Circulation, Vol 88, 2086-2096, Copyright © 1993 by American Heart Association
JA Hearn, SB King 3d, JS Douglas Jr, SF Carlin, NJ Lembo and ZM Ghazzal
BACKGROUND. Acute occlusion after balloon coronary angioplasty is
associated with an increased risk of angina, emergency coronary artery
bypass grafting (CABG), myocardial infarction (MI), and death. Stents offer
a way of restoring patency and avoiding these complications. METHODS AND
RESULTS. One hundred sixteen patients underwent attempted stent placement
for imminent or total acute closure after PTCA. In 103 patients (110
stents, 105 procedures) the stent was successfully deployed (89%).
Angiographic success (final diameter stenosis of < 50%) was achieved in
94 placements (85%). Seventy-one phase 2 procedures (CABG optional, n = 96;
phase 1, CABG required, n = 9) were angiographically successful without
complications of death, Q-wave myocardial infarction, or CABG (clinical
success 74%). Stent placement was associated with resolution of ST-segment
deviation and angina in 84% of patients. Five deaths and 5 Q-wave MIs
occurred during hospitalization. Two deaths were related to pulmonary
insufficiency from chronic lung disease and one patient died after rescue
stent placement for left main coronary artery occlusion during routine
angiography. Another patient died after CABG was followed by right
ventricular MI. The last death occurred in an elderly patient who suffered
a stroke while on intravenous heparin. During hospitalization nine patients
developed reocclusion after stent placement (8.6% of procedures) and six
had repeat PTCA. CABG was performed after 29 stent procedures (28%). The
first nine patients underwent CABG as a mandate of the phase 1 protocol. In
addition, nine patients had CABG after stenting with a good angiographic
result but with a large amount of myocardium at risk. Clinical follow-up
was obtained in all patients at a median of 14 months (range, 2 to 43).
There were three late deaths (3%), two Q-wave myocardial infarctions (2%),
16 repeat PTCAs (16%), and 15 CABG procedures (15%). Angiographic
restenosis (percent diameter > or = 50%) using caliper measurements was
found in 30 of 57 patients (53%) at a median of 4 months (93% of patients
eligible). A total of 41 procedures were successful and unaccompanied by
death, emergency or elective coronary artery bypass grafting, or
angiographic restenosis in follow-up. Restenosis and/or clinical events
(death, MI, CABG, repeat PTCA) were associated with non-Q MI, hypertension,
diabetes, left circumflex coronary artery stenting, saphenous vein graft
stenting, smaller caliber artery stenting, higher balloon to artery ratios,
and shorter inflation times. CONCLUSIONS. Coronary artery stenting for
acute closure after PTCA relieves myocardial ischemia and provides an
alternate means of treatment. This series includes early learning curve
experience; 70% (67 of 96) of patients were spared emergency coronary
artery bypass graft surgery when this adverse outcome occurred. Certain
clinical and angiographic subsets are at increased risk for restenosis and
future cardiac events.
ARTICLES
Clinical and angiographic outcomes after coronary artery stenting for acute or threatened closure after percutaneous transluminal coronary angioplasty. Initial results with a balloon-expandable, stainless steel design
Andreas Gruentzig Cardiovascular Center, Department of Internal Medicine, Emory University School of Medicine, Atlanta, Ga.
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