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Percutaneous transluminal coronary angioplasty: six years' experience
Percutaneous transluminal six years’ experience Andreas R. Gruentzig,
M.D. Athta,
coronary
angioplasty:
Ga.
It can be foreseen that with properly selected cases, percutaneous transluminal coronary angioplasty will have the same primary and long-term results as bypass surgery in this subset of patients. The socioeconomic and psychologic advantages of the procedure, compared to the advantages of heart surgery, are obvious. The classic indication for the procedure is single-vessel disease. At the present level of experience and case selection, approximately 10% of the surgical candidates could undergo dilatation. If patients with discrete proximal stenosis in double-vessel disease are included, the number will be slightly higher. Future developments in technique, as well as an increase in experience, will broaden the spectrum of this promising treatment. (AM HEART J 107:818, 1984.)
Atherosclerosis is a progressive disease that occurs focally and usually in a staggering course and cannot be cured. Progression of the disease may be favorably influenced by reducing the risk factors, and a sense of well-being may be enhanced with physical exercises. Often we are unable to control the symptoms and are therefore compelled to consider surgical treatment, even though it is known to be palliative. Besides the operative bypass techniques, pertransluminal cutaneous coronary angioplasty (PTCA) is now available and has reasonable primary success and patency rates.’ PROCEDURE
Coronary dilatation is done with a guiding catheter and a double-lumen balloon catheter. With the patient under local anesthesia, these catheters are introduced at the groin with the aid of an introducer sheath and advanced into the right or left coronary artery. The balloon is filled with a contrast medium mixture and inflated in a stepwise fashion up to 4 to 10 atm. The newest catheter generation allows even higher pressures. With this overpressure, the atherosclerotic material is compressed and pressed into the vessel wall, thereby partly disrupting and dissecting the intima and overstretching the media. The socalled “controlled injury” is repaired and the inner
From the Department of Medicine.
of Medicine
(Cardiology),
Reprint requests: Andreas R. Gruentzig, (Cardiology), Emory University School Atlanta, GA 30303.
818
Emory
University
School
M.D., Department of Medicine of Medicine, 69 Butler St., S.E.,
surface of the vessel wall smoothed during the follow-up period. The factors influencing the repair of the vessel wall after dilatation are still not known. The induction of a foreign body reaction may be a contributing factor. General prerequisites of PTCA are as follows: (1) The results of previous invasive and noninvasive testing of the potential candidate for the procedure are discussed with the cardiac surgeon. This is important not only for goodwill and cooperation within the hospital but also in case of complication. If the surgeon is informed about the case, the appropriate operative treatment can be given immediately if necessary. After the method has been established and agreement regarding the indications has been reached within the group, discussion of the cases may not be needed. (2) The possible benefits, risks, and alternative treatments are explained to the patient. After informed consent is obtained, the procedure is performed when surgical facilities become available for standby. Physicians starting to perform PTCA at the present time should be trained in centers where experience with the technique has already been gained. INDICATIONS
There are no general contraindications for the application of the technique. A short history of angina pectoris seems to be important. If the onset of pain goes back more than 1 or 2 years, the stenosed artery is most likely hardened or calcified, and passage of the coronary dilatation catheter might be difficult. The introduction of a smaller,
Volume107
Number
Percutaneous
4
low-profile dilatation catheter, with an outer diameter of less than 1 mm, has been of great value in some cases. In our experience the indications for PTCA are as follows: (1) The ideal candidate should have a proximal discrete stenosis, not more than 15 mm long, located in the left anterior descending (LAD), left circumflex, or right coronary artery. According to our results and those of other groups, passage through the LAD artery seems to be the easiest procedure. Stenosis of the right coronary artery and the left circumflex artery represented a technical difficulty, but the introduction of the “steerable” catheters has proved to be of great value. (2) The patient should have clinical symptoms that compromise his quality of life. Disabling angina pectoris necessitates consideration of a blood flow augmentation procedure and therefore makes the patient a candidate for coronary bypass surgery. If the circumstances and anatomic conditions are right, the dilatation should be done first. These rules apply because if emergency surgery becomes necessary because of complications, surgery would have been indicated for clinical reasons in any case. At the present time we do not feel justified in recommending the procedure for asymptomatic patients with mild coronary stenosis. RESULTS
Since September 1977 we have attempted PTCA 2783 times, in 2476 patients. We were able to pass the lesion and achieved angiographic, hemodynamic, and clinical success in 91% . In 3.1% of the cases, emergency aortocoronary bypass operations were required because of reclosure of the stenosis or unresolvable spasm. Myocardial infarction (Q wave) occurred in 1.06 % . Long-term follow-up results from our initial experience in Switzerland are now available. Of the 134
balloon
angioplasty
819
primary successes, there were 34 recurrences (25 % ). The 25 patients who had the 34 recurrences in the Swiss series were available for a second dilatation. Of these patients, 16 had continuing success during a mean follow-up period of 7 months (3 to 24 months), and 8 of the 25 had recurrences necessitating aortocoronary bypass grafting. One patient had a partial recurrence and is receiving medical therapy only. As in all technically oriented therapies, a learning curve exists. We had a primary success rate of 65% in our first 50 cases2; the primary success rate in the last 104 consecutive cases, between December 1, 1983, and January 1, 1984, has risen to 95%. Two emergency operations and no myocardial infarctions occurred. In 1983, of the vessels dilated, we had a greater primary success with the LAD coronary artery (95%), but the formerly low success rate in the right coronary artery had risen to 93 % . The general improvement of our results reflects not only improved skill and better case selection3 but also improvement in the catheter system. Improvements since 1979 include a flexible guiding catheter; guide wire systems with torque control (USCI, Billerica, Mass.; Schneider Medintag, Zurich, Switzerland); and a step-by-step increase of balloon pressure, thereby avoiding the abrupt opening of the stenosed artery and balloon inflation time (~30 seconds). REFERENCES
1. Gruentzig A, Fischer M, Goebel N, Schlumpf M: Percutaneous transluminal coronary angioplasty (PTCA). Ann Radio1 24:377, 1981. 2. Gruentzig A, Senning A, Siegenthaler W: Non-operative dilatation of coronary artery stenosis: Percutaneous transluminal coronary angioplasty (PTCA). N Engl J Med 301:61, 1979. 3. Cowley M, Block P: Percutaneous transluminal coronary angioplasty. Mod Concepts Cardiovasc Disease 50:25, 1981.
M.D. Athta,
coronary
angioplasty:
Ga.
It can be foreseen that with properly selected cases, percutaneous transluminal coronary angioplasty will have the same primary and long-term results as bypass surgery in this subset of patients. The socioeconomic and psychologic advantages of the procedure, compared to the advantages of heart surgery, are obvious. The classic indication for the procedure is single-vessel disease. At the present level of experience and case selection, approximately 10% of the surgical candidates could undergo dilatation. If patients with discrete proximal stenosis in double-vessel disease are included, the number will be slightly higher. Future developments in technique, as well as an increase in experience, will broaden the spectrum of this promising treatment. (AM HEART J 107:818, 1984.)
Atherosclerosis is a progressive disease that occurs focally and usually in a staggering course and cannot be cured. Progression of the disease may be favorably influenced by reducing the risk factors, and a sense of well-being may be enhanced with physical exercises. Often we are unable to control the symptoms and are therefore compelled to consider surgical treatment, even though it is known to be palliative. Besides the operative bypass techniques, pertransluminal cutaneous coronary angioplasty (PTCA) is now available and has reasonable primary success and patency rates.’ PROCEDURE
Coronary dilatation is done with a guiding catheter and a double-lumen balloon catheter. With the patient under local anesthesia, these catheters are introduced at the groin with the aid of an introducer sheath and advanced into the right or left coronary artery. The balloon is filled with a contrast medium mixture and inflated in a stepwise fashion up to 4 to 10 atm. The newest catheter generation allows even higher pressures. With this overpressure, the atherosclerotic material is compressed and pressed into the vessel wall, thereby partly disrupting and dissecting the intima and overstretching the media. The socalled “controlled injury” is repaired and the inner
From the Department of Medicine.
of Medicine
(Cardiology),
Reprint requests: Andreas R. Gruentzig, (Cardiology), Emory University School Atlanta, GA 30303.
818
Emory
University
School
M.D., Department of Medicine of Medicine, 69 Butler St., S.E.,
surface of the vessel wall smoothed during the follow-up period. The factors influencing the repair of the vessel wall after dilatation are still not known. The induction of a foreign body reaction may be a contributing factor. General prerequisites of PTCA are as follows: (1) The results of previous invasive and noninvasive testing of the potential candidate for the procedure are discussed with the cardiac surgeon. This is important not only for goodwill and cooperation within the hospital but also in case of complication. If the surgeon is informed about the case, the appropriate operative treatment can be given immediately if necessary. After the method has been established and agreement regarding the indications has been reached within the group, discussion of the cases may not be needed. (2) The possible benefits, risks, and alternative treatments are explained to the patient. After informed consent is obtained, the procedure is performed when surgical facilities become available for standby. Physicians starting to perform PTCA at the present time should be trained in centers where experience with the technique has already been gained. INDICATIONS
There are no general contraindications for the application of the technique. A short history of angina pectoris seems to be important. If the onset of pain goes back more than 1 or 2 years, the stenosed artery is most likely hardened or calcified, and passage of the coronary dilatation catheter might be difficult. The introduction of a smaller,
Volume107
Number
Percutaneous
4
low-profile dilatation catheter, with an outer diameter of less than 1 mm, has been of great value in some cases. In our experience the indications for PTCA are as follows: (1) The ideal candidate should have a proximal discrete stenosis, not more than 15 mm long, located in the left anterior descending (LAD), left circumflex, or right coronary artery. According to our results and those of other groups, passage through the LAD artery seems to be the easiest procedure. Stenosis of the right coronary artery and the left circumflex artery represented a technical difficulty, but the introduction of the “steerable” catheters has proved to be of great value. (2) The patient should have clinical symptoms that compromise his quality of life. Disabling angina pectoris necessitates consideration of a blood flow augmentation procedure and therefore makes the patient a candidate for coronary bypass surgery. If the circumstances and anatomic conditions are right, the dilatation should be done first. These rules apply because if emergency surgery becomes necessary because of complications, surgery would have been indicated for clinical reasons in any case. At the present time we do not feel justified in recommending the procedure for asymptomatic patients with mild coronary stenosis. RESULTS
Since September 1977 we have attempted PTCA 2783 times, in 2476 patients. We were able to pass the lesion and achieved angiographic, hemodynamic, and clinical success in 91% . In 3.1% of the cases, emergency aortocoronary bypass operations were required because of reclosure of the stenosis or unresolvable spasm. Myocardial infarction (Q wave) occurred in 1.06 % . Long-term follow-up results from our initial experience in Switzerland are now available. Of the 134
balloon
angioplasty
819
primary successes, there were 34 recurrences (25 % ). The 25 patients who had the 34 recurrences in the Swiss series were available for a second dilatation. Of these patients, 16 had continuing success during a mean follow-up period of 7 months (3 to 24 months), and 8 of the 25 had recurrences necessitating aortocoronary bypass grafting. One patient had a partial recurrence and is receiving medical therapy only. As in all technically oriented therapies, a learning curve exists. We had a primary success rate of 65% in our first 50 cases2; the primary success rate in the last 104 consecutive cases, between December 1, 1983, and January 1, 1984, has risen to 95%. Two emergency operations and no myocardial infarctions occurred. In 1983, of the vessels dilated, we had a greater primary success with the LAD coronary artery (95%), but the formerly low success rate in the right coronary artery had risen to 93 % . The general improvement of our results reflects not only improved skill and better case selection3 but also improvement in the catheter system. Improvements since 1979 include a flexible guiding catheter; guide wire systems with torque control (USCI, Billerica, Mass.; Schneider Medintag, Zurich, Switzerland); and a step-by-step increase of balloon pressure, thereby avoiding the abrupt opening of the stenosed artery and balloon inflation time (~30 seconds). REFERENCES
1. Gruentzig A, Fischer M, Goebel N, Schlumpf M: Percutaneous transluminal coronary angioplasty (PTCA). Ann Radio1 24:377, 1981. 2. Gruentzig A, Senning A, Siegenthaler W: Non-operative dilatation of coronary artery stenosis: Percutaneous transluminal coronary angioplasty (PTCA). N Engl J Med 301:61, 1979. 3. Cowley M, Block P: Percutaneous transluminal coronary angioplasty. Mod Concepts Cardiovasc Disease 50:25, 1981.