[Fenestration of a spontaneous coronary hematoma with life-threatening dissection: A case of recurrent and multivessel spontaneous coronary artery dissections in a young female]. / Fenestration d'un hématome coronaire spontané avec dissection menaçante : à propos d'un cas de dissections coronaires spontanées récidivantes sur plusieurs vaisseaux chez une jeune femme.

The fenestration of a coronary artery hematoma is a therapeutic option in case of a life-threatening spontaneous coronary artery dissection, if the conservative treatment is not feasible. Here we present the case of a 34-year-old woman who presented three spontaneous coronary artery dissections, on three different arteries, over a period of twenty-one months. The diagnosis was confirmed by endovascular imaging. During an acute coronary syndrome, emergent percutaneous coronary intervention of the left anterior descending artery was performed, successfully, by a fenestration of the hematoma, using an AngioSculpt® scoring balloon.

[Vascular approaches and closure devices for percutaneous coronary intervention]. / Les voies d'abord et systèmes de fermeture dans l'angioplastie coronaire.

The choice of a transradial or transfemoral approach remains a pivotal decision in percutaneous coronary angioplasty. We discuss here the varying criteria leading to a rational choice in the arterial access choice. Since the emergent transradial approach in France has led to a dramatic reduction in local vascular complications, we also discuss the remaining place of femoral approach and the usefulness of femoral percutaneous closure devices.

[Chronic total occlusions: Is there a woman specificity?] / Occlusions coronaires chroniques : existe-t-il une spécificité féminine ?

Many differences have been reported regarding gender in angioplasty procedures (PCI), but their potential influence on clinical outcomes after CTO PCI has not been elucidated. Aim of this paper is to analyse these potential differences starting from 2 clinical cases. The basic features found in the two clinical cases presented here, older age and presence of diabetes (that are more frequent in women), are in line with the differences identified in non-CTO studies on angioplasty. Furthermore, CTO in women are generally under-diagnosed and less frequently treated by angioplasty than in men. These features combined to the often atypical clinical presentation could explain why women are generally less frequently enrolled in CTO registries than men. Although data on the impact of gender on this topic are scarce, it appears that, despite a clear outcome difference in patients who have a successful CTO angioplasty and similar success rates, women are still under-referred for a CTO angioplasty. Indeed, CTO angioplasty seems a valid therapeutic option, in women as in men.

Can we provide reperfusion therapy to all unselected patients admitted with acute myocardial infarction?

OBJECTIVES: This study sought to assess the maximal rate of acute Thrombolysis in Myocardial Infarction (TIMI) grade 3 patency that can be achieved in unselected patients. BACKGROUND: Early and complete (TIMI grade 3 flow) reperfusion is an important therapeutic goal during acute myocardial infarction. However, thrombolysis, although widely used, is often contraindicated or ineffective. The selective use of primary and rescue percutaneous transluminal coronary angioplasty (PTCA) may increase the number of patients receiving reperfusion therapy. METHODS: A cohort of 500 consecutive unselected patients with acute myocardial infarction were prospectively treated using a patency-oriented scheme: Thrombolysis-eligible patients received thrombolysis (n = 257) and underwent 90-min angiography to detect persistent occlusion for treatment with rescue PTCA. Emergency PTCA (n = 193) was attempted in patients with contraindications to thrombolysis, cardiogenic shock or uncertain diagnosis and in a subset of patients admitted under "ideal conditions." A small group of patients (n = 38) underwent acute angiography without PTCA. Conventional medical therapy was used in 12 patients with contraindications to both thrombolysis and PTCA. RESULTS: Ninety-eight percent of patients received reperfusion therapy (thrombolysis, PTCA or acute angiography), and angiographically proven early TIMI grade 3 patency was achieved in 78%. Among patients with TIMI grade 3 patency, thrombolysis alone was the strategy used in 37%, emergency PTCA in 40% and rescue PTCA after failed thrombolysis in 15%; spontaneous patency occurred in 8%. CONCLUSIONS: Reperfusion therapy can be provided to nearly every patient (98%) with acute myocardial infarction. Rescue and direct PTCA provided effective early reperfusion to patients in whom thrombolysis failed or was excluded.

Reperfusion syndrome: relationship of coronary blood flow reserve to left ventricular function and infarct size.

OBJECTIVES: We tested the hypothesis that the reperfusion syndrome (RS), defined as an additional elevation of the ST segment upon reperfusion, may be a marker of microcirculatory reperfusion injury during acute myocardial infarction (AMI). BACKGROUND: The pathophysiology of the RS is unknown, and its prognostic implications are controversial. METHODS: Twenty-one patients with an anterior AMI treated < or =12 h after onset by primary coronary angioplasty (PTCA) were studied. Coronary velocity reserve (CVR), an index of microcirculatory function, was measured using a Doppler guidewire. Left ventricular (LV) ejection fraction, infarct size (percent defect) and LV end-systolic volume index (LVESVi) were evaluated by radionuclide ventriculography, 201T1 single-photon emission computed tomography and contrast ventriculography, respectively. RESULTS: Baseline ST elevation and pain-to-TIMI 3 time were similar in patients with and without RS. Patients with RS (10/21) had a lower post-PTCA CVR than patients without RS (median [95% confidence interval]: 1.2 [1-1.3] vs. 1.6 [1.5-1.7], p < 0.005). Even though predischarge CVR was similar in the two groups, infarct size at six weeks (26 [21 to 37] vs. 14 [10-17]% 201T1 defect, p = 0.001) and predischarge LVESVi (45% [40 to 52] vs. 30% [29 to 38] mL/m2, p = 0.001) were larger, and LV ejection fraction at six weeks (40% [37 to 46] vs. 55% [50 to 60], p = 0.004) was lower in patients with RS than in patients without RS. CONCLUSIONS: Patients with RS during primary PTCA for an anterior AMI have a transiently lower CVR than patients without RS, but sustained LV dysfunction and larger infarct size, suggesting that RS is a marker of microcirculatory reperfusion injury.

The French Randomized Optimal Stenting Trial: a prospective evaluation of provisional stenting guided by coronary velocity reserve and quantitative coronary angiography. F.R.O.S.T. Study Group.

OBJECTIVES: We sought to make a prospective comparison of systematic stenting with provisional stenting guided by Doppler measurements of coronary velocity reserve and quantitative coronary angiography. BACKGROUND: Despite the increasing use of stents during percutaneous transluminal coronary angioplasty, it is unclear whether systematic stenting is superior to a strategy of provisional stenting in which stents are placed only in patients with unsatisfactory results or as a bail-out procedure. METHODS: Two hundred fifty-one patients undergoing elective coronary angioplasty were randomly assigned either to provisional stenting (group 1, in which stenting was performed if postangioplasty coronary velocity reserve was <2.2 and/or residual stenosis > or =35% or as bail-out) or to systematic stenting (group 2). The primary end point was the six-month angiographic minimal lumen diameter (MLD). Major adverse cardiac events were secondary end points (death, acute myocardial infarction and target lesion revascularization). RESULTS: Stenting was performed in 48.4% of patients in group 1 and 100% of patients in group 2 (p<0.01). Six months after angioplasty, the MLD did not differ between groups (1.90+/-0.79 mm vs. 1.99+/-0.70 mm, p = 0.39), as was the rate of binary restenosis (27.1% vs. 21.4%, p = 0.37). Among patients with restenosis, 13/32 (40.6%) in group 1 but 100% (25/25) in group 2 had in-stent restenosis (p<0.01). Target lesion revascularization (15.1% vs. 14.4% in groups 1 and 2 respectively, p = 0.89) and major adverse cardiac events (15.1% vs. 16.0%, p = 0.85) were not significantly different. CONCLUSIONS: Systematic stenting does not provide superior angiographic results at six months as compared with provisional stenting.

A matched comparison of the combination of prehospital thrombolysis and standby rescue angioplasty with primary angioplasty.

This study sought to assess the rate of acute Thrombolysis In Myocardial Infarction (TIMI) trial grade 3 patency that can be achieved with the combination of prehospital thrombolysis and standby rescue angioplasty in acute myocardial infarction. No large angiographic study has been performed after prehospital thrombolysis to determine the 90-minute TIMI 3 patency rate in the infarct-related artery. Hospital outcome and artery patency were compared to 170 matched patients treated with primary angioplasty. Prehospital thrombolysis was applied 151+/-61 minutes after the onset of pain in 170 patients (56+/-12 years, 86% men), using recombinant tissue-type plasminogen activator, streptokinase, or eminase. Emergency 90-minute angiography was performed in every case. All patients in whom thrombolysis failed underwent rescue angioplasty. After thrombolysis alone, TIMI grade 3 flow in the infarct-related artery was observed in 108 patients (64%), TIMI grade 2 in 12 (7%), and TIMI grade 0 or 1 in 50 (29%). Rescue angioplasty was successful in 47 of 50 attempts. Overall, TIMI 3 patency was achieved in 91%, and additionally TIMI 2 flow in 7% of patients, an average of 113+/-39 minutes after thrombolysis and 55+19 minutes after admission. Therefore, < 2 hours after thrombolysis, only 2% of patients had persistent occlusion (TIMI 0 or 1) of the infarct-related artery. In-hospital mortality was 4% overall (7 of 170), and 3% in the 155 patients in whom TIMI 3 was obtained during the acute phase. Severe hemorrhagic complications occurred in 14 patients (8%) with 2 fatal cerebral hemorrhages (7% of patients required transfusions). The matched comparison with primary PTCA showed no significant difference in hospital outcome. Combined prehospital thrombolysis, 90-minute angiography, and rescue angioplasty yield a high rate of acute TIMI 3 patency rate early after thrombolysis and hospital admission. A randomized, prospective comparison between these 2 reperfusion strategies may be now warranted.

A randomized double-blind trial of intravenous trimetazidine as adjunctive therapy to primary angioplasty for acute myocardial infarction.

BACKGROUND: Despite high patency rates, primary angioplasty for myocardial infarction does not necessarily result in optimal myocardial reperfusion and limitation of infarct size. Experimentally, trimetazidine limits infarct size, decreases platelet aggregation, and reduces leukocyte influx into the infarct zone. To assess trimetazidine as adjunctive therapy to primary angioplasty for acute myocardial infarction a prospective, double-blind, placebo-controlled pilot trial was performed. METHODS: 94 patients with acute myocardial infarction were randomized to receive trimetazidine (40 mg bolus followed by 60 mg/day intravenously for 48 h) (n=44) or placebo (n=50), starting before recanalization of the infarct vessel by primary angioplasty. Patients underwent continuous ST-segment monitoring to assess return of ST-segment deviation to baseline and presence of ST-segment exacerbation at the time of vessel recanalization. Infarct size was measured enzymatically from serial myoglobin measurements. Left ventricular angiography was performed before treatment and repeated at day 14. RESULTS: Blinded ST segment analysis showed that despite higher initial ST deviation from baseline in the trimetazidine group (355 (32) vs. 278 (29) microV, P=0.07), there was an earlier and more marked return towards baseline within the first 6 h than in the placebo group (P=0.014) (change: 245 (30) vs. 156 (31) microV respectively, P=0.044). There was a trend towards less frequent exacerbation of ST deviation at the time of recanalization in the trimetazidine group (23.3 vs. 42.2%, P=0.11). There was no difference in left ventricular wall motion at day 14, or in enzymatic infarct size. There was no side effect from treatment. Clinical outcomes were similar between groups. CONCLUSION: Trimetazidine was safe and led to earlier resolution of ST-segment elevation in patients treated by primary angioplasty for acute myocardial infarction.

Coronary angiography using 4 or 6 French diagnostic catheters: a prospective, randomized study.

Diagnostic catheter size has been progressively decreased in order to reduce complications (particularly access-site complications) and permit early ambulation after coronary angiography. However, excessive down-sizing can result in poor catheter conformation and poor imaging quality of coronary angiograms (CA). This study randomly compared the accuracy and angiographic quality (QUAL) of CA performed with 4 French (Fr) vs. 6 Fr diagnostic catheters. Injections were done manually using a low-viscosity, non-heated, low-osmolality contrast media (Iomeprol). CAs were performed via the femoral approach using Judkins catheters. Handling, torque, selectively and stability were graded from 1 (excellent) to 4 (unacceptable) by the operator. QUAL was also graded from 1 (unacceptable) to 10 (excellent) by the operator in all patients and by an independent Core laboratory in 50 patients matched for gender and weight. Between January and April 1997, a total of 405 consecutive patients were randomized. Mean age was 63.4 +/- 11.1 years and 79% were male. Clinical characteristics of patients, quality of left coronary catheter and cross-over rates (1.5% with 6 Fr vs. 3.9% with 4 Fr catheters) were similar in both groups. Using the right coronary catheters, the only difference was handling, which was found to be easier with 6 Fr catheters (1.16 +/- 0.55 vs. 1.34 +/- 0.77, respectively; p = 0.007). Similarly, handling difficulty using the pigtail catheter was the only significant difference between the two groups (1.16 +/- 0.50 vs. 1.33 +/- 0.77, respectively; p = 0.009), but no cross-over was necessary in either group. The QUAL of CA was slightly but significantly better with 6 Fr than with 4 Fr catheters but considered non-diagnostic (< 7/10) in 1.4% vs. 6.8% of left CAs (p = NS). Procedural time (21.0 +/- 7.2 minutes vs. 19.0 +/- 8.1 minutes; p = 0.007) was shorter with 4 Fr catheters, but x-ray exposure, compression times and amount of contrast media used were similar. Ambulation was obtained at 2 hours in 15.1% vs. 34.0% of patients (p < 0.001) and at 4 hours in 43.8% vs. 52.4% (p < 0.05), respectively. The incidence of the worst access-site complication (moderate hematoma) was similar (1%) in both groups. CA can be performed using 4 Fr catheters and manual injections of low-viscosity contrast media with acceptable angiographic results in the majority of cases. This is associated with a shorter procedural time and earlier ambulation, and a decreased but acceptable angiographic quality.

[Effects of de-endothelialization and angiotensin II on the vascular remodeling in a model of rabbit aorta organ culture]. / Effets de la désendothélialisation et de l'angiotensine II sur le remodelage vasculaire dans un modèle d'aorte de lapin en culture organotypique.

The effects of de-endothelialization and angiotensin II (A II) on smooth muscle cell (SMC) growth are still controversial. Cell culture experiments suggest an hypertrophic effect of AII, whereas in vivo experiments in de-endothelialized arteries using angiotensin converting enzyme inhibitors suggest a possible role of AII on proliferation and/or migration of SMC. Phenotype of SMC in culture does not necessarily reflect that in the whole organ. Yet, in vivo models are too complex to permit conclusions as to the proper effect of AII or endothelium. Therefore, we examined the effect of de-endothelialization and AII on SMC growth in an organ culture of vessel wall. Rabbit thoracic descending aortas (n = 42) held at their in vivo length, perfused at 40 ml/min and pressurized to 70 mmHg (P70) were maintained in DME medium supplemented with 20% fetal calf serum for periods of time varying between 0 and 15 days. In another group (n = 26), aortas were relaxed and not pressurized (P0). In each group, some arteries were de-endothelialized; 21 arteries were exposed to AII (10(-6) M) and indomethacin (10(-5) M) during the incubation. SMC proliferation was evaluated by 3H-thymidine uptake by the vessel wall. Statistics were performed using covariance analysis. In P0 group, de-endothelialization or AII had no effect on the vessel wall. In P70 group, de-endothelialization or led to a significant increase in media area which was reported to extracellular matrix synthesis and in 3H-thymidine uptake (p < 0.005) which peaked at 3-5 days and returned to basis levels at 6-8 days. All had no effect on 3H-thymidine uptake (p = 0.516) in P70 group. Our results obtained in rabbit aortic organ culture suggest that de-endothelialization induces SMC growth depending on pressure and/or wall stretching. AII, per se, had no additional effect on SMC growth in this model.

[Classic treatment of chronic heart insufficiency. What if new?]. / Le traitement classique de l'insuffisance cardiaque chronique. Quoi de neuf?

The aims of treatment of chronic heart failure are to improve the symptoms and the quality of life, reduce mortality and prevent left ventricular dysfunction. Before the first symptom occurs, neurohormonal activation takes place (increased catecholamines and atrial natriuretic peptide levels). Diuretics improve symptoms and are irreplaceable for the elimination of salt and water overload. Loop diuretics are used more often than the thiazides. Their deleterious effects on electrolyte balance are well known. The fact that they activate the renin angiotensin system is a more recent acquisition; the increase in plasma renin activity is a poor prognostic factor. Diuretics potentialize the vasodilator effect of angiotensin converting enzyme inhibitors which inhibit the neurohumoral activation induced by the diuretics. This therapeutic association is very logical, effective and allows reduction in the dosage of the diuretic. To date, there are no large scale controlled studies of the effects of diuretics on mortality. Spironolactone corrects hypokalaemia and hypomagnesaemia induced by loop diuretics. Moreover, it has been shown experimentally in renovascular hypertension and in hyperaldosteronism, that this molecule can prevent myocardial fibrosis, a factor which leads to ventricular dysfunction. The RALES study will analyse the effect of associating spironolactone to diuretic and ACE inhibitor therapy on the mortality of patients in NYHA classes III-IV. The value of digitalis in heart failure patients with sinus rhythm is a classical controversy. Digitalis has a positive inotropic effect (inhibition of NaK-dependent ATPase). More recently, a favourable neurohormonal effect has been reported; digitalis decreases the activation of the sympathetic and renin-angiotensin systems.(ABSTRACT TRUNCATED AT 250 WORDS)

[Incidence and prognosis of early primary cardiogenic shock in myocardial infarction]. / Incidence et pronostic du choc cardiogénique primaire précoce de l'infarctus du myocarde.

The aim of this retrospective study was to analyse the results of coronary reperfusion on the incidence and short and medium term prognosis of early primary cardiogenic shock in acute myocardial infarction. Of 339 consecutive patients admitted within 6 hours of the onset of acute myocardial infarction, 25 (7.4%) had cardiogenic shock from the onset. The majority of patients (18) underwent direct angioplasty with a successful result in 16 cases. Intravenous thrombolysis was instituted in 5 cases followed by emergency coronary angiography leading to "rescue" coronary angioplasty in 3 cases, which was successful in 2 cases. Two patients had no coronary revascularisation because of a double contra-indication to thrombolysis and catheterization by the femoral approach. Intra-aortic balloon pumping was used in 17 cases. Complementary emergency surgical revascularization was necessary in 5 patients (20%). In all, early reperfusion of the infarct-related artery was obtained in 80% of cases (20 patients). The hospital mortality was 72% (18 patients) due to refractory cardiac failure in nearly all cases. After an average follow-up of 17 months, 3 of the 7 survivors of the hospital period have died and of the 4 remaining patients, 2 are in the NYHA classes III or IV. Recent therapeutic advances have not influenced the incidence of cardiogenic shock but have significantly increased the proportion of very early cardiogenic shock, whereas the late cardiogenic shocks of more progressive onset, have nearly disappeared (4/339, 1.2% in this series). The prognosis of these early shocks, caused by severe myocardial damage, remains catastrophic and hardly improved by emergency coronary reperfusion by angioplasty and intraaortic balloon pumping.(ABSTRACT TRUNCATED AT 250 WORDS)

[Orientated management towards reperfusion in the acute phase of myocardial infarction. Results in a cohort of 700 consecutive patients]. / Prise en charge orientée vers la reperfusion en phase aiguë d'infarctus du myocarde. Résultats sur une cohorte de 700 patients consécutifs.

The principal objective of treatment of the acute phase of myocardial infarction is the obtention of TIMI 3 complete patency. Usually, only a minority of patients receives thrombolytic therapy and complete reperfusion in unusual. Between June 1988 and April 1996, 700 consecutive patients were admitted to Bichat hospital within 6 hours of the onset of transmural myocardial infarction (81% men; age 59 +/- 13 years). The objective of treatment was to obtain maximal coronary patency in the acute phase, either by thrombolysis (with systematic angiography at 90 minutes and salvage angioplasty in case of failure), or primary angioplasty or conventional treatment (usually in cases of spontaneous reperfusion). The emergency angiography and angioplasty procedures were performed by a medical team on 24 hour duty. During the acute phase, 316 patients received intravenous thrombolysis (angiography at 90' in 302 patients with salvage angioplasty in 79 patients), 304 underwent primary angioplasty (TIMI 3 artery in 85% of cases) and 80 underwent conventional treatment (including 52 cases of angiographically documented spontaneous reperfusion). Therefore, a 81% (566/700) rate of patent TIMI 3 arteries was obtained. The hospital mortality was 8.9%, lower in TIMI 3 arterial patency (6%) than TIMI 2 (20%) or TIMI 0-1 (23%), p < 0.001. The mortality was 4% in patients treated by thrombolysis. Therefore, a reperfusion strategy associating thrombolysis and/or angioplasty provides a high TIMI 3 patency rate in the acute phase of myocardial infarction with a low mortality (6%) in consecutive, unselected patients.

[Acute myocardial infarction in patients over 70 years of age]. / L'infarctus myocardique aigu du sujet de plus de 70 ans.

Demographic changes in cardiovascular disease explain the marked increase in the number of myocardial infarctions affecting individuals aged over 70. The prognosis remains poor, with hospital mortality of the order of 30%. The reticence of physicians to use reperfusion techniques (intravenous thrombolysis and coronary angioplasty) is paradoxically considerable. Several studies have nevertheless shown that the benefit/risk ratio of such methods not only persists, but is increased in this age group, which should encourage the widening of their indications. Thorough evaluation of the best management strategy would require a randomised comparative trial, but angioplasty would probably ensure early reperfusion in a larger proportion of elderly patients than thrombolysis, because of the high incidence of contraindications to the latter as well as of cardiogenic shock in this age group.

[Congenital quadricuspid aortic valves]. / La quadricuspidie aortique congénitale.

BACKGROUND: Quadricuspid aortic valve is an uncommon congenital anomaly. We report a case in a patient hospitalized for heart failure. CASE REPORT: A 62-year old patient with exercise-induced dyspnea was hospitalized for heart failure. Heart auscultation revealed a diastolic aortic murmur attributed to a quadricuspid aortic valve evidenced at echocardiography. DISCUSSION: Quadricuspid aortic valves usually have three cusps of equivalent size and a small fourth cusp between the right coronary cusp and the non-coronary cusp. Aortic regurgitation is usually observed requiring valve replacement in 50% of the cases. The anomaly may be associated with other congenital anomalies of the coronary arteries warranting systematic coronarography prior to valve replacement.

Conservative management of patients with acute myocardial infarction and spontaneous acute patency of the infarct-related artery.

The role of systematic emergency percutaneous transluminal coronary angioplasty (PTCA) in patients with spontaneous reperfusion during myocardial infarction is debated. We retrospectively examined the inhospital outcome of 47 consecutive patients with myocardial infarction < 6 hours and angiographically proven spontaneous patency of the infarct artery managed without initial PTCA. There was one death (2.1%) and no incidence of reinfarction. Predischarge angiography showed regression of the culprit coronary lesion to < 50% stenosis in 23% of the patients, therefore obviating the need for PTCA. However, 17% of the patients had acute recurrent ischemia, requiring emergency intervention in 10.6%. Comparison with matched patients in whom Thrombolysis in Myocardial infarction grade 3 patency was achieved by thrombolysis or by primary PTCA showed that patients with spontaneous patency tended to have smaller infarctions, as judged from a lower peak creatine kinase level (1132 +/- 1002, 2051 +/- 1536, and 2715 +/- 2146 i.u., respectively; p = 0.001) and a higher left ventricular ejection fraction (56.4%, 47.9%, and 48.7% respectively; p = 0.02). In conclusion, these patients have an excellent inhospital outcome, with evidence of less myocardial damage than in patients in whom reperfusion therapy was required to achieve TIMI 3 patency. Initial conservative treatment appears safe.

Iliac artery patency before and immediately after percutaneous transluminal angioplasty: assessment with time-of-flight MR angiography.

PURPOSE: To assess the efficacy of magnetic resonance (MR) angiography of iliac arteries before and immediately after percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: In 14 patients with 22 diseased iliac artery segments (external or common), axial two-dimensional time-of-flight MR angiography was performed. Images were reconstructed with a maximum-intensity-projection (MIP) algorithm. MR angiography was performed 1-4 days after diagnostic digital angiography and 6-24 hours after PTA. Findings obtained before and immediately after PTA were compared for number and location of significant (ie, > 50%) stenoses, length and diameter of balloon to be employed, and diameter of the stenotic artery after PTA. Linear regression analysis was performed. RESULTS: Sensitivity and specificity of MR angiography for determination of significant stenoses were 95% and 97%, respectively. Before PTA, balloon dimensions depicted on MR angiograms and digital angiograms were well correlated (r = .76, P < .05). After PTA, MR angiograms and digital angiograms provided similar findings in all but one case. CONCLUSION: MR angiography helped determine if PTA is indicated and depicted iliac artery patency after PTA.

A randomized trial of a fixed high dose vs a weight-adjusted low dose of intravenous heparin during coronary angioplasty.

AIMS: Prospectively to compare success rate and complications in percutaneous transluminal coronary angioplasty using two doses of heparin. METHODS AND RESULTS: Four hundred patients undergoing coronary angioplasty were randomly assigned to receive 15,000 IU (group A) or 100 IU.kg-1 (group B) of heparin. The angioplasty success rate was 95% of both groups. Stents were placed in 28.5% and 26.5% of patients in groups A and B, respectively (P = 0.73). The primary endopoint (freedom from death, myocardial infarction, unplanned revascularization or bailout stenting) occurred in 91% vs 95% of patients in groups A and B, respectively (odds ratio: 1.88, 95% CI: 0.80-4.50, P = 0.12). Haemoglobin loss was 0.36 +/- 1 and 0.27 +/- 0.9 g.dl-1 in groups A and B, respectively (P = 0.37). The time to sheath removal (735 +/- 265 vs 558 +/- 246 min) and the time to transfer to a stepdown unit (12.7 +/- 4.5 vs 9.8 +/- 4.2 h) were longer in groups A (P = 0.0001 for both comparisons). CONCLUSION: A weight-adjusted low dose of intravenous heparin is at least as safe as a fixed high dose for coronary angioplasty. It allows earlier sheath removal and discharge to a stepdown unit.