Angiographic follow-up after successful percutaneous coronary angioplasty for chronic total coronary occlusion: Experience in 110 consecutive patients

Angiographic follow-up after successful percutaneous coronary angioplasty for chronic total coronary occlusion: Experience in 110 consecutive patients Percutaneous transluminal coronary angioplasty (PTCA) was performed in 110 consecutive patients (111 vessels) with chronically occluded coronary arteries and was successful in 69 patients (69 vessels). Successful initial PTCA was related to the extent of coronary artery disease, the morphology of the proximal surface of the occlusion site, and the clinical duration of occlusion. Repeat angiography was performed for 62 patients, with successful initial PTCA and demonstrated restenosis in 34 (55%) patients, of whom 11 had total occlusion. Repeat PTCA was performed in 30 patients and was successful in 60%. Follow-up angiography after repeat PTCA was carried out in all patients who underwent successful second PTCA, and, it demonstrated re-restenosis in 7 (29%) patients. In this study, among 111 total occlusions, 26 vessels undergoing successful initial PTCA and 17 undergoing successful repeat PTCA were free from restenosis or re-restenosis at the time of follow-up angiography. (AM HEART J 1994;127:6-12.)

Nobukazu Ishizaka, MD, Takaaki Issiki, MD, Fumihiko Saeki, MD, Yuko Ishizaka, MD, Yuji Ikari, MD, Junichi Abe, MD, Yasunari Soumitsu, MD, Hideki Hashimoto, MD, Kazunobu Masaki, MD, and Tetsu Yamaguchi, MD Tokyo, Japan

Technologic advances and the increasing experience of operators have brought about a broadening of the indications for and application of percutaneous transluminal coronary angioplasty (PTCA). In patients with chronic total coronary artery occlusions, PTCA is reported to achieve a lower primary successratelm and be associated with a higher restenosis rate.3, 5 However, previous studies of the success rate and restenosis rate of second PTCA were derived from the analysis of a few patients. The purpose of this study was to analyze the primary successrate and the restenosis rate after initial or repeat PTCA for chronic total coronary occlusion to assessthe factors predicting successof restenosis and to determine the long-term angiographic successrate.

From

the Division

of Cardiology,

Received

for publication

Reprint micho,

requests: Division Kanda, Chiyoda-ku,

Copyright @’ 1994 000%8703/94/$1.00

6

Jan.

Mitsui 8, 1993;

Memorial accepted

of Cardiology, Mitsui Tokyo 103, Japan.

by Mosby-Year + .lO 4/l/50696

Book,

Inc.

Hospital. May

8, 1993.

Memorial

Hospital,

1 Izu-

METHODS Patient population.

Between October 1, 1982,and February 31, 1990, 1023 patients underwent initial PTCA at our hospital. Among them, 110patients (ll%, 111 vessels) underwent PTCA for chronic total coronary occlusion;they formed the study population. Chronic total occlusionwas defined as absolute absenceof antegrade filling that was coupled to persist for >2 weekson the basisof clinical or angiographic data. Definitions. Successful angioplasty was defined as residual stenosisoccupying <50% of the vessel diameter. Restenosiswasdefined asresidual stenosisof >50 % of the vesseldiameter at angiographic follow-up. Thrombus was defined as a clearly visualized lucent-filling defect closely associatedwith a site of occlusion.A side branch was defined aspresent if a branch could be identified within 5 mm of the proximal aspect of the occlusion. The presenceof collaterals was noted, and they were graded to none or poor-fair-good. The major acute cardiac complications of angioplasty were defined as death, emergency bypass surgery, or Q-wave myocardial infarction within 7 days of angioplasty. Non-Q-wave myocardial infarction was defined as an increase of the serum creatine phosphokinase level to >3 times normal and a positive MB isozyme fraction in the absence of new Q-wave fractions on a 12-lead electrocardiogram.

Volume 127, Number 1 American Heal Jour~Ial

PTCA technique. PTCA was performed by using either an over-the-wire or on-the-wire system according to the location of the lesion. Intracoronary urokinase was used if extensive intraluminal thrombus was present. Sublingual nitroglycerine was administered just before the procedure. Anticoagulation was achieved with a bolus injection of 100 U/kg of heparin at the beginning of the procedure. If the PTCA procedure continued for >1 hour, a further bolus injection of heparin (50 U/kg) was given. Statistics. Data are presented as mean f SD. A p value < 0.05 was consideredstatistically significant. RESULTS Patient characteristics. The study population comprised 110 patients with 111 total occlusions. The mean age was 55 years (range 35 to 77 years), and 100 (91% ) of the patients were men. Occlusion was associated with myocardial infarction in 62 (56 % ) lesions. The clinical duration of total occlusion was estimated for 48 patients, and the mean duration of occlusion was 3.0 + 1.7 months. Intracoronary urokinase was used in 8 (7%) vessels. Seven patients had a history of intracoronary thrombolytic therapy >2 weeks before the procedure. The lesions for which PTCA was attempted are listed in Table I. Primary angiographic success. Acute angiographic success was obtained in 69 (62%) of 111 totally occluded vessels. The 42 procedures were performed unsuccessfully for the following reasons: inability to cross with the wire (36), inability to cross with the dilatation catheter (5), and creation of a false lumen (1). Among the 42 patients in whom recanalization failed, 5 underwent elective coronary artery bypass surgery, 37 received medical treatment alone, and none required emergency bypass surgery. The angiographic variables predictive of primary success are shown in Table I. Single parameter neither a cut-off morphology or a side branch at the site of occlusion was significant predictors of primary success, but the existence of both a cut-off sign and a side branch was significantly associated with primary success.The estimated duration of occlusion is shown in Fig. 1. Although the mean duration of occlusion was not significantly different between the patients with and without successful PTCA, occlusion for
Ishizaka et al. 9 Table I. Factors associated with successful first PTCA Factors

Success

Failure

(n = 69)

(n = 42)

P Value

56 c 8 39 (93)

NS NS

10 (24) 32 (76) 1 (2)


22 (52)

NS

37 (88) 36 (86) 3.6 t 1.9

<0.05 NS NS

Clinical factors Age (yr; mean * SD) 55 f 10 Male sex (% ) 62 (90) Extent of coronary artery disease Single vessel ( W) 41 (59) Multivessel ( % ) 28 (41) Prior thrombolytic 5 (7) therapy ( % ) MI-associated 40 (58) occlusion (%) Angina pectoris ( % ) 49 (71) Aspirin therapy (%) 63 (91) Clinical duration of 2.8 + 1.6 occlusion (mts) k SD 27 Duration
7

G.05

18 9 11 0

NS

31 (71) 23 (55)


18 (43)

<0.05

9 (22) 21 (55)

12 (29)

NS

2 (5)

NS

LAD, Left anterior descending artery; LCX, left circumflex artery; right coronary artery; LMZ’, left main trunks; UK, urokinase.

RCA,

distal embolization without significant creatine phosphokinase elevation. Restenosis. Sixty-two (90 % ) of the 69 patients with successful PTCA underwent follow-up coronary angiography, and restenosis was found in 34 (55 % ) patients (34 lesions) (Fig. 2). Eleven (33%) of the 34 patients had total occlusion. Restenosis was not clearly related to the severity of post-PTCA residual stenosis. In addition, the duration of occlusion, prior myocardial infarction, and the extent of coronary artery disease did not predict restenosis. Management of restenosis. Repeat PTCA was performed for 30 (88%) of the 34 patients with angiographic restenosis and was successful in 24 (80%) patients (24 lesions). All of the four patients who did not undergo repeat angioplasty had total reocclusions and were treated medically. The percentage of stenosis of the target vessel before the second PTCA

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et al.

American

n Success q Failure

O-l -2 3

-4 -5 8

-7 -8 8- (months)

Clinical duration of occlusion Fig. 1. Duration of occlusionin relation to successor failure of initial PTCA. Clinical duration of occlusionfor
was not a significant predictor of a successful repeat procedure (84 % in successful patients vs 80 % in unsuccessful patients). The success rate of second PTCA for patients with or without reocclusion was 71% and 82 % , respectively (p = NS). Re-restenosis. Angiographic follow-up was performed for all 24 patients with successful repeat angioplasty, and 7 (29 % ) of 24 showed further restenosis (re-restenosis) (Fig. 3). The mean residual percent stenosis after the repeat PTCA was not significantly different between the patients with and without rerestenosis (22 % vs 21% , respectively). Management of re-restenosis. Of the seven patients with re-restenosis, 4 of 5 successfully underwent a third PTCA procedure, and two were treated by medication. Re-re-restenosis. Angiographic follow-up data were available in all four patients with a successful third PTCA; three showed restenosis (re-re-restenosis). DISCUSSION Some investigators have demonstrated that PTCA for total coronary occlusion comprises approximately 10% of the total number of PTCA procedure@ and that the primary success rate of elective PTCA of total occlusion is lower than that of conventional PTCA.le5 Also, revascularization of a total occlusion can sometimes provide better survival rate and can reduce the need for coronary bypass surgery.l However, in most reports long-term angiographic follow-up has usually only been performed on a few patients. One reason for the low angiographic follow-up

January 1994 Heart Journal

rates in previous studies was that angiography was not performed if patients were asymptomatic. However, angiographic restenosis may occur even in patients without angina pectoris. For example, patients with angiographic restenosis may be asymptomatic because of a good collateral supply or a change in daily activities. In this study, patients with successful initial PTCA who had given informed consent underwent follow-up coronary angiography irrespective of symptoms. Eleven percent of all the patients who underwent initial PTCA at our hospital had angioplasty for chronic total occlusions, with the successrate being 62 % and the restenosis rate being 55 % . The rate of follow-up angiography was very high (90% after the initial PTCA and 100% after the repeat PTCA). Factors predicting successful initial PTCA. In this study the primary success rate of the initial PTCA was 62 % , which was comparable to the successrates reported previously (50 % 70 % ).lm4,8 Some predictors of primary success were identified by our study. When the duration of occlusion was l month, the success rate declined to 56%) and this difference was significant. In earlier studies the clinical duration of occlusion was also found to influence the primary success of angioplasty.2, 3,g DiSciascio et a1.2demonstrated that the successrate declined steeply if the duration of occlusion was >l month. In addition, a cut-off morphology plus a side branch at the site of occlusion was a predictor of failure. Whereas La Veau et al8 reported that no morphologic variables correlated with frequency of primary success, we found that the morphology of the occlusive site was an important factor. Acute complications. There was one Q-wave infarct and three non-Q-wave infarcts. In this study as in previous reports, 2,3 PTCA of a total occlusion was a low-risk procedure. Although the preexisting total occlusion naturally cannot become worse, myocardial damage may occur from dissection that disturbs blood flow proximal to the occlusion or from distal embolization that disturbs flow from the collateral vessels. Feyter et al.1° reported a high risk of distal embolization (6 of 15,40 % ) during angioplasty of totally occluded venous bypass grafts.lO In this study only one non-Q-wave infarct occurred, but this may have been because we did not treat saphenous vein grafts older than 6 months. Factors predicting restenosis after successful initial PTCA. The residual percentage of diameter after the first angioplasty was not significantly different in the vesselswith and without restenosis (24% vs 25 % , re-

Volume 127, Number 1 Amerlcsn Heart Journal

Ishizaka

First PTCA

CABGII:

coronsry

artery

bypsss

et al.

11

SUCCesS U u failure 42

69

surgery

Fig. 2. Number of vesselswith successfuland failed initial PTCA and with subsequentrestenosis.Acute angiographic successof initial PTCA wasobtained in 62% of 111lesions,and angiographicrestenosiswas found in 55% of lesionswith successfuldilatation.

1 no restenoeis ,,

1

\ medi?tion

(

Fig. 3. Number of vesselswith successfuland failed secondPTCA and with subsequentrestenosis.Acute

angiographicsuccessof secondPTCA wasobtained in 80% of 30 lesions,and angiographicrestenosiswas found in 29% of lesionswith successfuldilatation.

spectively). In addition, the grade of collateral supply was not different in the vessels with and without restenosis (none or poor-fair-good; 10-21-3 vs 6-16-6, respectively). In previous reports immediate postPTCA narrowing2 or well-developed collateral circulation5, l1 was found to be predictive of restenosis, but we could not find them as significant predictors of restenosis in our series.

Factors predicting successful repeat PTCA. The success rate of second PTCA was 24 (80%) of 30. This was higher than the rate for the initial PTCA but was still lower than that for conventional PTCA. The percentage of diameter stenosis or existence of total reocclusion was not found to be predictive of successful second PTCA. Although the difference was not significant, the successrate of second PTCA per-

12

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et al.

formed for the reoccluded vessels was greater than that of initial PTCA for occluded vessels. Until now, there seem to be few articles that discuss repeat PTCA for initially chronic total occlusion. DiSciascio et a1.2reported that the successrate of repeat PTCA was 86 % , but they studied only seven patients. In addition, there seem to be no previous reports on the predictors of successfor repeat PTCA for chronic total occlusion. Factors predicting re-restenosis after successful repeat PTCA. Seven (29 % ) of the 24 vessels for which repeat PTCA was successful developed restenosis; this rate was significantly lower than that after initial PTCA (55%, p < 0.05). One of seven vessels that showed re-restenosis was a totally reoccluded vessel immediately before second PTCA. So re-restenosis occurred in 1 (20 % ) of 5 reoccluded vessels and in 6 (32 % ) of 19 nonreoccluded vessels. None of the angiographic, clinical, or procedural variables that we studied were predictive of re-restenosis after repeat PTCA. Expected a sustained success rate with initial and second PTCA. Twenty-eight vessels undergoing successful initial PTCA and 17 undergoing successful repeat PTCA were free from restenosis or re-restenosis at the time of follow-up angiography. Thus 45 (43%) of the 104 vessels (7 of 111 vessels were not monitored) were judged to show successat the time of follow-up angiography. Recently, Ellis et al-l2 demonstrated that the restenosis rate does not reach a plateau after 6 months of follow-up, so it is possible that the successrate would be lower with a longer follow-up period. In conclusion, angioplasty can be performed safely for coronary vessels with chronic total occlusion and saphenous vein grafts not older than 6 months, and sustained success can be obtained for 43% of the vessels after initial or repeat PTCA. However, the morphology of the occluded site (cut-off or side branch) and the duration of occlusion need to be

American

January 1994 Heart Journal

considered because these factors may reduce the initial success. REFERENCES

1. Kereiakes DJ, Selmon MR, McAuley BJ, McAuley DB, Sheehan DJ, Simpson JB. Angioplasty in total coronary artery occlusion: experience in 76 consecutive patients. J Am Co11Cardiol 1985;6:526-33. 2. DiSciascio G, Vetrovec GW, Cowley MJ, Wilfgang TC. Early and late outcome of percutaneous transluminal coronary angioplasty for subacute and chronic total coronary occlusion. AMHEARTJ 1986;111:833-9. 3. Melchoir JP, Meier B, Urban P, Finci L, Steffenino G, Noble J, Rutishauser W. Percutaneous transluminal coronary angioplasty for chronic total coronary arterial occlusion. Am J Cardiol 1987;59:535-8. 4. Saifian RD, McCabe CH, Sipperly ME, McKay RG, Bairn DS. Initial success and long-term follow-up of percutaneous transluminal angioplasty in chronic total occlusion versus conventional stenosis. Am J Cardiol 1988;61:23-28G. 5. Libow MA, Leimgrububer PP, Roubin GS, Greuntzig AR. Restenosis after angioplasty (PTCA) in chronic total coronary artery occlusion [Abstract]. J Am Co11 Cardiol 1985;5:445. 6. Savaee R. Hollman J. Greuntziz A. Kine S. Douelas J. Tnakersley R. Can percutaneous t~ansluminal angioplasty be performed in patients with chronic occlusion of coronary artery. Circulation 1982;66(suppl 2):2-5. 7. Warren RJ, Black AJ, Valentine PA, Manolas EG, Hunt D. Coronary angioplasty for chronic total occlusion reduces the need for subsequent coronary bypass surgery. AM HEART J 1990;120:270-4. 8. LaVeau PJ, Remetz MS, Cabin HS, Hennecken JF, McConnell SH, Rosen RE, Cleman MW. Predictors of success in percutaneous transluminal coronary angioplasty of chronic total occlusions. Am J Cardiol 1989;64:1264-9. 9. Holmes DR, Vliestra RE, Reeder GS, Bresnahan JF, Smith HC, Bove AA, Schaff HV. Angioplasty in total coronary artery occlusion. J Am Co11 Cardiol 1984,3:845-9. 10. Feyter PJ, Serruys P, Brnad M, Meester H, Beatt K, Suryapranata H. Percutaneous transluminal angioplasty of a totally occluded venous bypass graft: a challenge that should be resisted. Am J Cardiol 1989;64:88-90. 11. Dervan JP, Bairn DS, Cherniles J, Grossman W. Transluminal angioplasty of occluded coronary arteries: use of a movable - _ guide wire system. Circulation 1983;68:776-84. 12. Ellis SG, Shaw RE, Gershony, Thomas R, Roubin GS, Douglas JS, Top01 EJ, Startzer SH, Myler RK, King SB III. Risk factors, time course and treatment effect for restenosis after successful percutaneous transluminal coronary angioplasty of chronic total occlusion. Am J Cardiol 1989;63:897-901.