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To better understand the factors predisposing a patient to death after elective percutaneous transluminal coronary angioplasty (PTCA) and to gain insight into indications for high-risk PTCA both with and without adjunctive use of support devices, the outcomes of 8,052 consecutive procedures were reviewed. Death occurred after 32 procedures (0.4%) and was directly related to coronary artery closure in 26 (81%) of these cases. Left ventricular failure due to vessel closure at the dilated site, the most common cause of death, was independently correlated with female sex (p, Percutaneous transluminal coronary angioplasty (PTCA) has become a commonly used alternative to coronary bypass grafting for many cases of coronary artery disease. The procedure, which uses an inflatable balloon to open coronary arteries narrowed by atherosclerosis, is generally safe, and the number of deaths resulting from the procedure is small. The small number of deaths makes it difficult, however, to determine the factors that may make this procedure risky for a minority of patients. To determine the factors that contribute to death following PTCA, a large number of cases must be reviewed. This has now been done for a series of 8,052 PTCA procedures performed at three medical centers. Among these cases, there were 32 deaths, yielding 0.4 percent mortality. In 26 of these 32 cases, death resulted from the abrupt closure of the coronary artery. In the majority of these cases, the left ventricle of the heart failed after the artery that had been opened suddenly closed. Left ventricular failure was found to be more common among women. However, the risk of left ventricular failure was unrelated to left ventricular ejection fraction, a measure of the effectiveness of the heart's pumping action, and was also unrelated to the presence of artery disease in more than one location. The authors have used the available data to construct what they call a ''jeopardy score.'' Tabulation of this score is based on the sites of the lesions within the coronary arteries and the risks to the heart muscle should the circulation fail at any of these points. The authors suggest that the jeopardy score may help to identify patients at highest risk from PTCA; the use of advanced support technology during the PTCA procedure to aid the heart in the event of sudden artery closure may improve the outcome in these cases. (Consumer Summary produced by Reliance Medical Information, Inc.)

The role of tomographic thallium-201 exercise and redistribution imaging in the detection of restenosis after percutaneous transluminal coronary angioplasty (PTCA) was evaluated in 116 patients: 61 (53%) with 1- and 55 (47%) with multivessel PTCA, with a total of 185 dilated vessels. Complete revascularization was performed in 89 (77%) and partial revascularization in 27 (23%) of the patients. Restenosis was angiographically demonstrated in 69 (60%) of the patients and 85 (46%) of the vessels 6.4 [+ or -] 3.1 months after PTCA. Disease progression in previously normal vessels was noted in 11 patients. The results were: (1) for detection of restenosis in the group of patients, single-photon emission computed tomographic (SPECT) versus exercise electrocardiographic sensitivity was 93 vs 52% (p [is less than]0.001), specificity 77 vs 64%, and accuracy 86 vs 57% (p [is less than]0.001). The results were similar in the complete and partial revascularization groups. (2) SPECT was 86% sensitive, specific and accurate for restenosis detection in specific vessels with comparable results for 1- versus multivessel PTCA and complete versus partial revascularization. Sensitivity, specificity and accuracy were: 89, 95 and 92% for the left anterior descending coronary artery; 88, 79 and 82% for the right coronary artery; and 76, 83 and 85% for the left circumflex coronary artery. Eighty-one percent of the diseased nondilated vessels were correctly identified. (3) Disease progression to [is greater than]50% stenosis was detected with 91% sensitivity, 84% specificity and 85% accuracy. SPECT thallium-201 imaging is an excellent tool for the detection of restenosis and disease progression after PTCA in the settings of 1- and multivessel angioplasty and complete and partial revascularization. (Am J Cardiol 1990;66:1314-1318), Narrowing, or stenosis, of the blood vessels supplying the heart results in myocardial ischemia (insufficient blood supply to the heart), a condition that may lead to heart attack. Percutaneous transluminal coronary angioplasty (PTCA) is a technique used to treat stenosis of the coronary arteries by balloon dilatation. With the adoption of PTCA for the treatment of multi-vessel stenosis, post-PTCA evaluation has become more complex, owing to the high incidence of restenosis (40 to 50 percent of cases) and the development of stenosis in previously normal coronary vessels. It would be very useful to have a reliable noninvasive technique for monitoring the progress of PTCA patients, and for distinguishing restenosis from other causal factors in the development of ischemia. Single-photon emission computed tomographic thallium-201 imaging (SPECT) is a noninvasive imaging technique that determines the patency of blood vessels. To assess the suitability of SPECT for monitoring blood flow in coronary arteries, 116 patients with questionable restenosis were evaluated with SPECT within one week of undergoing angiography (a highly accurate, albeit invasive, diagnostic radiologic technique). Results from both procedures were compared with another noninvasive diagnostic test, exercise electrocardiography. Patients were being followed-up after particularly complex PTCA procedures or receiving treatment for recurrent chest pain following PTCA (65 percent). They had undergone PTCA for either single- (53 percent) or multi-vessel (47 percent) coronary artery occlusion. Restenosis was determined to have occurred in 60 percent of the patients (and 46 percent of the coronary vessels) approximately six months after PTCA. SPECT correctly identified restenosis in 93 percent of the cases, compared with a 52 percent correct identification rate for exercise electrocardiography. A comparable rate of SPECT accuracy was observed with regard to single- versus multi-vessel PTCA, different coronary arteries, and various degrees of disease progression. SPECT is a useful, noninvasive diagnostic tool for monitoring coronary blood flow following PTCA. (Consumer Summary produced by Reliance Medical Information, Inc.)

Percutaneous Transluminal Coronary Angioplasty: Part 1 A decade ago, percutaneous transluminal coronary angioplasty (PTCA) was considered appropriate only for those patients having a solitary, discrete stenosis in a single coronary [...]

Percutaneous Transluminal Coronary Angioplasty: Part 2 Because of the increased level of local thrombogenicity, unstable ischemia is not an optimal environment for mechanical intervention. Nevertheless, in certain clinical situations (as [...]

• In this multicenter clinical series of peripheral laser-assisted balloon angioplasty with an argon laser-heated, metallic-capped fiberoptic, angiographic and clinical success was achieved in a total of 155 (71%) of 219 attempted lesions. When the anatomy of the lesion was subjectively categorized by the angiographer into those considered possible or impossible to treat by conventional balloon angioplasty, clinical success was achieved in 116 (78%) of 149 lesions considered possible to treat with balloon angioplasty (39 [95%] of 41 stenoses and 77 [71%] of 108 occlusions). More importantly, clinical success was achieved in 39 (56%) of 70 lesions considered impossible to treat by conventional means. The incidence of complications, including vessel perforation (4.1%), with this new technique was equal to that reported for conventional balloon angioplasty, decreased with operator experience, and was less than that reported for argon laser angioplasty with bare fiberoptics. Thus, laser thermal angioplasty with a laser-heated, metallic-capped fiberoptic is a safe procedure that is easily learned by physicians skilled in interventional techniques. It allows for nonsurgical treatment of lesions considered difficult or impossible to treat by conventional balloon angioplasty.(Arch Surg 1989;124:1099-1103)

In a 60 month period (January 1981 to December 1985), 82 patients (79% male with a mean age of 60 years) had 83 saphenous vein grafts and 5 internal mammary artery grafts with a total of 101 stenotic sites treated with percutaneous transluminal coronary angioplasty. The mean time between bypass surgery and angioplasty was 51.2 months. The procedure was technically successful in 85% of patients, 86% of grafts and 85% of the sites attempted. In these cases, the mean diameter stenosis was reduced from 77 ± 14 to 27 ± 20% (p < 0.001), the mean pressure gradient from 49 ± 16 to 7 ± 6 mm Hg (p < 0.001). Emergency coronary artery bypass graft surgery was necessary in one patient (1.2%) whereas myocardial infarction occurred in three patients (3.6%). There were no hospital deaths.

To compare the amount of myocardium jeopardized during silent ischemia and painful ischemia, 112 consecutive patients undergoing coronary arteriography with ischemia demonstrated by exercise and redistribution tomographic thallium-201 myocardial imaging (SPECT) were divided into two groups: 84 patients without anginal pain (silent ischemia) and 28 with pain (painful ischemia). The SPECT apical, mid and basal ventricular levels of the short-axis view and the apical portion of the long-axis view were divided into 20 segments.