Tibioperoneal (outflow lesion) angioplasty can be used as primary treatment in 235 patients with critical limb ischemia: five-year follow-up.

BACKGROUND: In a prospective, nonrandomized, consecutive series of tibioperoneal vessel angioplasty (TPVA), critical limb ischemia (CLI) patients' data were analyzed with regard to immediate and follow-up success. METHODS AND RESULTS: TPVA was successful in 270 of 284 critically ischemic limbs (95%), with 167 limbs (59%) requiring dilatation of 333 ipsilateral inflow obstructions to access and successfully dilate 486 of 529 (92%) tibioperoneal lesions. A clinical success (relief of rest pain or improvement of lower-extremity blood flow) was attained in 270 limbs at risk (95%). Clinical 5-year follow-up of 215 of 221 successful CLI patients (97%) with 266 successfully revascularized limbs revealed that bypass surgery occurred in 8% and significant amputations in 9% of limbs; 91% of the limbs were salvaged. The cohort's probability of survival was 56%: 58% for Fontaine class III and 33% for class IV patients. Class III compared with class IV patients had significantly (P<0.05) fewer surgical bypasses (3% versus 16%) and amputations: above-knee, 1% versus 4%; below-knee, 3% versus 12%; and transmetatarsal, <1% versus 21%. CONCLUSIONS: TPVA, often in combination with inflow lesions, is an effective primary treatment for critical limb ischemia. The poor cumulative survival reflects the existence of severe comorbidities, which could potentially be affected by aggressive and effective cardiovascular diagnostic and therapeutic strategies.

Percutaneous coronary intervention in the current era compared with 1985-1986: the National Heart, Lung, and Blood Institute Registries.

BACKGROUND: Although refinements have occurred in coronary angioplasty over the past decade, little is known about whether these changes have affected outcomes. METHODS AND RESULTS: Baseline features and in-hospital and 1-year outcomes of 1559 consecutive patients in the 1997-1998 Dynamic Registry who were having first coronary intervention were compared with 2431 patients in the 1985-1986 National Heart, Lung, and Blood Institute Registry. Compared with patients in the 1985-1986 Registry, Dynamic Registry patients were older (mean age, 62 versus 58 years; P:<0.001) and more often female (32.1% versus 25.5%; P:<0.001). In the Dynamic Registry, procedures were more often performed for acute myocardial infarction (22.9% versus 9.9%; P:<0.001) and treated lesions were more severe (84.5% versus 82.5% diameter reduction; P:<0.001), thrombotic (22.1% versus 11.3%; P:<0.001) or calcified (29.5% versus 10.8%; P:<0.001). Stents were used in 70.5% of Dynamic Registry patients, whereas 1985-1986 patients received balloon angioplasty alone. Procedural success was higher in the Dynamic Registry (92.0% versus 81.8%; P:<0.001) and the rate of in-hospital death, myocardial infarction, and emergency coronary bypass surgery combined was lower (4.9% versus 7.9%; P:=0.001) than in the 1985-1986 Registry. The 1-year rate for CABG was lower in the Dynamic Registry (6.9% versus 12.6%; P:<0.001). CONCLUSIONS: Although Dynamic Registry patients had more unstable and complex coronary disease than those in the 1985-1986 Registry, their rate of procedural success was higher whereas rates of complications and subsequent CABG were lower. Results of percutaneous coronary intervention have improved substantially over the past decade.

Multiple lesion transluminal coronary angioplasty in single and multivessel coronary artery disease: acute outcome and long-term effect.

Multiple lesion transluminal coronary angioplasty was performed in 428 patients. Angioplasty was attempted in 1,047 lesions (2.4/patient), with an angiographic success achieved in 94%: 2 lesions were attempted in 74%, 3 in 21%, 4 in 5% and 5 or more in 1% of cases. A clinical success was achieved in 404 (94%) of the patients: 95% with and 93% without prior surgery and in 94% of those with single vessel disease and 94% of those with multivessel disease. Significant complications occurred in 17 patients (4.0%): 11 (2.5%) had a transmural infarction, 9 (2.1%) required urgent surgery and 6 (1.4%) died. An apparent lesion recurrence occurred in 106 (26%) of 404 patients with 81 of 89 patients (91%) having a successful second angioplasty. A second apparent lesion recurrence occurred in 15 patients (19%), with 13 of the 15 patients having a successful third angioplasty. A sustained clinical improvement (mean follow-up period 28.3 +/- 16 months) was obtained in 208 (83%) of 250 patients with successful angioplasty. The cumulative probability of survival at 51 months was 93% in these 250 patients. Survival was adversely affected by the presence of prior bypass surgery (no prior surgery 97% versus prior surgery 81%; p less than 0.05). These data suggest that multiple lesion angioplasty can be successfully performed with a good success rate, an acceptable incidence of complications and a reasonable expectation of satisfactory long-term clinical improvement.

Percutaneous transluminal aortic valvuloplasty: acute outcome and follow-up of 125 patients.

Percutaneous transluminal aortic valvuloplasty was performed on 125 patients (59 men [47%], mean age 76 +/- 13 years) between July 1986 and May 1988, with presenting symptoms of severe congestive heart failure in 88 (70%), moribund state in 15 (12%) and syncope in 17 (14%). Surgical valve replacement was considered unsuitable in 79% of cases. A multiple balloon technique was utilized in 119 patients (95%). Valvuloplasty produced significant changes in peak pressure gradient (87 +/- 38 to 32 +/- 17 mm Hg), mean pressure gradient (70 +/- 26 to 30 +/- 13 mm Hg) and valve area (0.6 +/- 0.2 to 1.0 +/- 0.3 cm2). Complications included: in-hospital mortality in 10% (6 of 13 deaths in moribund patients), neurologic deficit in 3% and myocardial infarction in 2%. Arterial repair was required at 12 (4%) of 325 entry sites. Multivariate analysis identified severe congestive heart failure, preprocedure left ventricular ejection fraction and cardiac output as the only independent variables significantly affecting mortality. The cumulative probability of survival at 12 months was 62 +/- 6% and, excluding non-cardiac deaths, was 77 +/- 5%. At a mean of 12 +/- 4 months' follow-up, 55 of 72 patients were symptomatically improved; 10 patients with symptom recurrence underwent repeat valvuloplasty and 5 had valve replacement. Cardiac catheterization was repeated in 12 symptomatically improved patients, 9 of whom had valve restenosis. These data indicate that aortic valvuloplasty should be considered a palliative therapy for elderly patients with symptomatic calcific aortic stenosis who are poor surgical candidates.

Recommendations for training in vascular medicine. American College of Cardiology Peripheral Vascular Disease Committee.

Each trainee in vascular medicine must be eligible for the board certification examination of the American Board of Internal Medicine or its equivalent. Training faculty, preferably at least two members, should meet the qualifications and training requirements described in this report. They must be dedicated, effective teachers and should spend most of their time in research, education and patient care related to peripheral vascular diseases. A curriculum of training should be established. Faculty experts in related specialties and in the related basic sciences should be available for teaching. The institution should have a fully equipped noninvasive vascular laboratory and areas where catheter revascularization techniques and vascular surgery are performed. The period of training should not be less than 1 year, preferably continuous.

Prophylactic versus standby cardiopulmonary support for high risk percutaneous transluminal coronary angioplasty.

OBJECTIVES: Data from a national registry of 23 centers using cardiopulmonary support (CPS) were analyzed to compare the risks and benefits of prophylactic CPS versus standby CPS for patients undergoing high risk coronary angioplasty. BACKGROUND: Early data from the CPS registry documented a high angioplasty success rate as well as a high procedural morbidity rate. Because of this increased morbidity some high risk patients were placed on standby CPS instead of prophylactic CPS. METHODS: Patients in the prophylactic CPS group had 18F or 20F venous and arterial cannulas inserted and cardiopulmonary bypass initiated. Patients in the standby CPS group were prepared for institution of cardiopulmonary bypass, but bypass was not actually initiated unless the patient sustained irreversible hemodynamic compromise. RESULTS: There were 389 patients in the prophylactic CPS group and 180 in the standby CPS group. The groups were comparable with respect to most baseline characteristics, except that left ventricular ejection fraction was lower in the prophylactic CPS group. Thirteen of the 180 patients in the standby CPS group sustained irreversible hemodynamic compromise during the angioplasty procedure. Emergency institution of CPS was successfully initiated in 12 of these 13 patients in < 5 min. Procedural success was 88.7% for the prophylactic and 84.4% for the standby CPS group (p = NS). Major complications did not differ between groups. However, 42% of patients in the prophylactic CPS group sustained femoral access site complications or required blood transfusions, compared with only 11.7% of patients in the standby CPS group (p < 0.01). Among patients with an ejection fraction < or = 20%, procedural morbidity remained significantly higher in the prophylactic CPS group (41% vs. 9.4%, p < 0.01), but procedural mortality was higher in the standby group (4.8% vs. 18.8%, p < 0.05). CONCLUSIONS: Patients in the standby and prophylactic CPS groups had comparable success and major complication rates, but procedural morbidity was higher in the prophylactic group. When required, standby CPS established immediate hemodynamic support during most angioplasty complications. For most patients, standby CPS was preferable to prophylactic CPS during high risk coronary angioplasty. However, patients with extremely depressed left ventricular function (ejection fraction < 20%) may benefit from institution of prophylactic CPS.

Comparison of complications during percutaneous transluminal coronary angioplasty from 1977 to 1981 and from 1985 to 1986: the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry.

Because the effects of changing technology in percutaneous transluminal coronary angioplasty, increased operator experience and use of the procedure in patients with extensive disease are unknown in regard to complication patterns, the initial 1977-1981 cohort and the recent 1985-1986 cohort of the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry were analyzed with respect to complications. Compared with the initial cohort of 1,155 patients, the 1,801 new cohort patients were older and had an increased prevalence of multivessel coronary artery disease, depressed left ventricular function and prior infarction. Overall complication rates in the recent cohort were either unchanged or decreased from the rates in the initial cohort despite a higher risk patient population. The most significant decreases were in the incidence of coronary spasm (p less than 0.001) and the need for emergency coronary bypass surgery (p less than 0.01). Overall in-hospital mortality was low but was dependent on the extent of vessel disease--0.2% for single vessel disease, 0.9% for double vessel disease and 2.2% for triple vessel disease (p less than 0.001 for linear trend). Acute coronary complications of branch occlusion, dissection or abrupt closure were associated with increased rates of death, nonfatal infarction or need for emergency surgery. Factors showing a multivariate association with increased mortality included a history of congestive heart failure (p less than 0.001), age greater than or equal to 65 years (p less than 0.01), triple vessel or left main coronary artery disease (p less than 0.05), female gender (p less than 0.05) and new onset angina.(ABSTRACT TRUNCATED AT 250 WORDS)

Follow-up of primary Palmaz-Schatz stent placement for atherosclerotic renal artery stenosis.

A Palmaz-Schatz stent was successfully placed in 92 stenotic renal arteries (76 patients) for (1) hypertension in 62 (82%), and/or (2) chronic renal failure (serum creatinine > or = 1.5 mg/dl) and preservation of renal function in 39 (51%). Patients were followed to assess clinical and angiographic 6-month outcome. Angiography, performed in 45 of 62 eligible patients (73%) and in 56 of 74 treated arteries (76%), showed restenosis occurring in 14 renal arteries (25%). Serum creatinine improved or remained stable in 78% of patients. In patients with chronic renal failure, improvement or stability was observed in 55%. Blood pressure recordings significantly decreased for the entire cohort (systolic: 168 +/- 25 to 156 +/- 22 mm Hg, p < 0.0001; diastolic: 87 +/- 11 to 81 +/- 11 mm Hg, p < 0.005), and for hypertensive patients with normal creatinine (systolic: 179 +/- 20 to 155 +/- 23 mm Hg, p < 0.0001; diastolic: 92 +/- 9 to 83 +/- 12 mm Hg, p < 0.002). These follow-up data of a prospective, nonrandomized, observational study showed that stent recanalization of atherosclerotic renal artery stenoses was beneficial with regard to renal function and blood pressure response, and had a restenosis incidence of 25%.

Complex coronary angioplasty: multiple coronary dilatations.

Selected patients underwent PTCA of multiple stenoses in different vessels or in the same vessel. Three hundred nine patients underwent 685 PTCA procedures in various combinations of arterial and vein graft stenoses. A multiple dilatation procedure was defined as successful when all lesions attempted were successfully dilated, or when the considered-critical-stenosis was successfully dilated and this resulted in a patient clinical improvement. Angiographic success was achieved in 599 of 685 lesions attempted (87.4%) and in 285 of 309 patients (92.2%). Complications included a mortality rate of 1.0%, an MI rate of 4.2% per patient and 1.9% per lesion attempted, and a 3.6% incidence of emergency CABG. Follow-up data show that 58 patients (20.4%) had clinical evidence of a lesion recurrence, and that 92.5% (37 of 40 patients) who underwent repeat angioplasty had a successful procedure. A sustained clinical improvement was obtained in 264 of 309 patients (85.4%). The data indicate that multiple dilatations are feasible with good success rates and acceptable complication rates. Further evaluation of this extended application of PTCA is needed to clearly establish its role in the therapy of CAD.

Acute coronary events associated with percutaneous transluminal coronary angioplasty.

Acute coronary events reported in patients enrolled in the NHLBI PTCA Registry were analyzed. Data were collected on 3,079 patients from 105 contributing centers. Coronary vascular events (dissection, occlusion, spasm, embolism, perforation or rupture) or ischemic events (MI or prolonged angina) occurred in 418 patients (13.6%). Major complications (MI), emergency surgery or death) occurred in 280 patients (67%) with acute coronary events. The most frequent events were prolonged angina, which occurred in 211 (6.8%), and MI, in 170 (5.5%). Coronary dissection, occlusion and spasm each occurred in approximately 5% of patients. Coronary embolism, perforation and rupture were rare (less than 0.2% for each). Dissection and occlusion each had a high frequency (greater than 80%) of associated major complications. A substantially lower incidence of major complications occurred in patients with isolated coronary spasm (18%) or prolonged angina (35%). Clinical and angiographic predictors for overall and specific events were identified. Coronary events occurred more frequently in women and patients with unstable angina. Eccentric lesions were associated with a higher rate of coronary events, and event rates were lower with single discrete lesions than with other types of lesions. The frequency of any coronary event, MI, prolonged angina and coronary spasm each decreased with increasing experience with PTCA. The frequency of dissection and occlusion did not change with experience.

In-hospital mortality rate in the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry.

Twenty-nine patients died among the first 3,079 patients enrolled in the NHLBI PTCA Registry. The overall morality rate was 0.9%; the mortality rate was 0.8% in patients with 1-vessel CAD, 1.0% in those with multivessel CAD (excluding left main CAD), and 3.8% in those with left main CAD (p less than 0.01). The in-hospital morality rate was significantly higher among women (p less than 0.01), in patients older than 60 years, in patients with previous CABG (p less than 0.01), the presence of left main CAD, (p less than 0.01), in patients who required dilatation of a vein graft stenosis (p less than 0.05), and in patients who had had angina for longer than 6 months (p less than 0.01).

Emergency coronary bypass surgery after coronary angioplasty: the National Heart, Lung, and Blood Institute's Percutaneous Transluminal Coronary Angioplasty Registry experience.

The frequency and outcome of emergency CABG for complications of PTCA in the NHLBI PTCA Registry were analyzed. Emergency surgery was performed in 202 patients (6.6%). The most frequent indications for emergency operation were coronary dissection in 46%, coronary occlusion in 20%, prolonged angina in 14% and coronary spasm in 11%. Emergency surgery was most often necessary in patients in whom lesions could not be reached or traversed, but more than 25% of patients who required emergency surgery had initially successful dilatation followed by abrupt reclosure of the vessel. The mortality rate with emergency CABG was 6.4%, and nonfatal MI occurred in 41% of patients, with Q waves developing in approximately 60% of patients with MI. However, 53% of patients managed with emergency CABG for severe ischemic events with PTCA did not have evidence of MI or die and had an uncomplicated postoperative course. No baseline clinical predictors of emergency surgery were identified. Lesion eccentricity was associated with a significant increase in frequency of emergency operation, and the incidence of emergency surgery declined with increasing experience with PTCA.

Percutaneous transluminal coronary angioplasty in patients with two or more previous coronary artery bypass grafting operations.

Between 1979 and 1986, 65 of 76 patients (86%) (82% men, with a mean age of 58 +/- 8 years) with greater than or equal to 2 previous coronary artery bypass grafting (CABG) operations and symptomatic myocardial ischemia underwent successful percutaneous transluminal coronary angioplasty (PTCA). Sixty-two patients had 2 prior CABG operations, 10 had 3 and 4 had 4. Clinical characteristics included prior myocardial infarctions in 49 (65%), severe angina (class III or IV) in 47 (62%) and left ventricular ejection fraction less than or equal to 35% in 13 (17%). There were 139 lesions dilated: 1 lesion in 39 (51%), 2 in 22 (29%) and greater than or equal to 3 in 15 (20%) patients. Arterial lesions were successfully dilated in 71 of 81 cases (88%), vein grafts in 44 of 53 (83%) and mammary artery grafts in 3 of 5 (60%). In 12 patients, PTCA was used to dilate significant lesions less than 15 days after CABG in vessels which were unable to be bypassed. Significant complications were encountered in 4 patients (5%). These included 3 of 53 vein graft dilatations with embolization (6%), with 1 resulting in infarction and death, and 1 patient dying after emergency CABG. At hospital discharge, 65 patients were clinically improved. An apparent symptom-related lesion recurrence occurred in 23 of 65 patients (35%), with 5 patients dying of cardiac causes, 4 having CABG without previous angiography and 12 of 14 patients undergoing repeat successful PTCA (mean time and standard deviation 9 +/- 6 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of results of percutaneous balloon valvuloplasty in patients with mild and moderate mitral stenosis to those with severe mitral stenosis. The North American Inoue Balloon Investigators.

Most reported studies of percutaneous balloon valvuloplasty in adults with acquired mitral stenosis have used patients with severely stenosed valves. The risks and benefits of valvuloplasty were examined in a multicenter registry of patients to determine whether balloon valvuloplasty can effectively dilate less severely obstructed valves, and to clarify the role of this procedure in symptomatic patients with mild and moderate mitral stenosis. The study groups were derived from the North American Inoue Balloon Valvuloplasty Registry. Full hemodynamic data were available in 264 patients; 45 (17%) with mild or moderate mitral stenosis (mitral valve area > or = 1.3 cm2) were compared with the remaining 219 with severe mitral stenosis (valve area < 1.3 cm2). Percutaneous balloon valvuloplasty was performed using the anterograde transseptal technique with an Inoue balloon. The mean age of patients with mild and moderate mitral stenosis was 53 +/- 13 years, and all were symptomatic with a mean New York Heart Association functional class of 2.9 +/- 0.7. Balloon valvuloplasty resulted in an increase in calculated mitral valve area from 1.4 +/- 0.1 to 2.3 +/- 0.7 cm2 (p < 0.05), and a final valve area > or = 1.9 cm2 was achieved in 37 patients (82%). There were no procedural deaths, but complications included right atrial perforation, transient ischemic attack and emergency surgery for severe mitral regurgitation. One-year follow-up evaluation revealed symptomatic improvement in most patients (mean New York Heart Association class 1.4 +/- 0.6; p < 0.0001). However, 2 patients needed repeat valvuloplasty for restenosis, and 5 had mitral valve replacements.(ABSTRACT TRUNCATED AT 250 WORDS)

Employment and recreation patterns in patients treated by percutaneous transluminal coronary angioplasty: a multicenter study.

Employment and recreational patterns were analyzed in 279 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) for treatment of symptomatic coronary artery disease. PTCA was successful in 180 patients (65%). When it was unsuccessful, coronary artery bypass graft surgery was usually performed (80%). Return-to-work rates were high irrespective of the outcome of PTCA. Of patients employed full-time or part-time before treatment, 98.5% of those who had successful PTCA alone and 97% of those whose PTCA was unsuccessful but who underwent uncomplicated coronary artery bypass surgery maintained or improved their work status. In a subgroup of men who had been employed in occupations requiring physical labor, 85% of the men whose PTCA was successful returned to work, compared with 68% of those whose PTCA was unsuccessful. The interval from attempted PTCA to return to work was significantly shorter in the successfully treated group; in patients with successful PTCA, the median time to return to work was 14 days, compared with 60 days in patients in whom PTCA was unsuccessful (p less than 0.001). During follow-up, patients with successful PTCA had less angina and were more active in recreational activities than patients who required alternative treatments.

Long-term efficacy of percutaneous transluminal coronary angioplasty (PTCA): report from the National Heart, Lung, and Blood Institute PTCA Registry.

The NHLBI PTCA Registry has collected data from 3,079 patients who underwent PTCA at 105 centers from September 1977 through September 1981 that document the initial risks and benefits of PTCA. A subgroup of 2,272 patients at 65 centers was chosen to examine the long-term effects of PTCA (97% follow-up). All patients were followed for 1 year, 191 for 3 years and 57 for 4 years. Initial success occurred in 1,397 (61%), and 72% remained improved at 1 year with no further procedures; during the first year of follow-up, 14% had repeat PTCA, 12% had CABG, 3% had MI and 1.6% died. After 1 year, 67% were asymptomatic; of these, 52% had no other procedure, 7% had a second PTCA and 8% had CABG. Follow-up at 2 to 4 years was similar except that there were few repeat PTCA or CABG procedures after 1 year. The annual mortality rate after PTCA in patients with 1-vessel diseases was less than 1% per year and with multivessel CAD, 3% per year. Thus, successful PTCA alone results in sustained improvement in 84% of patients; 59% were asymptomatic (12% had repeat PTCA). PTCA offers extended effective therapy in selected patients with CAD.

Return to work after coronary angioplasty: a report from the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry.

Employment status was analyzed in 2,250 patients enrolled at 65 clinical centers in the NHLBI PTCA Registry. Patients were classified into 3 groups depending on the outcome of PTCA. In 63.6%, PTCA was successful without MI or CABG (Group A); in 25.3%, PTCA was unsuccessful and was followed by CABG (Group B); and in 11.1%, PTCA was unsuccessful and was followed by medical therapy alone (Group C). At entry, 68.3% of all patients were employed full- or part-time. The clinical characteristics of the 3 groups were different. Patients in Group C had a higher incidence of previous MI and previous CABG. In addition, patients in Group C had a significantly decreased baseline employment rate compared with those in Group A. At a mean follow-up of 1.5 years, there was a small but similar decrease in the percentage employed full- or part-time in all groups. Employment status also was analyzed in a subset of 1,150 patients working full- or part-time at baseline and aged 60 years or younger, who would be expected to have the highest return to work rates. At a mean follow-up of 1.4 years, 81 to 86% of patients remained working irrespective of the outcome of PTCA. However, patients with successful PTCA returned to work significantly sooner. The occurrence of chest pain during follow-up in these patients was an important predictor of return to work, irrespective of the outcome of dilatation. In patients with chest pain during follow-up, only 77% were working, compared with 90% of patients who had not had chest pain.

Relative cost of coronary angioplasty and bypass surgery in a one-vessel disease model.

A national study was carried out to determine the relative costs of PTCA and CABG. Baseline clinical criteria for the 2 groups were similar. Data were collected in 186 sets for the PTCA group and 175 sets for the CABG group. Male patients make up 81% of the PTCA group and 80% of the CABG group. Mean hospital stay was 12 +/- 5 days in the CABG group, compared with 4 +/- 2 days in the PTCA group (p less than 0.001). The base charges for hospital and professional components of the CABG procedure were $15,580 +/- $2,159, whereas the same charges for the PTCA procedure were $5,315 +/- $2,159 (p less than 0.001). With an 80% primary success rate, which was the group mean success rate, the average dollar savings per PTCA procedure would be $7,149, or $7,149,000 per 1,000 cases. Thus, PTCA for revascularization in 1-vessel CAD is significantly more cost-effective than CABG in the short term.

Percutaneous transluminal coronary angioplasty: report from the Registry of the National Heart, Lung, and Blood Institute.

Data have been collected from 34 centers in the United States and Europe performing percutaneous transluminal coronary angioplasty since September 1977. The procedure was carried out in 631 patients, with an average age of 51 years (range 23 to 76), of whom 80 percent had single vessel coronary disease, 17 percent had double or triple vessel disease and 3 percent had stenosis of the left main coronary artery. Coronary angioplasty was successful (greater than 20 percent decrease of coronary stenosis) in 59 percent of the stenosed arteries. The mean degree of stenosis was reduced from 83 to 31 percent. Emergency coronary bypass operation was required in 40 patients (6 percent). Myocardial infarction occurred in 29 patients (4 percent). In-hospital death occurred in six patients (1 percent), three with single vessel and three with multivessel disease. Ninety-one patients have been followed up for at least 1 year after coronary angioplasty. Of the 65 patients with an initially successful angioplasty, 83 percent were in improved condition compared with their status before angioplasty. Thus, the initial satisfactory results obtained in a few centers have now been confirmed in many centers using transluminal coronary angioplasty.

Percutaneous transluminal coronary angioplasty in patients with prior coronary artery bypass grafting.

Percutaneous transluminal coronary angioplasty (PTCA) has been used to treat patients with prior coronary artery bypass grafting who have stenosis of a saphenous vein graft and/or a native artery. During 53 months, 61 patients underwent 105 angioplasty attempts. Eighty lesions (76%) were successfully dilated in 46 of 61 patients (75%). Success in a patient was determined by a greater than or equal to 20% decrease in the percent diameter stenoses coupled with an improved clinical response; 52 patients had one prior CABG and nine patients had two or more prior CABGs. Multivessel disease was present in 56 patients (92%). A vein graft stenosis was successfully dilated in 26 of 33 cases (79%)--19 of 25 (76%) at an anastomotic site and seven of eight (88%) in the graft body. An arterial stenosis was successfully dilated in 37 of 52 cases (71%)--18 of 22 (82%) in the left anterior descending, 13 of 22 (59%) in the circumflex, 21 of 26 (81%) in the right coronary, and two (100%) in the left main coronary artery. There is no statistically significant difference in the incidence of success in dilating a vein graft or native artery. Complications included: one emergency CABG (1.6%), three myocardial infarctions (4.9%), and two deaths (3.3%). There were 15 unsuccessful PTCAs: Ten patients had elective CABG, one had emergency CABG, two received medical treatment, and two died. Forty-six patients are being followed-up: Twenty-eight (61%) continue to do clinically well, seven (15%) had another PTCA and remain well, and 10 (16%) had elective CABG because of restenosis and/or disease progression. There was one late death and one late myocardial infarction. Thus, 35 patients (57%) had continued clinical success without the need for repeat CABG; 89% had no angina or improved angina, and 90% had improved exercise treadmill results. PTCA is technically feasible in selected patients with prior CABG and can achieve a clinical response with an acceptable complication rate when compared to repeat CABG.