Emergency stenting for acute occlusion after coronary balloon angioplasty.

Abstract

Acute coronary artery occlusion complicates 2-12% of the balloon angioplasty procedures, and despite repeat angioplasty, emergency surgical revascularization is often necessary. We report our initial experience with the emergency implantation of endoluminal stents for acute vessel closure after coronary balloon angioplasty. Nine patients received one stent, and two patients received two stents during the study period. Implantation was technically successful in all patients; there were no deaths, no myocardial infarctions as evidenced by Q wave on the electrocardiogram, and no need for emergency surgery. One additional patient, not satisfying the study inclusion criteria, died 16 hours after stent implantation from left ventricular failure and intractable arrythmias. Two patients in the study group had a moderate creatinine phosphokinase rise during the first 48 hours after implantation. During a median follow-up period of 3 months (range, 1-20 months), there have been no deaths and no need for elective coronary bypass surgery. One patient required emergency recanalization 3 months after implantation because of acute occlusion of the stented segment with limited myocardial infarction. Six patients have undergone control angiography, and none has developed chronic restenosis within the stented segment. For selected patients, coronary artery stenting appears to be a promising alternative to emergency bypass surgery after acute vessel occlusion during balloon angioplasty.

Incidence, predictors, and management of acute coronary occlusion after coronary angioplasty

“…Clinical experience with bail-out stent implantation was first reported by Sigwart et a1. 35 In a very limited number of patients, the self-expanding Wallstent was implanted, which resulted in an immediate restoration of adequate coronary flow, with normalization of the electrocardiogram (ECG) and relief of symptoms with no evidence of acute myocardial infarction. Since then, each of the current clinically available stents has been used for this purpose with encouraging results (Table VII).…”

“…It appears that bail-out stenting reduces the need for emergency bypass surgery and decreases the incidence of acute myocardial infarction (Table VII). [35][36][37][38][39][40][41][42] The results compare very favorably with those after abrupt closure following angioplasty without the use of bail-out stenting. This has prompted the recommendation that intracoronary stents should be available in all centers for bailout procedures.…”

“…For optimal clinical decision-making and patient counseling, it would be desirable if one could identify preprocedural and procedural high-risk procedures. Several predictors for acute coronary occlusion have been identified (Table II), but unfortunately they generally have a low positive or negative predictive value.3-5,8> 13-16 However, the make-up of a risk profile for each patient is often helpful and allows a crude estimation of the potential risk, such that in case of (35) 18 (33) 56 (Wt 78 (55)t 49 (40) 49 (40) 37 (36) 30 (31) 22 (20) 25 (23) 9 (33) 11 (41) 192 (35) 211 (38) AMI, Acute myocardial infarction; CAEG, coronary artery bypass grafting; NHLBI, National Heart, Lung, and Blood Institute; PTCA, percutaneous transluminal coronary angioplasty. *Acute occlusion + major dissection causing complications.…”

Intracoronary stenting for acute and threatened closure complicating percutaneous transluminal coronary angioplasty.

“…13-15"18-22 Intracoronary stents (intra-arterial prosthetic scaffolding devices) have recently been developed to reduce the problems of acute closure complicating PTCA. 17,[23][24][25][26] Use of the intracoronary stent for acute or threatened closure should serve to control dissection and residual stenosis, the morphological predictors of a major ischemic event. Because the use of these intracoronary prostheses is not benign and because some patients with suboptimal PTCA results do well in the long term, one difficulty has been in selecting patients who may benefit from the implantation of these devices.…”

Bioresorbable scaffold—the holy grail of percutaneous coronary intervention: fact or myth?

“…While a reasonable procedural and clinical outcome was achievable with balloon angioplasty alone, sustained arterial patency was ultimately undermined by elastic recoil, acute secondary closure and constrictive remodeling (2). The second technological leap in percutaneous coronary intervention (PCI) occurred with the advent of bare metal stents (BMS), which promised to overcome these issues by providing a mechanical scaffold within the coronary arteries (3).…”