In percutaneous transluminal coronary angioplasty, a catheter system is introduced through a systemic artery under local anesthesia to dilate a stenotic artery by controlled inflation of a distensible balloon. Over the past 18 months, we have used this technic in 50 patients. The technic was successful in 32 patients, reducing the stenosis from a mean of 84 to 34 per cent (P less than 0.001) and the coronary-pressure gradient from a mean of 58 to 19 mm Hg (P less than 0.001). Twenty-nine patients showed improvement in cardiac function during follow-up examination. Because of acute deterioration in clinical status, emergency bypass was later necessary in five patients; three showed electrocardiographic evidence of infarcts. Patients with single-vessel disease appear to be most suitable for the procedure, and a short history of pain indicates the presence of a soft (distensible) atheroma likely to respond to dilatation. We estimate that only about 10 to 15 per cent of candidates for bypass surgery have lesions suitable for this procedure. A prospective randomized trial will be necessary to evaluate its usefulness in comparison with surgical and medical management.
Controversies in the literature regarding definition, diagnosis, and therapy of chronic pancreatitis may be related in part to differences in the natural history of alcoholic and idiopathic (nonalcoholic) chronic pancreatitis. In order to evaluate this problem the long-term course of 205 patients with alcoholic (85.4% with calcifications) (group A) and 82 patients with idiopathic (nonalcoholic) chronic pancreatitis (76.8% with calcifications) (group B) has been analyzed prospectively since 1963. The patients were studied at regular intervals with particular regard to pain, pancreatic exocrine, and endocrine function and calcifications. The observation time was 2 years or longer in 230 patients with a median observation time of 6.7 years from diagnosis in group A and 10.6 years in group B. In group B over 50% of the cases had primary painless chronic pancreatitis. Progressive deterioration of exocrine and endocrine function was observed in both groups. However, in group A the rate of progression of exocrine dysfunction after diagnosis was more rapid and the incidence of diabetes in relation to marked exocrine insufficiency was much higher than in group B. Steatorrhea preceded diabetes in 56% (group A) and 80% (group B), respectively. Onset of pancreatic calcifications was closely associated with pancreatic exocrine insufficiency in group A in contrast to group B. In addition lasting pain relief occurred spontaneously in about 30% of patients in group B despite a normal exocrine function for 6 years or longer which is in disaccord with the results in alcoholic chronic pancreatitis. In conclusion group A and B have many features in common, in particular the high incidence of pancreatic calcifications and the progressive pancreatic dysfunction. However, the long-term profile of both groups differs in some important aspects, particularly in the clinical pattern and in the rate of progression of pancreatic dysfunction and morphology. These differences should be appreciated in the discussion of problems regarding definition, diagnosis, and surgical therapy of chronic pancreatitis.The natural history of chronic pancreatitis (CP) is not well defined. Many controversies regarding definition, diagnosis, and therapy result mainly from the limited knowledge of the long-term course of CP. Clinically relevant problems of CP are still debated such as the relationship between pancreatic morphology and function (1-6), the rate of progression of exocrine dysfunction ( 4 3 , the interaction Of exocrine and endocrine insufficiency (7-9)9 the correlation of pain and exocrine insufficiency
The first 169 patients in whom percutaneous transluminal coronary angioplasty was performed have now been followed for five to eight years. The procedure was technically successful in 133 patients (79 percent). In the follow-up period, nine of the 133 patients died (five of cardiac disease), and actuarial cardiac survival was 96 percent at six years. All patients were symptomatic before angioplasty, but 67 percent of the 133 who had technically successful procedures were asymptomatic at the last follow-up evaluation. Exercise stress testing, positive in 97 percent before angioplasty, was positive at the last follow-up study in only 10 percent of the patients who had technically successful procedures. Stenosis recurred during the first six months in 30 percent of the patients, and six more recurrences were observed among the 41 patients who had follow-up angiograms at two to seven years. A second angioplasty was required in 27 patients, and coronary bypass surgery was subsequently needed in 19. Actuarial event-free survival (freedom from death, myocardial infarction, and coronary bypass surgery) was 79 percent at six years. Follow-up of patients with multivessel disease showed a higher mortality from cardiac causes and a lower rate of long-term success than occurred among patients with single-vessel disease. These long-term results indicate that most episodes of restenosis occurred within six months of angioplasty, but some late recurrences were seen. Patients with single-vessel disease had a better long-term outcome after angioplasty than those with multivessel disease.
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