Coronary stenting in patients undergoing percutaneous transluminal coronary angioplasty during acute myocardial infarction.

Although coronary stenting has been useful in the treatment of patients with suboptimal results, abrupt closure, and threatening occlusion after percutaneous transluminal coronary angioplasty (PTCA), its use in patients with acute myocardial infarction (AMI) is controversial because of the presence of intracoronary thrombus. In this study intracoronary stenting was used to treat suboptimal results and complications in 30 patients (35 lesions) undergoing PTCA during AMI. There were 28 men and 2 women, mean age 58 +/- 12 years. Thirteen patients (43%) had undergone rescue PTCA because of unsuccessful thrombolysis. Four patients had Killip's grade IV, 5 Killip's grade III, and 21 Killip's grade < or = 2 heart failure. Stents were placed in the 35 lesions because of suboptimal result (n = 19), early loss (n = 9), abrupt closure (n = 2), and coronary dissection with threatening occlusion (n = 5). All stents were deployed successfully. In-hospital complications included 1 in-hospital death (3.0%); no patient required emergency coronary artery bypass graft surgery. One patient (3.0%) developed abrupt closure and was successfully treated with PTCA and intracoronary thrombolysis. Vascular complications requiring blood transfusion developed in 3 of 30 patients (10%). At 11.8 months (range 4 to 24) follow-up, there were no deaths or myocardial infarction. One patient underwent coronary artery bypass grafting. The remaining patients were free of angina at follow-up. Thus, intracoronary stents can be used successfully to treat both suboptimal results and complications occurring in patients undergoing PTCA during AMI.

Time course and mechanism of early luminal diameter loss after percutaneous transluminal coronary angioplasty.

To assess the time course and mechanism of early minimal luminal diameter (MLD) loss, serial angiographic observations were performed. Seventy-four patients (with 74 severe narrowings [ > or = 70%]) with acute ischemic syndromes who had an early loss in MLD of > 0.3 mm at 24 hours after percutaneous transluminal coronary angioplasty (PTCA) also underwent 1 hour post-PTCA angiography. In 12 consecutive patients with early loss 1 hour after PTCA, angioscopy was also performed to assess the mechanism of early loss. The percent diameter stenosis for the 74 lesions was 16.8 +/- 8.4% immediately after PTCA, 35.1 +/- 14.2% 1 hour after PTCA (p < 0.002 vs immediately after), and 41.4 +/- 13.2% at 24 hours (p < 0.10 vs 1 hour after). The MLD also showed similar differences: 2.6 +/- 0.3 mm immediately after to 2.0 +/- 0.4 mm 1 hour after(p < 0.002) to 1.8 +/- 0.4 mm 24 hours after PTCA (p < 0.10 vs 1 hour). In 60 patients (81%), the > 0.3 mm loss was detected 1 hour after PTCA. These 60 patients had no further decreases in MLD at 24 hours (1.9 +/- 0.4 vs 1.8 +/- 0.4 mm at 1 and 24 hours, respectively, p = NS). Adequate angioscopic images available in 11 patients showed that red thrombus was present in 1, minor or multiple dissection in 5, and neither thrombus nor dissection in 5 other patients (consistent with early wall recoil). Thus, in narrowings demonstrating early loss in MLD at 24 hours, 81% showed that the early loss occurred within 1 hour after PTCA. Early loss is not related to thrombus but usually to dissection or recoil.

Coronary stenting decreases restenosis in lesions with early loss in luminal diameter 24 hours after successful PTCA.

BACKGROUND: Early loss of minimal luminal diameter (MLD) after successful percutaneous transluminal coronary angioplasty (PTCA) is associated with a higher incidence of late restenosis. METHODS AND RESULTS: Sixty-six patients (66 lesions) with > 0.3 mm MLD loss at 24-hour on-line quantitative coronary angiography were randomized into two groups: 1, Gianturco-Roubin stent (n = 33) and 2, Control, who received medical therapy only (n = 33). All lesions were suitable for stenting. Baseline demographic, clinical, and angiographic characteristics were similar in the two groups. Restenosis (> or = 50% stenosis) for the overall group occurred in 32 of 66 patients (48.4%) at 3.6 +/- 1-month follow-up angiography. Restenosis was significantly greater in group 2 than in group 1 (75.7% versus 21.2%, P < .001). Vascular complications (21.2% versus 0%) and length of hospital stay (7.3 +/- 1 versus 2.4 +/- 0.5 days, P < .01) were higher for the stent group. Although at follow-up there were no differences in mortality or incidence of acute myocardial infarction between the two groups, patients in the control group had a higher incidence of repeat revascularization procedures (73% versus 21%, P < .001). CONCLUSIONS: In patients with successful PTCA but reduced luminal diameter demonstrated by repeat angiography at 24 hours, the Gianturco-Roubin stent appears to reduce angiographic restenosis at follow-up.