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

Abstract

BACKGROUND. Acute closure remains a significant limitation of percutaneous transluminal coronary angioplasty (PTCA) and underlies the majority of ischemic complications. This study details the clinical and angiographic characteristics of a series of patients receiving an intracoronary stent device to manage acute and threatened closure and presents the early clinical results. METHODS AND RESULTS. From October 1989 through June 1991, 115 patients undergoing PTCA received intracoronary stents to treat acute or threatened closure in 119 vessels. Sixty-three percent had multivessel coronary disease, 33 (29%) had undergone prior coronary artery bypass grafting (CABG), and 52 (45%) had had previous PTCA. Using the American College of Cardiology/American Heart Association (ACC/AHA) classification, 15% of lesions were class A, 55% were class B, and 30% were class C. Eight patients were referred with severe coronary dissection and unstable angina after PTCA at other institutions. Acute closure was defined as occlusion of the vessel with TIMI (Thrombolysis in Myocardial Infarction) 0 or 1 flow immediately before stent placement. Threatened closure required two or more of the following criteria: 1) a residual stenosis greater than 50%, 2) TIMI grade 2 flow, 3) angiographic dissection comprising extraluminal dye extravasation and/or a length of greater than 15 mm, 4) evidence of clinical ischemia (either typical angina or ECG changes). Twelve vessels (10%) met the criteria for acute closure, and 87 vessels (73%) satisfied the criteria for threatened closure. Twenty vessels (17%) failed to meet two criteria. Stenting produced optimal angiographic results in 111 vessels (93%), with mean diameter stenosis (+/- 1 SD) reduced from 83 +/- 12% before to 18 +/- 29% after stenting. Overall, in-hospital mortality was 1.7% and CABG was required in 4.2%; Q wave myocardial infarction (MI) occurred in 7% and non-Q wave MI in 9%. Stent thrombosis occurred in nine patients (7.6%). For the 108 patients who presented to the catheterization laboratory without evolving MI, Q wave MI occurred in 4% and non-Q wave MI occurred in 7%. Angiographic follow-up has been performed in 81 eligible patients (76%), and 34 patients (41%) had a lesion of greater than or equal to 50%. CONCLUSIONS. This stent may be a useful adjunct to balloon dilatation in acute or threatened closure. Randomized studies comparing this stent with alternative technologies are required.

Safety and efficacy of coronary stent implantation. Acute and six month outcomes of 1,126 consecutive patients treated in 1996 and 1997

“…The results from a consecutive series of patients like ours and randomized trials confirm the superiority of stents to balloon PTCA, both in the hospital and late followup outcomes. In the presence of some high-risk subgroups of patients, such as those with diabetes [20][21] , unstable angina 7 , acute myocardial infarction [15][16][17][18][19] , vessels with reference size <3.0mm 7 , balloon PTCA failures 6 , lesions located in he proximal left anterior descending artery 7,22 , chronic occlusions [13][14] , vein grafts 11 , restenotic lesions 12 and multivessel coronary disease 23 , who undergo percutaneous coronary revascularization, stents will promote better results and should be the technique of first choice.…”

“…The comparison demonstrates that, stents can create significancy higher coronary lumen diameters, reduce the restenosis rate at the end of the first 6 months and as a consequence the need for further revascularization procedures, percutaneous or surgical, compared with the standard balloon PTCA method [4][5][6][7] . In 1995, Colombo et al 8 demonstrated that intravascular ultrasound could optimize stent delivery and implantation, applying higher balloon pressures (>12 ATM), promoting better stent symmetry, with a nearly full apposition of the stent struts in the vessel wall.…”

<b>Comparison of Initial Efficacy and Long-term Follow-up of Heparin-coated Jostent With Conventional NIR Stent</b>

“…Stents have been shown to successfully treat acute or threatened vessel closure after failed PTCA 6) and to significantly reduce restenosis. [7][8][9] Adjunctive use of potent antiplatelet agents such as ticlopidine or clopidogrel markedly decreased the incidence of stent thrombosis and bleeding complications.…”

Homocysteine and Malondialdehyde as Predictors of Restenosis Following Percutaneous Coronary Intervention

“…Intracoronary stent implantation along with balloon angioplasty is highly effective in the treatment of acute vessel closure (Sigwart et al 1987;Roubin et al 1992;de Jaegere et al 1993a;Fischman et al 1994). However, bare metal stents are thrombogenic, and the benefit achieved at the expense of high-risk vascular complications (Schatz et al 1991;Serruys et al 1994;de Jaegere et al 1993b;Serruys et al 1991) must be considered.…”