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Percutaneous transluminal coronary angioplasty in patients with prior coronary bypass surgery
645
News and Views IJC 00186
Percutaneous transluminal coronary angioplasty in patients with prior coronary bypass surgery * (Key words:
coronary
bypass
grafting;
percutaneous
transluminal
coronary
angio-
plasty) Current surgical treatment of coronary artery disease represents the culmination of an evolutionary process that began with early ineffective procedures such as thoracic sympathectomy, epicardial abrasion, and internal mammary artery ligation. Coronary artery bypass grafting today offers immediate palliation of symptoms in the vast majority of individuals with the promise of improved longevity in many patients. With its extremely low operative mortality, it is easy to understand why coronary bypass grafting has become the most common major surgical procedure in the United States. Despite its merits, disease progression in the native circulation and in grafts poses a continuing threat to the individual patient [l-6]. Recurrent or worsening symptoms are reported in 5 to 10% of postoperative patients annually [1,5,6], leading to reoperation in up to 10% of individuals followed long term [7-91. Reoperations are technically difficult and are associated with more frequent complications and a higher operative mortality [lO,ll]. Since its introduction by Gruentzig in 1977 [12], percutaneous transluminal coronary angioplasty (PTCA) has become a widely accepted alternative means of revascularization in some individuals with obstructive coronary disease. With proper case selection and experienced teams, complication rates are low and intermediateterm follow-up is favorable [13-191. In addition to avoidance of the risks of reoperation, FTCA boasts a lower procedural cost and has demonstrated better preservation of patient productivity [20,21]. Despite early reports from the National Heart, Lung and Blood Institute Registry of higher in-hospital mortality of angioplasty in patients with prior bypass grafting [17,18], more recent experience has been favorable. Douglas et al. have previously reported our early experience with this subset of patients [22]. This report presents the results of 168 consecutive patients undergoing PTCA at Emory University Hospital after previous coronary bypass grafting to further define initial success and complication rates and examine more recent trends. Patient Population and Clinical Profile From January (180 procedures)
1978 to June 1983, 168 patients underwent coronary angioplasty after prior coronary bypass surgery. The mean age of the group
* From Interventional Cardiovascular of Medicine, Atlanta, Georgia.
Medicine,
International Journal of Cardiology, 6 (1984) 645-650 0 Elsevier Science Publishers B.V.
Department
of Medicine, Emory University
School
646
was 55.2 years (range 37-72); 143 (85%) were men and 25 (15%) were women. The mean interval between coronary bypass surgery and coronary angioplasty was 27.1 months (range 2 to 132). On a clinical basis, patients were selected because of disabling symptoms despite adequate medical therapy with nitrates, beta-blockers and/or calcium antagonists. Angiographically the stenosis subtending the jeopardized vascular bed had to appear acceptable for dilatation. Multiple stenoses in a single vessel or graft or in several vessels were in general referred for surgery. Technique
Although described previously, the technique of percutaneous transluminal coronary angioplasty has continued to evolve. Technical advances that have fostered recent success include the following: (1) advanced radiographic equipment capable of multiangular projections and multiple field sizes, (2) high-resolution recorders and video disks that permit constant display of appropriate frames for comparison with real-time images, (3) a variety of guiding catheters in both 8 and 9 French sizes, and (4) a selection of dilatation catheters including multiple sizes, tandem arrangement, and low profile configuration.
Proximal anastomosis
(13)
Distal anastomosis
(54)
Native
coronky
artery
(83)
Fig. 1. Sites of 180 first transluminal angiophsty attempts. IMA = internal mammary artery graft.
641
Protocol Following definition of functional capacity utilizing exercise testing with nuclear imaging, the patient is taken to the laboratory where the femoral artery and vein are cannulated. Pharmacologic dilatation and anticoagulation are accomplished with sublingual nifedipine and heparin respectively and the pacing catheter is positioned in the right ventricular apex. The appropriate guiding catheter is then selected as to allow adequate seating in the coronary or graft ostium but still avoid wedging with limitation of flow. Judkins-type right coronary guiding catheters, Rowe-CastilloAmplatz type, and multipurpose guiders were most frequently used to engage graft ostia. Baseline angiograms are obtained and frozen for reference and a balloon catheter is chosen based on the severity of the stenosis and the size of the adjacent vessel. Under biplane fluoroscopic control the soft-tipped guidewire is carefully steered across the stenosis and down the distal vessel. Next the dilatation catheter is slowly advanced over the guidewire until the stenosis is bridged as evidenced by fluoroscopy and the recording of a pressure gradient between the guiding catheter and the balloon catheter tip. Once correct position is assured, balloon inflation (actually a misnomer as the balloon contains a mixture of saline and contrast material) is begun. Care is taken to note the deformity imposed by the lesion on the balloon to further confirm position. Inflations are maintained for approximately 15 to 60 set and are repeated until the pressure gradient is optimally reduced. The wire is then advanced simultaneously with dilatation catheter withdrawal so that the wire remains distal to the stenosis and the balloon is positioned proximal to the site of the original stenosis. Injections are performed through both the guide and balloon catheters to define the status of the dilated vessel segment. With favorable results the balloon catheter is removed and a repeat angiogram is obtained. Postangioplasty care is designed to monitor the patient for signs and symptoms of myocardial ischemia. Included in the routine protocol are serial electrocardiograms, telemetry for 18 h, and serial CK measurements. Before discharge, all data pertinent in assessing the consequences of the procedure are reviewed. These include: (1) preand post-angioplasty exercise tests, (2) review of PTCA films to measure pre- and post-PTCA stenoses and evaluate angiographic degree of intimal disruption, (3) initial and final gradients, (4) serial electrocardiograms, and (5) serial CK values. Routine medications at discharge include a calcium antagonist and one aspirin per day. Initial
Results
Successes, Failures and Complications. Angiographic success (> 20% absolute reduction in stenosis) was obtained in 161 (89%) of 180 first attempts at transluminal angioplasty. Mean stenosis calculated by the diameter method in the 161 successful procedures was reduced from 77 k 13% (mean f SD) to 26 f 14% with a concomitant pressure gradient fall from 48 &- 17 to 11 f 8 mm Hg. It was not possible to cross the stenosis with the balloon catheter in 12 patients (7%) and 10 of these patients underwent elective reoperation; 2 patients refused surgery and con-
648
tinued on medical therapy. Five patients required emergency bypass grafting; 4 because of dissection at the dilatation site at the time of balloon passage; 1 because of distal embolization of the plaque. One patient with juvenile onset diabetes sustained an anterior infarction the night after apparent successful dilatation of an LAD graft. Other complications were: CK-MB > 20 U (2 patients), prolonged ischemic pain requiring intraaortic balloon pumping (1 patient) and ventricular fibrillation (3 patients). There were no early deaths. One late death was recorded after failure to cross the stenosis in a patient who subsequently refused surgery. The patient died suddenly 14 months later. Native Coronary Artery Stenosis. Eighty-three coronary angioplasty procedures were performed in 81 patients for stenosis of the native coronary arteries. Seventy-one (86%) of these procedures were successful with the success rate being lowest in the right coronary artery (79%) and highest in the left anterior descending artery (95%). Distal Anastomosis (Sapbenous Vein to Coronary Artery Junction). Fifty-four patients underwent angioplasty of lesions involving the distal anastomosis. In 35 patients (65%) the vein graft was to the left anterior descending artery, in 14 patients (26%) to the right coronary artery, and in 5 patients (9%) it was to the circumflex artery. In 51 patients (94%) the dilatation was successful. In 1 patient the saphenous vein could not be cannulated with the guiding catheter and in another coronary dissection with occlusion dictated emergency coronary bypass surgery. Saphenous Vein Independent of Anastomoses. Transluminal dilatation was attempted on the body of the graft in 29 patients; in 14 patients the graft supplied the right coronary artery, in 12 the left anterior descending, and in three, the circumflex. Initial success was achieved in 27 patients (93%). One individual required emergency bypass surgery because of dissection with occlusion while the other failure was due to inability to reduce the degree of stenosis in another diseased graft. Angioplasty was attempted in one patient with stenosis of the mid-portion of an internal mammary graft; the stenosis could not be crossed and coronary bypass surgery was recommended. Proximal Anastomosis (Saphenous Vein to Aorta). In 13 patients dilatation attempted for stenosis at the site of aortic implantation. The procedure successful in 12 patients with the single failure due to inability to cannulate severely stenosed graft orifice. This individual underwent elective reoperation.
was was the
Follow-up At present, follow-up has been compiled only on the first 116 patients as reported earlier by Douglas et al. [22]. According to their original data, at a mean follow-up of 8.3 months, 88 patients (76%) were free of angina or in improved condition. In patients followed up for at least 6 months, evidence of restenosis occurred in 9 (53%)
649
of 17 saphenous veins, 1 (50%) of 2 proximal graft anastomoses, graft anastomoses and 5 (14%) of 37 native coronary arteries.
4 (18%) of 22 distal
Discussion The role of transluminal angioplasty continues to be defined as applied to patients post-bypass grafting. Despite the initial NHLBI report suggesting increased hazard in this subgroup of individuals [17,18], more recent efforts have demonstrated high success rates and infrequent complications [22]. The initial success rate in the group of patients discussed in this report was 89%. This compares favorably with our recent total experience with coronary angioplasty. Examining the data for the year 1983, PTCA was successful in 1296/1424 vessels attempted (91%) 1231. Complications at the time of the procedure were infrequent - contrasting earlier data. Since the low frequency of significant complications also paralleled those results from our total experience, it would appear that it is operator experience and not prior bypass surgery that played a major role in the NHLBI data. Late Results of Angioplasty in Patients after Bypass. While the long-term outcome of patients after PTCA continues to be defined, intermediate follow-up in the post-coronary artery bypass grafting subgroup appears favorable. Patency after dilatation appears to be particularly excellent at distal anastomotic sites. Less favorable sustained results were noted after dilatation of mid-saphenous vein grafts where the recurrence rate in this small group was > 50% [22]. PTCA at this site and at the proximal anastomosis requires further investigation. Clinical Implications. Examining the safety and efficacy of the procedure, transluminal coronary angioplasty represents a viable alternative to reoperation for progressive coronary disease. Despite the advanced state of the art of present-day bypass surgery, repeat procedures are significantly more hazardous. Even with the characteristic less extensive revascularization, operative morbidity and mortality is significantly increased. At Emory University Hospital and at the Cleveland Clinic operative mortality rate in reoperations was four times that of first operations, perioperative infarctions occurred three times more frequently and the risk of infection and blood transfusion-related complications was significantly higher [10,22]. Coupling this knowledge with the fact that the cost of PTCA is approximately one-third that of bypass grafting [20,22] and convalescence is short, the appeal is evident. As the pool of patients having undergone prior bypass grafting grows, the number with recurrent symptoms secondary to progressive disease will also grow. Percutaneous angioplasty now offers a gentle effective mode of therapy to a significant subgroup of these individuals with favorable vascular anatomy. Department of Medicine Emory University School of Medicine 1364 Clifton Road N.E. Atlanta, GA 30322, U.S.A.
David Hall Orlando Corzo John Douglas Andreas R. Gruentzig
650
References 1 Campeau L, Lesperance J, Hermann J, Corbara F, Grondin CM, Bourassa MC. Loss of improvement of angina between 1 and 7 years after aortocoronary bypass surgery. Correlations with changes in vein grafts and in coronary arteries. Circulation 1979;60 (suppl I):l-5. NT, Karp RB, Oberman A, Russell RO Jr, Allison HW, Holt JH Jr. Long-term patency 2 Kouchoukos of saphenous veins for coronary bypass grafting. Circulation 1978:58 (suppl 1):96-99. saphenous vein bypass grafts. Long-term 3 Hamby RI, Aintablian A, Handler M, et al. Aortocoronary patency, morphology and blood flow in patients with patent grafts early after surgery. Circulation 1979;60:90-909. 4 Chesebro JH, Clements IP, Fuster V, et al. A platelet-inhibitor-drug trial in coronary-artery bypass operations: benefits of perioperative dipyridamole and aspirin therapy on earIy postoperative vein-graft patency. N Engl J Med 1982;307:73-78. 5 Seides SF, Borer JS, Kent KM, Rosing DR. McIntosh CL, Epstein SE. Long-term anatomic fate of coronary bypass grafts and functional status of patients five years after operation. N Engl J Med 1978;298:1213-1217. DF, Robert EW, Alderman EL, Wesler L. Long-term serial angiographic studies after 6 Guthaner coronary artery bypass surgery. Circulation 1979;60:250-258. 7 Lawrie GM, Morris GC Jr., Calhoun JH, et al. Clinical results of coronary bypass in 500 patients at least 10 years after operation. Circulation 1982;66 (suppl l):l-5. 8 Loop FD, Sheldon WC, Lytle BW, Cosgrove DM III, Proudfit WL. The efficacy of coronary artery surgery. Am Heart J 1981;101:86-96. 9 Schaff HV, Gersh BJ, Pluth JR, et al. Survival and functional results after coronary artery bypass grafting; results lo-12 years post-operatively in 500 patients (abstract). Circulation 1982;66 (suppl 11):246. results in 500 coronary 10 Loop FD, Cosgrove DM, Kramer JR, et al. Late clinical and arteriographic artery moperations. J Thorac Cardiovasc Surg 1981;81:675-685. for recurrent coronary 11 Reul GJ Jr., Cooley DA, Ott DA, Coelho A, Chapa L, Eterovic 1. Reoperation artery disease. Causes, indications, and results in 168 patients. Arch Surg 1979;114:1269-1275. 12 Gruentzig AR. Transluminal dilatation of coronary artery stenosis. Lancet 1978;1:263. coronary angioplasty using 13 Gruentzig AR, Hollman J. Improved primary success rate in transluminal a steerable guidance system (abstract). Circulation 1982;66 (suppl 11):330. W. Nonoperative dilatation of coronary artery stenosis. N 14 Gruentzig AR, Senning A, Siegenthaler Engl J Med 1979;301:61-68. transluminal coronary angioplasty: 15 Cowley MJ, Vetrovee GW, Wolfgang T. Efficacy of percutaneous technique, patient selection, salutary results, limitations and complications. Am Heart J 1981;101:272-280. AR, Schlumpf M, Siegenthaler W. Late functional results after success or failure of 16 Gruentzig coronary angioplasty (abstract). Circulation 1981;64 (suppl IV):193. Transluminal Coronary Angioplasty: Report 17 Kent KM, Bentivoglio LG, Block PC, et al. Percutaneous from the Registry of the National Heart, Lung, and Blood Institute. Am J Cardiol1982;49:2011-2020. 18 Mock MB, Kent KM, Bentivoglio LG. The National Heart, Lung and Blood Institute percutaneous transluminal coronary angioplasty registry: the first 1116 cases. In: Kaltenbach M, Gruentzig A, Rentrop K, Bussman WD, eds. Transluminal coronary angioplasty and intracoronary thrombolysis. Coronary heart disease IV. Berlin, Heidelberg, New York: Springer-Verlag, 1982;11-19. transluminal coronary angioplasty. Sem Roentgen01 1981;2:152-153. 19 Gruentzig AR. Percutaneous cost analysis of coronary angioplasty and coronary 20 Jang JC, Block PC, Cowley MJ, et al. Comparative bypass surgery: results from a national cooperative study (abstract). Circulation 1982;66 (suppl 11):124. or 21 Jang CC, tiruentzig AR, Block PC. et al. Work profile of patients following coronary angioplasty coronary bypass surgery; results from a national cooperative study (abstract). Circulation 1982;66 (suppl 11):123. 22 Douglas J, Gruentzig AR, King SB III, et al. Percutaneous transluminal coronary angioplasty in patients with prior coronary bypass surgery. J Am Co11 Cardiol 1983;2:745-754. 23 Emory University Data Bank Statistics.
News and Views IJC 00186
Percutaneous transluminal coronary angioplasty in patients with prior coronary bypass surgery * (Key words:
coronary
bypass
grafting;
percutaneous
transluminal
coronary
angio-
plasty) Current surgical treatment of coronary artery disease represents the culmination of an evolutionary process that began with early ineffective procedures such as thoracic sympathectomy, epicardial abrasion, and internal mammary artery ligation. Coronary artery bypass grafting today offers immediate palliation of symptoms in the vast majority of individuals with the promise of improved longevity in many patients. With its extremely low operative mortality, it is easy to understand why coronary bypass grafting has become the most common major surgical procedure in the United States. Despite its merits, disease progression in the native circulation and in grafts poses a continuing threat to the individual patient [l-6]. Recurrent or worsening symptoms are reported in 5 to 10% of postoperative patients annually [1,5,6], leading to reoperation in up to 10% of individuals followed long term [7-91. Reoperations are technically difficult and are associated with more frequent complications and a higher operative mortality [lO,ll]. Since its introduction by Gruentzig in 1977 [12], percutaneous transluminal coronary angioplasty (PTCA) has become a widely accepted alternative means of revascularization in some individuals with obstructive coronary disease. With proper case selection and experienced teams, complication rates are low and intermediateterm follow-up is favorable [13-191. In addition to avoidance of the risks of reoperation, FTCA boasts a lower procedural cost and has demonstrated better preservation of patient productivity [20,21]. Despite early reports from the National Heart, Lung and Blood Institute Registry of higher in-hospital mortality of angioplasty in patients with prior bypass grafting [17,18], more recent experience has been favorable. Douglas et al. have previously reported our early experience with this subset of patients [22]. This report presents the results of 168 consecutive patients undergoing PTCA at Emory University Hospital after previous coronary bypass grafting to further define initial success and complication rates and examine more recent trends. Patient Population and Clinical Profile From January (180 procedures)
1978 to June 1983, 168 patients underwent coronary angioplasty after prior coronary bypass surgery. The mean age of the group
* From Interventional Cardiovascular of Medicine, Atlanta, Georgia.
Medicine,
International Journal of Cardiology, 6 (1984) 645-650 0 Elsevier Science Publishers B.V.
Department
of Medicine, Emory University
School
646
was 55.2 years (range 37-72); 143 (85%) were men and 25 (15%) were women. The mean interval between coronary bypass surgery and coronary angioplasty was 27.1 months (range 2 to 132). On a clinical basis, patients were selected because of disabling symptoms despite adequate medical therapy with nitrates, beta-blockers and/or calcium antagonists. Angiographically the stenosis subtending the jeopardized vascular bed had to appear acceptable for dilatation. Multiple stenoses in a single vessel or graft or in several vessels were in general referred for surgery. Technique
Although described previously, the technique of percutaneous transluminal coronary angioplasty has continued to evolve. Technical advances that have fostered recent success include the following: (1) advanced radiographic equipment capable of multiangular projections and multiple field sizes, (2) high-resolution recorders and video disks that permit constant display of appropriate frames for comparison with real-time images, (3) a variety of guiding catheters in both 8 and 9 French sizes, and (4) a selection of dilatation catheters including multiple sizes, tandem arrangement, and low profile configuration.
Proximal anastomosis
(13)
Distal anastomosis
(54)
Native
coronky
artery
(83)
Fig. 1. Sites of 180 first transluminal angiophsty attempts. IMA = internal mammary artery graft.
641
Protocol Following definition of functional capacity utilizing exercise testing with nuclear imaging, the patient is taken to the laboratory where the femoral artery and vein are cannulated. Pharmacologic dilatation and anticoagulation are accomplished with sublingual nifedipine and heparin respectively and the pacing catheter is positioned in the right ventricular apex. The appropriate guiding catheter is then selected as to allow adequate seating in the coronary or graft ostium but still avoid wedging with limitation of flow. Judkins-type right coronary guiding catheters, Rowe-CastilloAmplatz type, and multipurpose guiders were most frequently used to engage graft ostia. Baseline angiograms are obtained and frozen for reference and a balloon catheter is chosen based on the severity of the stenosis and the size of the adjacent vessel. Under biplane fluoroscopic control the soft-tipped guidewire is carefully steered across the stenosis and down the distal vessel. Next the dilatation catheter is slowly advanced over the guidewire until the stenosis is bridged as evidenced by fluoroscopy and the recording of a pressure gradient between the guiding catheter and the balloon catheter tip. Once correct position is assured, balloon inflation (actually a misnomer as the balloon contains a mixture of saline and contrast material) is begun. Care is taken to note the deformity imposed by the lesion on the balloon to further confirm position. Inflations are maintained for approximately 15 to 60 set and are repeated until the pressure gradient is optimally reduced. The wire is then advanced simultaneously with dilatation catheter withdrawal so that the wire remains distal to the stenosis and the balloon is positioned proximal to the site of the original stenosis. Injections are performed through both the guide and balloon catheters to define the status of the dilated vessel segment. With favorable results the balloon catheter is removed and a repeat angiogram is obtained. Postangioplasty care is designed to monitor the patient for signs and symptoms of myocardial ischemia. Included in the routine protocol are serial electrocardiograms, telemetry for 18 h, and serial CK measurements. Before discharge, all data pertinent in assessing the consequences of the procedure are reviewed. These include: (1) preand post-angioplasty exercise tests, (2) review of PTCA films to measure pre- and post-PTCA stenoses and evaluate angiographic degree of intimal disruption, (3) initial and final gradients, (4) serial electrocardiograms, and (5) serial CK values. Routine medications at discharge include a calcium antagonist and one aspirin per day. Initial
Results
Successes, Failures and Complications. Angiographic success (> 20% absolute reduction in stenosis) was obtained in 161 (89%) of 180 first attempts at transluminal angioplasty. Mean stenosis calculated by the diameter method in the 161 successful procedures was reduced from 77 k 13% (mean f SD) to 26 f 14% with a concomitant pressure gradient fall from 48 &- 17 to 11 f 8 mm Hg. It was not possible to cross the stenosis with the balloon catheter in 12 patients (7%) and 10 of these patients underwent elective reoperation; 2 patients refused surgery and con-
648
tinued on medical therapy. Five patients required emergency bypass grafting; 4 because of dissection at the dilatation site at the time of balloon passage; 1 because of distal embolization of the plaque. One patient with juvenile onset diabetes sustained an anterior infarction the night after apparent successful dilatation of an LAD graft. Other complications were: CK-MB > 20 U (2 patients), prolonged ischemic pain requiring intraaortic balloon pumping (1 patient) and ventricular fibrillation (3 patients). There were no early deaths. One late death was recorded after failure to cross the stenosis in a patient who subsequently refused surgery. The patient died suddenly 14 months later. Native Coronary Artery Stenosis. Eighty-three coronary angioplasty procedures were performed in 81 patients for stenosis of the native coronary arteries. Seventy-one (86%) of these procedures were successful with the success rate being lowest in the right coronary artery (79%) and highest in the left anterior descending artery (95%). Distal Anastomosis (Sapbenous Vein to Coronary Artery Junction). Fifty-four patients underwent angioplasty of lesions involving the distal anastomosis. In 35 patients (65%) the vein graft was to the left anterior descending artery, in 14 patients (26%) to the right coronary artery, and in 5 patients (9%) it was to the circumflex artery. In 51 patients (94%) the dilatation was successful. In 1 patient the saphenous vein could not be cannulated with the guiding catheter and in another coronary dissection with occlusion dictated emergency coronary bypass surgery. Saphenous Vein Independent of Anastomoses. Transluminal dilatation was attempted on the body of the graft in 29 patients; in 14 patients the graft supplied the right coronary artery, in 12 the left anterior descending, and in three, the circumflex. Initial success was achieved in 27 patients (93%). One individual required emergency bypass surgery because of dissection with occlusion while the other failure was due to inability to reduce the degree of stenosis in another diseased graft. Angioplasty was attempted in one patient with stenosis of the mid-portion of an internal mammary graft; the stenosis could not be crossed and coronary bypass surgery was recommended. Proximal Anastomosis (Saphenous Vein to Aorta). In 13 patients dilatation attempted for stenosis at the site of aortic implantation. The procedure successful in 12 patients with the single failure due to inability to cannulate severely stenosed graft orifice. This individual underwent elective reoperation.
was was the
Follow-up At present, follow-up has been compiled only on the first 116 patients as reported earlier by Douglas et al. [22]. According to their original data, at a mean follow-up of 8.3 months, 88 patients (76%) were free of angina or in improved condition. In patients followed up for at least 6 months, evidence of restenosis occurred in 9 (53%)
649
of 17 saphenous veins, 1 (50%) of 2 proximal graft anastomoses, graft anastomoses and 5 (14%) of 37 native coronary arteries.
4 (18%) of 22 distal
Discussion The role of transluminal angioplasty continues to be defined as applied to patients post-bypass grafting. Despite the initial NHLBI report suggesting increased hazard in this subgroup of individuals [17,18], more recent efforts have demonstrated high success rates and infrequent complications [22]. The initial success rate in the group of patients discussed in this report was 89%. This compares favorably with our recent total experience with coronary angioplasty. Examining the data for the year 1983, PTCA was successful in 1296/1424 vessels attempted (91%) 1231. Complications at the time of the procedure were infrequent - contrasting earlier data. Since the low frequency of significant complications also paralleled those results from our total experience, it would appear that it is operator experience and not prior bypass surgery that played a major role in the NHLBI data. Late Results of Angioplasty in Patients after Bypass. While the long-term outcome of patients after PTCA continues to be defined, intermediate follow-up in the post-coronary artery bypass grafting subgroup appears favorable. Patency after dilatation appears to be particularly excellent at distal anastomotic sites. Less favorable sustained results were noted after dilatation of mid-saphenous vein grafts where the recurrence rate in this small group was > 50% [22]. PTCA at this site and at the proximal anastomosis requires further investigation. Clinical Implications. Examining the safety and efficacy of the procedure, transluminal coronary angioplasty represents a viable alternative to reoperation for progressive coronary disease. Despite the advanced state of the art of present-day bypass surgery, repeat procedures are significantly more hazardous. Even with the characteristic less extensive revascularization, operative morbidity and mortality is significantly increased. At Emory University Hospital and at the Cleveland Clinic operative mortality rate in reoperations was four times that of first operations, perioperative infarctions occurred three times more frequently and the risk of infection and blood transfusion-related complications was significantly higher [10,22]. Coupling this knowledge with the fact that the cost of PTCA is approximately one-third that of bypass grafting [20,22] and convalescence is short, the appeal is evident. As the pool of patients having undergone prior bypass grafting grows, the number with recurrent symptoms secondary to progressive disease will also grow. Percutaneous angioplasty now offers a gentle effective mode of therapy to a significant subgroup of these individuals with favorable vascular anatomy. Department of Medicine Emory University School of Medicine 1364 Clifton Road N.E. Atlanta, GA 30322, U.S.A.
David Hall Orlando Corzo John Douglas Andreas R. Gruentzig
650
References 1 Campeau L, Lesperance J, Hermann J, Corbara F, Grondin CM, Bourassa MC. Loss of improvement of angina between 1 and 7 years after aortocoronary bypass surgery. Correlations with changes in vein grafts and in coronary arteries. Circulation 1979;60 (suppl I):l-5. NT, Karp RB, Oberman A, Russell RO Jr, Allison HW, Holt JH Jr. Long-term patency 2 Kouchoukos of saphenous veins for coronary bypass grafting. Circulation 1978:58 (suppl 1):96-99. saphenous vein bypass grafts. Long-term 3 Hamby RI, Aintablian A, Handler M, et al. Aortocoronary patency, morphology and blood flow in patients with patent grafts early after surgery. Circulation 1979;60:90-909. 4 Chesebro JH, Clements IP, Fuster V, et al. A platelet-inhibitor-drug trial in coronary-artery bypass operations: benefits of perioperative dipyridamole and aspirin therapy on earIy postoperative vein-graft patency. N Engl J Med 1982;307:73-78. 5 Seides SF, Borer JS, Kent KM, Rosing DR. McIntosh CL, Epstein SE. Long-term anatomic fate of coronary bypass grafts and functional status of patients five years after operation. N Engl J Med 1978;298:1213-1217. DF, Robert EW, Alderman EL, Wesler L. Long-term serial angiographic studies after 6 Guthaner coronary artery bypass surgery. Circulation 1979;60:250-258. 7 Lawrie GM, Morris GC Jr., Calhoun JH, et al. Clinical results of coronary bypass in 500 patients at least 10 years after operation. Circulation 1982;66 (suppl l):l-5. 8 Loop FD, Sheldon WC, Lytle BW, Cosgrove DM III, Proudfit WL. The efficacy of coronary artery surgery. Am Heart J 1981;101:86-96. 9 Schaff HV, Gersh BJ, Pluth JR, et al. Survival and functional results after coronary artery bypass grafting; results lo-12 years post-operatively in 500 patients (abstract). Circulation 1982;66 (suppl 11):246. results in 500 coronary 10 Loop FD, Cosgrove DM, Kramer JR, et al. Late clinical and arteriographic artery moperations. J Thorac Cardiovasc Surg 1981;81:675-685. for recurrent coronary 11 Reul GJ Jr., Cooley DA, Ott DA, Coelho A, Chapa L, Eterovic 1. Reoperation artery disease. Causes, indications, and results in 168 patients. Arch Surg 1979;114:1269-1275. 12 Gruentzig AR. Transluminal dilatation of coronary artery stenosis. Lancet 1978;1:263. coronary angioplasty using 13 Gruentzig AR, Hollman J. Improved primary success rate in transluminal a steerable guidance system (abstract). Circulation 1982;66 (suppl 11):330. W. Nonoperative dilatation of coronary artery stenosis. N 14 Gruentzig AR, Senning A, Siegenthaler Engl J Med 1979;301:61-68. transluminal coronary angioplasty: 15 Cowley MJ, Vetrovee GW, Wolfgang T. Efficacy of percutaneous technique, patient selection, salutary results, limitations and complications. Am Heart J 1981;101:272-280. AR, Schlumpf M, Siegenthaler W. Late functional results after success or failure of 16 Gruentzig coronary angioplasty (abstract). Circulation 1981;64 (suppl IV):193. Transluminal Coronary Angioplasty: Report 17 Kent KM, Bentivoglio LG, Block PC, et al. Percutaneous from the Registry of the National Heart, Lung, and Blood Institute. Am J Cardiol1982;49:2011-2020. 18 Mock MB, Kent KM, Bentivoglio LG. The National Heart, Lung and Blood Institute percutaneous transluminal coronary angioplasty registry: the first 1116 cases. In: Kaltenbach M, Gruentzig A, Rentrop K, Bussman WD, eds. Transluminal coronary angioplasty and intracoronary thrombolysis. Coronary heart disease IV. Berlin, Heidelberg, New York: Springer-Verlag, 1982;11-19. transluminal coronary angioplasty. Sem Roentgen01 1981;2:152-153. 19 Gruentzig AR. Percutaneous cost analysis of coronary angioplasty and coronary 20 Jang JC, Block PC, Cowley MJ, et al. Comparative bypass surgery: results from a national cooperative study (abstract). Circulation 1982;66 (suppl 11):124. or 21 Jang CC, tiruentzig AR, Block PC. et al. Work profile of patients following coronary angioplasty coronary bypass surgery; results from a national cooperative study (abstract). Circulation 1982;66 (suppl 11):123. 22 Douglas J, Gruentzig AR, King SB III, et al. Percutaneous transluminal coronary angioplasty in patients with prior coronary bypass surgery. J Am Co11 Cardiol 1983;2:745-754. 23 Emory University Data Bank Statistics.