymptomatic: there were 7.7% cases of cardiac failure, 2.4% of recurrent infarction; 1.2% died of non-cardiac causes and 1.2% died of a cardiac cause. The statistical difference was significant in favour of the patients who had successful complete revascularisation with respect to the others in terms of numbers of asymptomatic patients (p=0.004) and of numbers of cardiac failure (p=0.002). The follow-up rate of patients who had complete revascularisation in a single procedure was 98.8%. After two and a half years of follow-up, 74.1% of patients were totally asymptomatic; the cumulative major cardiac adverse event rate (death, infarction, angioplasty or bypass surgery) was 29.4% and the reoperation rate by angioplasty or bypass surgery was 27%.

Influence of the echocardiographic score and not of the previous surgical mitral commissurotomy on the outcome of percutaneous mitral balloon valvuloplasty.

OBJECTIVE: To evaluate prior mitral surgical commissurotomy and echocardiographic score influence on the outcomes and complications of percutaneous mitral balloon valvuloplasty. METHODS: We performed 459 complete mitral valvuloplasty procedures. Four hundred thirteen were primary valvuloplasty and 46 were in patients who had undergone prior surgical commissurotomy. The prior commissurotomy group was older, had higher echo scores, and a tendency toward a higher percentage of atrial fibrillation. RESULTS: When the groups were compared with each other, no differences were found in pre- and postprocedure mean pulmonary artery pressure, mean mitral gradient, mitral valve area, and mitral regurgitation. Because we found no significant differences, we subdivided the entire group based on echo scores, those with echo scores < or =8 and those with echo scores >8 the mitral valve area being higher in the < or =8 echo score group 2.06+/-0.42 versus 1.90+/-0.40 cm2 (p=0.0090) in the >8 echo score group. CONCLUSION: Dividing the groups based on echo score revealed that the higher echo score group had smaller mitral valve areas postvalvuloplasty.

[Primary angioplasty associated with systemic coronary stenting in acute myocardial infarction. Results at the end of the hospitalization period and at 24 months]. / Angioplastie primaire associée à la mise en place systématique d'une endoprothèse en phase aiguë d'infarctus du myocarde. Résultats en fin de période hospitalière et à 24 mois.

A series of 149 consecutive patients admitted for myocardial infarction (excluding cardiogenic shock), dilated and systematically stented in the acute phase before the 12th hour and followed up for a period from 30 days to 2 years, was studied. The criteria of follow-up were: number of asymptomatic patients, deaths, reinfarction, residual ischaemia, cardiac failure, angioplasty or bypass surgery. On admission, 40.9% of the infarcts were anterior, 44.3% inferior and 14.8% lateral. One hundred and eighty-three stents with a diameter of over 3 mm were inserted. The angioplasty success rate was 98.6%. During the hospital period, 90.6% of patients were asymptomatic. 4.7% had recurrent infarction, 4% had cardiac failure, 0.7% had residual ischaemia, and there were 0.7% of cardiac deaths. The survival rate was 97.2% at 2 years: 69.8% of patients were totally asymptomatic: the cumulative major cardiac event rate (death, reinfarction, angioplasties or bypass graft) was 25.9% and the reoperation rate on the culprit vessel was 20.1%. These results show the short and long-term value of angioplasty associated with coronary stenting over other techniques in the acute phase of infarction based on the criteria studied. The long-term results of larger randomised studies using glycoprotein inhibitors (Gp IIb IIIa) associated with angioplasty and stenting are expected for validating the use of these products.

Emergency coronary artery bypass surgery following coronary angioplasty and stenting: results of a French multicenter registry.

This study investigates the influence of coronary stenting on the risk of emergency bypass surgery performed within 24 hr of percutaneous transluminal coronary angioplasty (PTCA) with particular concern for incidence and indication. Since 1995, coronary stenting has been increasingly performed in France during angioplasty procedures, altering significantly the role of emergency bypass surgery. The outcome of elective stenting and widespread use of coronary stenting and its influence on emergency surgery have not been evaluated so far. Through a retrospective (1995) and prospective (1996) registry, we analyzed the incidence, indication and results of emergency bypass surgery performed within 24 hr of PTCA in 68 and 57 centers, respectively, accounting for nearly half of all angioplasty procedures in France. Data were collected through questionnaires consisting of separate forms for every case report that were sent to every center. Over the two years, 26,885 and 27,497 procedures were investigated with a stenting rate of 46% and 64%, respectively. The observed need for emergency surgery was constantly low throughout this period (0.38% and 0.32%, respectively). Indications for surgery included complications directly due to stent in 37% of cases in the 2-year period. Outcome remained poor, with in-hospital mortality in 10% and 17% and myocardial infarction in 27% and 25% of cases, respectively. A comparison of the results in centers with and without surgical facilities showed no differences in outcome, despite a longer time to surgery (359 min +/- 406 min vs. 170 min +/- 205 min, P = 0.0001) and a lower incidence of emergency surgery (0.25% vs. 0.44%, P = 0.0001) in centers without on-site surgery backup. The French multicenter registry reveals an increase in the use of stents together with a dramatic decrease in the incidence of emergency bypass surgery (below 0.5%) following PTCA. There has been a significant evolution in the indication, and stent implantation now accounts for a third of the indications for emergency bypass surgery.

[Single balloon versus Inoue balloon in percutaneous mitral balloon valvuloplasty. Short-term results and complications]. / Balãco Unico versus balão de Inoue na valvoplastia mitral percutânea por balão. Resultados imediatos e complicações.

PURPOSE: To assess short-term results and complications of percutaneous mitral balloon valvuloplasty (PMBV) performed with Inoue balloon (IB) and single low profile balloon (SB). METHODS: We performed 390 PMBV procedures, 29 with IB and 337 with SB. There were no differences in age, sex, echocardiographic score distribution and echocardiographic mitral valve area (MVA). RESULTS: We performed 29 complete procedures with IB and 330 of 337 in SB group. Comparing IB and pre and pos-PMBV data we obtained: mean pulmonary artery pressure (MPAP) 36 +/- 15 and 39 +/- 14 mmHg, p = 0.2033, mean mitral gradient 17 +/- 6 and 20 +/- 77 mmHg, p = 0.0396 and MVA 0.9 +/- 0.2 and 0.9 +/- 0.2 cm2, p = 0.8043 and pos-PMBV:MPAP 25 +/- 8 and 28 +/- 10 mmHg, p = 0.2881, gradient 5 +/- 3 and 5 +/- 4 mmHg, p = 0.2778 and MVA 2.2 +/- 0.2 and 2.0 +/- 0.4 cm2, p = 0.0362. Mitral valve (MV) was competent in 26 patients in IB and in 280 in SB group and we had +/4 mitral regurgitation in 3 patients in IB and in 57 in SB group (p = 0.3591) pre-PMBV respectively and pos-PMBV there was also no difference in MV competence (p = 0.7439). CONCLUSION: Both techniques were effective. Hemodynamic data were also similar although MVA was greater in IB group after PMBV.

[Percutaneous mitral valvuloplasty with the single balloon technique. Short-term results, complications and in-hospital follow-up]. / Valvoplastia mitral percutânea com a técnica do balão único. Resultados imediatos, complicações e evolução intra-hospitalar.

PURPOSE: To study the short-term results, complication and in-hospital follow-up of 268 percutaneous mitral balloon valvuloplasty (PMBV) procedures performed with the low-profile monofoil balloon (LPMB) technique from 1990 to 1995. METHODS: A single 30mm balloon diameter was used in 247 (92.9%) procedures, a single 25mm balloon diameter in 9 (3.3%), a single 25mm balloon followed by a single 30mm balloon diameter in 7 (2.6%) and in 5 procedures a balloon was not used. The mean age group was 36 +/- 12 years. Two hundred nineteen (81.7%) procedures were performed in women (mean age 36 +/- 12 years) and 49 (18.3%) in men (mean age, 35 +/- 14 years) (p = 0.78). Patients were in functional class II (NYHA) in 39 (14.5%), class III in 198 (73.9%) and class IV in 31 (11.6%). Patients were in sinus rhythm in 228 (85.1%) procedures and in atrial fibrillation in 40 (14.9%). The echocardiographic score ranged from 4 to 14 (mean 7.2 +/- 1.5). RESULTS: There were 256 complete procedures, 249 of which were successful (mitral valve area (MVA) > or = 1.5cm2 after PMBV). Echocardiographic calculated MVA before PMBV was 0.9 +/- 0.2cm2. Hemodynamic calculated MVA before PMBV was 0.9 +/- 0.2cm2 and after was 2.0 +/- 0.4cm2 (p < 0.000001). Mean pulmonary artery pressure decreased from 40 +/- 15mmHg to 28 +/- 10mmHg (p < 0.000001) and mitral mean gradient from 20 +/- 7mmHg to 5 +/- 4mmHg (p < 0.000001). In the 256 complete procedures mitral valve (MV) was competent in 214 and there was 1+ mitral regurgitation (MR) in 42. After PMBV, MV was competent in 166 and there was 1+ MR in 68, 2+ in 16, 3+ in 5 and 4+ MR in 1. There were complications in 14 (5.2%) procedures, severe MR in 6 (3 or 4+), stroke in 2 and cardiac tamponade in 6. Two patients died during emergency cardiac surgery after left ventricular perforation and 1 after stroke. CONCLUSION: PMBV with the LPMB was an effective procedure with a high success rate and a low rate of complications as the more usual double-balloon and Inoue balloon techniques.

[Percutaneous balloon mitral valvoplasty. Immediate results, complications and hospital outcome]. / Valvoplastia mitral percutânea por balão. Resultados imediatos, complicações e evolução hospitalar.

PURPOSE: To study the short-term results, complications and in-hospital follow-up of 223 percutaneous mitral balloon valvuloplasty (PMBV) procedures (proc)in 219 patients. METHODS: It was used a single 20mm balloon diameter in 4 proc, double balloon in 7, Inoue balloon in 4 and low profile balloon in 196. The mean-age group was 37.19 years. One hundred eighty three (82.1%) procedures were performed in women (mean age, 36.99 years) and 40 (17.9%) in men (mean age, 38.10 years) (p = 0.63). Patients were in functional class II, (NYHA) in 25 (11.2%) procedures, class III in 165 (74.0%) and class IV in 33 (14.8%). Patients were in sinus rhythm in 182 procedures (81.6%) and in atrial fibrillation in 41 (18.4%). The echocardiographic score range from 4 to 14 (7.4% +/- 1.7). Among 4 and 11 were 98.2% of patients. RESULTS: We had 203 complete proc and success, mitral valve area (MVA) > or = 1.5cm2 after PMBV in 194 proc. Echocardiographic MVA before PMBV was 0.9 +/- 0.2cm2 and after 1.8 +/- 0.3cm2 (p < 0.01). Hemodynamic measures MVA before PMBV was 0.9 +/- 0.2cm2 and after was 1.9 +/- 0.3cm2 (p < 0.01). Mean pulmonary artery pressure decreased from 39 +/- 14mmHg to 27 +/- 11mmHg (p < 0.01) and mitral mean gradient from 20 +/- 9mmHg to 6 +/- 5mmHg (p < 0.01). In the 203 proc, mitral valve (MV) was competent in 176 and there were 1+ mitral regurgitation (MR) in 27. After PMBV, MV was competent in 126, and there were 1+ MR in 60, 2+ in 10.3+ in 6 and 4+ MR in 1. There was complication in 15 proc, severe MR in 7 (3 or 4+), stroke in 3 and cardiac tamponade in 5. Two patients died during emergency cardiac surgery after left ventricular perforation and one by stroke. CONCLUSION: PMBV was an effective procedure with a high grade of success and low rate of complication.

[Evaluation, by flow cytometry, of activated platelet levels after coronarography and intraluminal angioplasty]. / Evaluation, par la cytométrie en flux, du taux de plaquettes activées après les coronarographies et les angioplasties intraluminales.

Coronarography and intraluminal angioplasty induce platelet activation. In this study, activated platelets were evaluated by measuring platelet-bound fibrinogen using a polyclonal fluorescent antibody in flow cytometry on whole blood. For normal subjects, the percentage of platelets binding fibrinogen was low (16.67%) and reached 81.0% in response to ADP. The percentages of platelets binding fibrinogen were evaluated 24 hours before and after coronarography. During intracoronary angioplasty, blood was collected from the catheter before and after the dilation and aspirin bolus (1 g). In both groups, the percentages of activated platelets were lower compared with those of the control group (respectively 3.96% and 5.59% versus 16.67%) following aggregation inhibitor, anticoagulant and calcium inhibitor therapies. Twenty-four hours after coronarography, platelet activation was noted (9.71% versus 3.96%). During angioplasty no significant activation was observed immediately after dilation (6.54% versus 5.59%). In both groups before the intervention, ADP stimulation was still responsible for platelet activation but to a lesser extent than in the control group (60.42% and 66.31% versus 81.0%). After coronarography, the platelet response to ADP was identical to that in the control group (81.01% versus 81.0%). Immediately after dilation, this activation was not observed in patients with an angioplasty. This study shows that platelet activation occurs 24 hours after coronarography, whereas after dilation and an aggregation inhibitor bolus this activation is not observed during angioplasty.

Valvoplastia mitral percutânea por baläo, resultados imediatos e complicaçöes / Percutaneous mitral balloon valvuloplasty. Immediate results and complications

Foram estudados os resultados obtidos em 156 procedimentos de valvoplastia mitral percutânea por baläo (VMPB) realizados em 153 pacientes, no período de 6 de julho de 1987 a 31 de maio de 1993. A idade do grupo foi de 37,62 +/_ 13,76 anos. Foram 126 procedimentos (80,8 por cento) em mulheres (idade média 37,30 +/_ 13,00 anos) e 30 procedimentos (19,2 por cento) em homens (idade média de 38,93 +/_ 16,74 anos) p= 0,568181). A classe funcional (CF) de NYHA foi II em 12 procedimentos (7,7 por cento), I em 118(75,6 por cento) e IV EM 26(16,7 por cento). Em 131 procedimentos (84,0 por cento) os pacientes estavam em ritmo sinusial e em 25 (16,0 por cento) estavam em fibrilaçäo atrial. O escore ecocardiográfico variou de 4 a 14 pontos com média 7,7 +/_ 1,7 pontos, entre 4 a 9 pontos situou-se 90,4 por cento dos pacientes. Foram efetivados com dados pré e pós VMPB, 139 procedimentos e houve sucesso, área valvar mitral (AVM) 1,5 centímetros ao quadrado pós VMPB, em 131 procedimentos. Quando medida pela ccardiografia AVM pré VMPB foi de 0,9 +/_ 0,2 cm ao quadrado e após VMPB 1,8 +/_ 0,3 cm ao quadrado (p<0,000001) e quando medida por métodos hemodinâmicos foi de 0,9 +/_ 0,2 cm ao quadrado pós VMPB (p<0,000001). A pressäo pulmonar média caiu de 41 +/_ 15 mmHg 27 +/_ 11 mmHg pós VMPB (p<0,000001) e o gradiente mitral médio caiu de 22 +/_ 7 mmHg para 6 +/_ 5 mmHg (p<0,000001). Foram utilizados baläo único de 20 mm (4 procedimentos), duplo baläo (7 procedimentos), baläo de Inoue (4 procedimentos) e baläo nio de baixo perfil (131 procedimentos). Dos 139 procedimentos pré VMPB, em 121 a valva mitral (VM) era competente e em 18 havia regurgitaçäo mitral (RM) de 1+. Após a VMPB a VM era competente em 91 e havia RM de 1+ em 39, de 3+ em 4 e de 4+ em 1. Houve complicaçäo em 10 procedimentos, sendo insuficiência mitral grave IM em 5 (3 ou 4+), acidente vascular cerebral (AVC) em 3 e tamponamento cardíaco em 2. Dos 10,2 evoluíram para óbito, um após tamponamento cardíaco por perfuraçäo de ventrículo esquerdo e utr por descerebraçäo após AVC. Conclui-se que a VMPB foi um procedimento efetivo, com alto grau de suceso nos procedimentos efetivados e com baixo percentual de complicaçöes.

[Percutaneous transluminal renal angioplasty in the treatment of renovascular hypertension]. / Angioplastia renal transluminal percutânea no tratamento da hipertensão renovascular.

PURPOSE: To analyze the effect of percutaneous transluminal renal angioplasty (PTRA) in renovascular hypertension. METHODS: Twenty-three patients with renal artery stenosis and arterial hypertension underwent PTRA. There were 11 male and 12 female, 19 to 78 years old (45.8 +/- 17.41). In 20 lesions the diagnosis was atherosclerosis, in 7 fibromuscular dysplasia and in 1 Takayasu arteritis. Three patients underwent bilateral dilatation and 2 patients repeated the procedure due to restenosis. Two patients presented with acute renal failure and severe bilateral renal artery stenosis. RESULTS: There were 21 technical success in 25 procedures. After 20 satisfactory dilatations, clinical success followed in 17 (100% of cases of fibromuscular dysplasia cases and 77% of atherosclerosis. The fall in diastolic arterial pressure after PTRA was statistical significant (p < 0.001). In two cases acute renal failure the renal function became normal after angioplasty. There were 2 complications and no death attributed to PTRA. CONCLUSION: The method was effective and safe in the management of renovascular hypertension during the short-term follow-up. It was possible in two cases of acute renal failure to normalize renal function.

[Angioplasty of distal aorta and iliac, femoral, popliteal, renal and subclavian arteries. Early and late results]. / Angioplastia de aorta distal e artérias ilíaca, femoral, poplítea, renal e subclávia. Resultados imediatos e tardios.

PURPOSE: To study the late results of peripheral angioplasty. PATIENTS AND METHODS: In the period of 8 years from August, 1981 until August, 1989, 27 patients were submitted to 33 procedures of peripheral angioplasty. RESULTS: There was success in 29 procedures, an insufficient dilatation in 1 and and failure in 3 (2 new attempts were effective). Success rate was 88% of the procedures; clinical and angiographic success was reached in 25 (93%) of the 27 patients. Thirty four obstructions were successful dilated: 12 in renal artery, 12 in common iliac artery, 4 in external iliac artery, 3 in superficial femoral artery, 1 in distal aorta. In the evolution we had a restenosis of a renal artery that was redilated, a precocious occlusion of a common iliac artery (9% of common iliac artery dilatations and 6% of the total of the iliac dilatations) and a popliteal occlusion. Of the 34 dilatations we had a patency of 91% until 2 months. CONCLUSION: Angioplasty showed to be an effective method with good results in the long term follow-up.

[Value of the combined Lastac laser-angioplasty technic in symptomatic superficial femoral occlusion]. / Intérêt de la technique combinée Lastac laser-angioplastie dans les occlusions fémorales superficielles symptomatiques.

The results of peripheral transluminal angioplasty are satisfactory in stenotic arteries but those observed in the recanalisation of occluded peripheral arteries are not so good. There would therefore seem to be a good therapeutic opportunity for laser between angioplasty and surgery for patients with symptomatic arterial occlusion. The authors report their experience with the Lastac laser in 12 patients with symptomatic superficial femoral arterial occlusion. This is a no-contact laser. All patients had surgical indications in case of failure to recanalise by laser, despite collateral circulation by the profunda artery which was inadequate on effort leading to claudication and a limited walking perimeter. After 1 initial failure, 11 successful procedures were performed. There were no perforations due to the Argon laser beam but 2 were observed with the guide wire which was rapidly sealed by the balloon catheter. A surgical haematoma at the percutaneous puncture point resulted in 1 reocclusion during the patient's hospital period so that the 11 technical successes became 10 clinical successes. At medium-term follow-up, one asymptomatic occlusion had occurred and one restenosis was successfully redilated. The advantages of a continuous Argon "Lastac" laser compared with a contact laser are its capacity for auto-control, its coaxial fibre placement and the absence of direct contact with the lesion. The coaxial fibre arrangement plays an important role in preventing vascular perforation. These factors enable it to be used with more safety in patients with arterial occlusion.

[Transluminal coronary angioplasty using a percutaneous axillary route with an arterial sheath]. / Angioplastie coronaire transluminale par voie percutanée axillaire avec introducteur artériel.

Out of 1400 percutaneous transluminal coronary angioplasties (PTCA), 23 (1.6 p. 100) were performed by the left percutaneous axillary approach because the bifemoral approach could not be used. There were 18 patients (17 men, 1 woman) with a mean age of 58 years. The coronary vessels dilated were the anterior interventricular artery (n = 4), the circumflex artery (n = 9) and the right coronary artery (n = 10), i.e. a total of 25 stenoses. The success rate in procedures was 83 p. 100 (19/23), and the primary success rate in patients was 83.3 p. 100 (15/18): Despite a good initial result, one patient developed inferior myocardial infarction as a result occlusion of a dominant distal circumflex artery, due to protamine administration immediately after the procedure. Another failure ascribable to the approach was due to selective catheterization being impossible. The mean duration of TCA was 38 min. In every cases the arterial introducer was withdrawn after neutralization with protamine. There were 4 cases of restenosis (25 p. 100) :3 were treated by a second PTCA using the percutaneous axillary approach and 1 by surgery. The method has the following disadvantages: (1) neutralization with protamine is mandatory (we had 1 case of occlusion with infarction after protamine in this series); (2) it is imperative to prevent the formation of a blood collection that would infiltrate the brachial plexus; for this purpose, the axillary cavity must be compressed effectively after PTCA and the puncture area must be watched for 24 to 48 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

[Electro-mechanical dissociation concomitant with myocardial reperfusion in the acute phase of myocardial infarction]. / Dissociation électro-mécanique contemporaine de la reperfusion myocardique en phase aiguë d'infarctus du myocarde.

An unusual case of transient electro-mechanical dissociation concomitant with myocardial reperfusion is reported. The patient had myocardial infarction caused by occlusion of the middle anterior interventricular artery relieved by injection of urokinase and plasminogen in situ. The dissociation could be documented by simultaneous ECG recording on 3 leads and direct intravascular recording of femoral arterial pressure, the patency of that artery, and its maintenance, being demonstrated by angiography. This clinical case can be added to the list of events which occur during reperfusion of the myocardium after prolonged ischaemia. Its mechanisms, so far, are purely conjectural.

[Intracavitary extraction of fragments of intracardiac catheters using a pigtail catheter. Apropos of 14 operations]. / Extraction endocavitaire de fragments de cathéters intracardiaques à l'aide d'une sonde "queue de cochon". A propos de 14 interventions.

Endocavitary extraction of intracardiac fragments of intravenous catheters was attempted in 14 patients over a 7 year period. The fragments were recovered in 13 cases under local anaesthesia without complications. The average duration of the procedure was less than 15 minutes. The technique requires a pigtail catheter, a material which is usually readily available in all catheter laboratories. This simple procedure may prevent complications and enable some patients to avoid surgery.

[Delayed filling of the anterior interventricular artery. Apropos of 9 cases]. / Retard de remplissage de l'artère interventriculaire antérieure. A propos de 9 cas.

Selective coronary angiography has shown that typical angina pectoris may occur in the absence of atheromatous coronary stenosis. Other causes of these attacks of pain have been found: coronary spasm, small vessel disease, abnormal dissociation of haemoglobin or metabolic disturbances of the myocardial cell. Of all the patients undergoing coronary angiography in 1984 at the Centre Cantini, 9 had no classical coronary lesions but delayed filling of the left anterior descending artery. This syndrome was described for the first time in 1972 by Tambe as the "slow flow velocity syndrome". The aim of this study was to analyse the clinical, ECG and haemodynamic profiles of those patients. Five of them also underwent stress Thallium myocardial scintigraphy. An ergometrine provocation test was performed afterwards under ECG control. Delayed filling was appreciated by comparison with the other vessels and also by measuring the filling time which was two or three times longer than in a control series of 9 patients with angina and normal coronary arteries. The difference was statistically significant. These findings were only observed in strictly normal coronary vessels; they were reproducible and unaffected by the administration of nitrate derivatives. In our series all 9 patients were men with an average age of 51.4 years. One patient was asymptomatic and had a history suggestive of myocardial infarction, and 4 others had typical angina of effort: all had abnormal exercise stress tests. The other 3 patients had spontaneous atypical chest pain, normal resting ECG and a negative exercise stress test (impossible in one case). The five stress Thallium scintigraphies showed myocardial perfusion defects.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary revascularization at the acute phase of myocardial infarction. Short and median-term survival of 359 patients. Multicenter study]. / Désobstruction coronarienne à la phase aiguë de l'infarctus du myocarde. Survie à court et moyen terme de 359 patients. Etude multicentrique.

Three hundred and fifty nine consecutive patients from 4 different French centres who underwent attempted early coronary revascularisation during the acute phase of myocardial infarction by intracoronary thrombolysis (309 cases) intravenous thrombolysis (26 cases) and transluminal angioplasty (24 cases) were reviewed to evaluate the short and medium term results of these non-surgical techniques. Three groups of patients were identified from the results of initial and secondary coronary angiography: 1) deaths during the procedure (1.9%), 2) successes, with immediate and stable revascularisation (65%), 3) failures, also including initial successes with secondary reocclusion (33.1%). The global mortality at one month was 10.9%. This was significantly lower after revascularisation (p less than 0.001): 4.7% in patients with successful procedures and 17.6% in the others. The one year survival rate was also significantly higher in patients successful revascularisation (93 +/- 4% vs 75 +/- 8%, p less than 0.001). There were more recurrent infarctions and residual angina in patients with successful early coronary revascularisation: 7.7% and 12% respectively vs 4.2% and 8.4% respectively in the other patient group. In the successful group, 200 patients (86%) had one or more stenoses greater than 70% narrowing after coronary revascularisation. The recurrent infarction rate in the 94 patients treated medically was 9% and 17% had residual angina compared to 6% and 10% respectively in the 106 patients referred for coronary bypass surgery or undergoing complementary angioplasty. Three conclusions may be drawn from this non-randomised study of coronary revascularisation during the acute phase of myocardial infarction: attempts at coronary revascularisation do not aggravate the immediate prognosis of myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)