Prediction of acute closure in percutaneous transluminal coronary angioplasty.
Despite significant advances in the technology of percutaneous transluminal coronary angioplasty (PTCA) and the ability to perform the procedure in more complex cases, there are still problems of acute closure and resultant acute myocardial infarction. Approximately two thirds of patients who undergo acute closure will require bypass surgery. Independent factors that can be predictive of patients who will undergo acute closure include stenosis length exceeding a two-lumen diameter, female gender, stenosis at a bend of 45 degrees or more, stenosis at a branching point, stenosis-associated thrombus or filling defect, other stenoses in the vessel undergoing dilatation, and multivessel disease. Factors that can be identified only at the time of the procedure are post-PTCA percentage of stenosis, an intimal tear or dissection, and a post-PTCA gradient of 20 mm Hg or more. The outcome of abrupt closure depends on several factors. The features that have been found to be predictive of fatal outcome are female gender, collateral channels originating from the dilated vessel, a large amount of jeopardized myocardium, left ventricular hypertrophy, hypertension before PTCA, diabetes, and multivessel disease. When abrupt closure occurs, attempts should be made to reopen the artery even if a decision has been made to proceed to bypass surgery. Techniques that can help when the artery cannot be kept open include prolonged inflation (3-5 minutes), use of a bailout or perfusion catheter, and infusion of an oxygenated perfluorochemical (Fluosol, Alpha Therapeutic Corp., Los Angeles, California). Intracoronary stenting and laser balloon angioplasty are new techniques that might prove useful in the management of the dissection that commonly leads to abrupt closure.
King
S B
SB
Emory University School of Medicine, Atlanta, Georgia.
D000208:Acute Disease; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects*; D001157:Arterial Occlusive Diseases / Q000209:etiology* / Q000601:surgery; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000209:etiology* / Q000601:surgery; D003331:Coronary Vessels / Q000293:injuries; D004632:Emergency Medical Services; D005544:Forecasting; D006801:Humans; D009203:Myocardial Infarction / Q000209:etiology / Q000601:surgery; D012086:Reoperation; D014950:Wounds, Penetrating / Q000628:therapy