Experience with a double loop guiding catheter for angioplasty of the right coronary artery.

UNLABELLED: An 8 French (F) double loop guiding (DLG) catheter was developed for percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery (RCA) and tested in 80 patients: primary use in 59 patients, and after failure of an 8 F right Judkins guiding (RJG) catheter in 21 patients. Primary use resulted in stable intubation of RCA in 55 patients (93%), but PTCA was successful in 50 (91%). Five failures resulted from inability to cross or dilate the lesion. After failure of an 8 F RJG in 21 patients, successful stable intubation of RCA with a DLG was achieved in 19 patients (90%), but PTCA was successful in 17 patients (81%). Failure of RJGs in 21 patients resulted from inability to intubate the RCA in 12 patients, or inadequate back up support by the guiding in 9 patients. CONCLUSION: DLGs increased the success rate of PTCA of the RCA after failure of RJGs.

Coronary angioplasty via saphenous vein grafts.

Percutaneous transluminal angioplasty of coronary stenoses distal to anastomosis of a venous graft was attempted through the graft 22 times in 19 patients. Ten patients had stable angina, seven unstable angina and two patients acute myocardial infarction. The mean interval between bypass surgery and angioplasty was 6.5 years (range 1-15). Fifteen lesions were dilated in the left anterior descending artery, five in the right coronary artery, and two in the circumflex artery. Three procedures were for double lesions. In two cases, a stenosed vein graft was also dilated. All grafts were cannulated with an El Gamal guiding catheter. The procedure failed in two cases. The remaining 20 lesions were successfully dilated. Early and late occlusion of the graft occurred in one patient, and coronary arterial stenosis recurred in two patients. All three patients underwent successful redilatation. The 17 patients undergoing successful dilatation were asymptomatic, with a normal exercise test and/or maintained angiographic result at follow-up of 14 months mean duration (range 2-48). Angioplasty of coronary stenosis through a vein graft is feasible, safe and effective. This therapeutic approach avoids the need for repeat bypass surgery and, as judged by long-term follow-up, has a favourable clinical outcome.

Clinical characteristics and coronary angiographic findings of patients with unstable angina, acute myocardial infarction, and survivors of sudden ischemic death occurring during and after sport.

The clinical characteristics and coronary angiographic findings of 42 well-conditioned subjects with an acute ischemic event related to sport are reported. Five patients had unstable angina, 25 had acute myocardial infarction (AMI), and 12 were resuscitated victims of sudden ischemic death. Twenty-two events occurred during sport (group A) and 20 after sport (group B). There were two women and 40 men. The mean age was 46 years (range 25 to 65). Twelve out of 30 patients who smoked cigarettes had an adjunctive risk factor for coronary artery disease. Twelve others (28%) had no identifiable risk factor. Prodromal cardiac symptoms were detected in three patients (group A). Two patients had previous myocardial infarction (group B). Coronary angiography was performed acutely in 39 patients. The distribution of the ischemia-related coronary artery was comparable in both groups. The lesion morphology of 35 culprit coronary arteries was described as concentric in six patients and eccentric with regular borders (type I lesion) in 11 and irregular borders (type II lesion) in 18. Eccentric lesions consistent with ruptured plaques prevailed in both groups. Associated coronary artery disease was present in 10 patients. There was no relationship between the number of risk factors and the extent of diseased coronary arteries. Clinical characteristics and coronary angiographic findings of patients with unstable angina, AMI, and sudden death either during or after sport are similar and indicate a common pathogenesis. The probable mechanism of a coronary event related to sport is exercise-induced plaque rupture. In most instances such an event is unexpected and unpredictable. Identification of some subjects at risk is possible.

Acute myocardial ischaemia and cardiogenic shock after percutaneous transluminal coronary angioplasty; risk factors for and results of emergency coronary bypass.

Between 1 September, 1980 and 1 January, 1989, 4142 patients underwent percutaneous transluminal coronary angioplasty (PTCA). We retrospectively studied the 155 [3.7%; 119 males, mean age 53.4 years, (range 33-78 years) and 36 females, mean age 59.6 years (range 40-74 years)] who required urgent coronary artery bypass grafting (CABG) (Group I) and a select control group of 155 patients, in whom PTCA was performed without complications (Group II). Before PTCA, 14 Group I and 42 Group II patients had angina Class II, and 78 Group I and 49 Group II patients had angina class IV (chi 2-test, P less than 0.05). There were 445 complications in the 155 group I patients: 303 (68%) early (during PTCA) and 141 (32%) late (within 24 h). On arrival in the operating room 126 patients were stable; five were in cardiac arrest and 19 in cardiogenic shock (AS-group; 24 patients). In the AS-group and control group, respectively, angina Class II occurred in 2/24 (8.3%) and 42/155 (27.1%) patients, angina Class IV in 14/24 (58.3%) and 49/155 (31.6%) (P less than 0.05), single-vessel disease in 8/24 (33.3%) and 85/155 (54.8%), triple-vessel disease in 7/24 (29.2%) and 23/155 (14.9%) (P less than 0.05); elective PTCA in 11/24 (45.8%) and 92/155 (59.4%), urgent PTCA in 12/24 (50%) and 48/155 (30.9%) (P less than 0.05), PTCA of the left anterior descending artery (LAD) in 18/24 (75%) and 86/166 (51.8%), PTCA of the right coronary artery in 2/24 (8.3%) and 47/166 (28.3%) (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Catheter reperfusion for failed emergency coronary angioplasty without subsequent bypass surgery.

A transluminal intracoronary reperfusion catheter was used in eight patients, seven with acute myocardial infarction and one with unstable angina after failed emergency coronary angioplasty. After placement of the reperfusion catheter across the occlusion, symptoms of ischemia resolved in each patient. Chest pain recurred 3 hr later in a single patient who underwent successful repeat angioplasty. The catheter was withdrawn within 6 hr after introduction. Control coronary angiography showed a patent vessel in all but one. Repeat angioplasty or bypass surgery was unnecessary. During 1 year mean follow-up time all patients remained free of symptoms. The reperfusion catheter is a safe and effective means of perfusing a coronary artery after failure of thrombolytic therapy and coronary angioplasty in cases where emergency bypass surgery is not performed because operative morbidity is expected to outweigh the benefit of myocardial salvage, or when it cannot be immediately organized.

Myocardial infarction and sudden death after sport: acute coronary angiographic findings.

Thirteen patients, seven with acute myocardial infarction and six survivors of sudden death after sport, underwent coronary angiography within a mean of 104 min after the onset of symptoms. The admission electrocardiogram showed transmural myocardial ischemia in all patients. The ischemia-related vessel was occluded in all cases of sudden death and in three cases of acute myocardial infarction. Reperfusion was achieved in eight vessels: after intracoronary streptokinase in three, after intracoronary nitroglycerin in three, and mechanically in two. Coronary spasm was demonstrated in three vessels, and coronary thrombi, in four. The coronary lesion was described as either concentric in two or eccentric with irregular borders in eight. There was a high incidence of eccentric lesions consistent with ruptured plaques. The acute coronary angiographic findings of acute myocardial infarction and sudden death after sport are similar. Physical exercise can provoke myocardial infarction and sudden death probably by inducing plaque rupture that can evoke coronary spasm, thrombosis, or both.