Circulation, Vol 86, 812-819, Copyright © 1992 by American Heart Association
HC Herrmann, M Buchbinder, MW Clemen, D Fischman, S Goldberg, MB Leon, RA Schatz, P Tierstein, CM Walker and JW Hirshfeld Jr
BACKGROUND. The balloon-expandable intracoronary stent developed by Palmaz
and Schatz is undergoing clinical evaluation for use in unfavorable
anatomic situations and in the prevention of restenosis. Because the
stent's mechanism of action would suggest effectiveness in salvaging
certain percutaneous transluminal coronary angioplasty (PTCA) failures, we
retrospectively examined the results of emergency unplanned coronary artery
stenting for failed PTCA procedures, including acute occlusion. METHODS AND
RESULTS. The study population consisted of all US patients receiving
emergency unplanned stent implantation in a nonrandomized fashion at seven
centers over a 2 1/2- year period (n = 56). All available medical records
and angiograms were reviewed to determine retrospectively the reason for
stenting: Group 1 consisted of 23 patients with a suboptimal angioplasty
result; group 2 included patients with evidence of impending vessel closure
after PTCA (n = 15); and group 3 were patients with frank acute occlusion
after PTCA (n = 18). The immediate and final (30-day) results of stenting
were examined with respect to major complications, which included death,
need for coronary artery bypass graft surgery, and occurrence of myocardial
infarction. Finally, restenosis rates (greater than or equal to 50%
stenosis) based on follow-up angiography were calculated. Baseline
characteristics of the study population included a mean +/- SD age of 58
+/- 11 years and a large prevalence of angiographic characteristics
generally considered unfavorable for PTCA, which include lesion
eccentricity (49%), intimal dissection (9%), or angiographically visible
thrombus (6%). After conventional balloon angioplasty, there was an
increased incidence of intimal dissection (74%) and thrombus formation
(38%), and overall stenosis severity was unchanged (75 +/- 12% versus 70
+/- 27%, p = NS). Successful stent deployment was achieved in 55 (98%) of
56 patients with initial success (freedom from death, surgery, and
infarction) in 52 (93%) of 56 patients. The success rate at 1 month fell to
71% primarily because of the occurrence of subacute stent thrombosis (16%)
and its associated complications. Overall, major complications occurred in
16 (29%) of 56 patients within 30 days. The only predictor of subacute
stent thrombosis in multiple stepwise logistic regression analysis was the
presence of angiographically visible thrombus after stenting (p = 0.03).
Angiographic restenosis was documented in eight (23%) of 35 eligible
patients. CONCLUSIONS. Emergency stenting may be a useful and effective
treatment for failed angioplasty. High initial success rates (greater than
90%) can be achieved, but subsequent complications, often related to
subacute thrombosis, occur in a substantial portion of patients. Patients
who receive stents on an emergency basis, particularly those with previous
acute occlusion, should be considered to be at greater than usual risk for
complications and receive more careful anticoagulation and follow-up.
ARTICLES
Emergent use of balloon-expandable coronary artery stenting for failed percutaneous transluminal coronary angioplasty
Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia 19104.
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