Transluminal catheter reperfusion: A new technique to reestablish blood flow after coronary occlusion during percutaneous transluminal coronary angioplasty

doi:10.1016/0002-9149(86)90860-X

The American Journal of Cardiology

Volume 57, Issue 8, 3 May 1986, Pages 684-686

https://doi.org/10.1016/0002-9149(86)90860-X Get rights and content

Abstract

Percutaneous transluminal coronary angioplasty (PTCA) may be complicated by total coronary artery occlusion from major dissection, spasm or thrombosis.^1,2 If coronary blood flow is not reestablished immediately, myocardial infarction or death may occur, despite the availability of emergency surgical backup.³ The morbidity and mortality of the emergency bypass procedure may also be increased under these circumstances.⁴ We describe the investigational use of a percutaneously introduced stenting reperfusion catheter to reestablish blood flow before bypass surgery in 3 patients.

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Abrupt closure of a coronary artery after successful angioplasty remains a problem for the interventionalist. Many laboratories continue to administer heparin intravenously for 12 to 24 hours in an attempt to alleviate this problem. But prolonged heparin therapy delays sheath removal and may lead to groin and vascular complications, and so prolong the hospital stay. To test the hypothesis that subcutaneous heparin was as efficacious as intravenous heparin in preventing acute closure while reducing the vascular complications associated with extended sheath placement, we prospectively randomized 151 patients to two groups. The intravenous group, 77 patients, received continuous intravenous heparin at 1000 units/hour for 12 to 18 hours; the subcutaneous group, 74 patients, received 12,500 units subcutaneously every 12 hours for three doses after sheath removal 2 to 3 hours after the angioplasty. The activated clotting time immediately after the angioplasty was 401 ± 108 seconds in subcutaneous group, as compared with 368 ± 67 seconds in the intravenous group (p = 0.028). Patients receiving subcutaneous heparin continued to show adequate anticoagulation, with a PTT of 85 ± 21 seconds obtained approximately 12 hours after the procedure. The PTT at discharge was statistically greater in the subcutaneous group, at 49.2 ± 21 seconds, versus 35.6 ± 13 seconds in the intravenous group (p <- 0.001). Abrupt occlusion was similar in both groups, but the hematomas and bleeding/oozing in the intravenous group was significantly higher when compared with that of the subcutaneous group, 16 versus 6 (p = 0.026) and 26 versus 7 (p <- 0.002), respectively. The subcutaneous administration of heparin provides an alternative management strategy after angioplasty. It achieves adequate and extended anticoagulation, exhibiting a similar incidence of abrupt occlusion as compared with the intravenous administration, while decreasing heamtoma and hemorrhagic complications because of early sheath removal.
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Objectives. This study was designed to determine the efficacy of synchronized coronary sinus retroperfusion of arterial blood in reducing myocardial ischemia associated with the performance of high risk coronary angioplasty.
Background. Previous animal and clinical work has demonstrated the efficacy of this technique in supporting ischemic myocardium.
Methods. Twenty-one patients were randomized to alternately receive coronary sinus retroperfusion support during either the second or the third coronary angioplasty balloon inflation, after an initial unsupported brief control inflation. Myocardial ischemia was assessed by the extent of echocardiographic left ventricular wall motion abnormality, quantified ST segment deviation and hemodynamic and anginal variables during balloon inflations performed with and without coronary sinus retroperfusion support. Regional wall motion score was defined as hyperkinesia (−1), normokinesia (0), hypokinesia (+1), akinesia (+2) and dyskinesia (+3).
Results. A reduction in the echocardiographic left anterior descending regional wall motion score in retroperfusion-supported (1.7 ± 2.1) versus unsupported (2.7 ± 1.6) inflations (p < 0.05) was noted. Twelve-lead electrocardiographic monitoring revealed no additional ST segment deviation during supported (173 ± 95 s) compared with unsupported (129 ± 87 s) angioplasty inflations despite a significantly longer duration of supported inflations (p < 0.004). Mean and peak systolic coronary sinus pressures differed during supported inflations (21 ± 6 and 44 ± 13 mm Hg) versus unsupported inflations (10 ± 4 and 16 ± 5 mm Hg) (p < 0.001). There was no difference in hemodynamic or anginal variables.
Conclusions. A reduction in ischemia as defined by wall motion abnormality during retroperfusion-supported compared with unsupported angioplasty balloon inflations was documented. No additional ST segment deviation occurred during retroperfusion-supported compared with unsupported balloon inflations despite a significantly longer duration of supported inflations. No difference in hemodynamic or anginal variables was noted.
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As more high-risk patients undergo percutaneous transluminal coronary angioplasty (PTCA), the changing profiles of PTCA patients who may require emergent coronary artery bypass grafting may alter operative morbidity and mortality. This study compared profiles of recent patients undergoing emergent coronary artery bypass grafting after a failed PTCA with earlier patients to determine their impact on operative results. From 1980 to 1988, 53 patients underwent emergent coronary artery bypass grafting after a failed PTCA at the Boston University Medical Center. These patients were divided into two groups based on the year of the PTCA: group I, 1980 to 1985 (n = 18); and group II, 1986 to 1988 (n = 35). Group II patients tended to be older (age ≥65 years, 47% group II versus 11% group I), were more likely to have unstable angina before PTCA (74% versus 33%), and had lower ejection fractions (0.53 ± 0.02 versus 0.63 ± 0.05) and more vessels with 50% or greater stenosis (2.1 ± 0.2 versus 1.6 ± 0.2). Nevertheless, there was no significant difference in the incidence of perioperative myocardial infarcts using enzyme and electrocardiographic criteria (37% in group II versus 39% in group I), 30-day operative mortality (11% in group II versus 11% in group I), or major postoperative complications (14% in group II versus 22% in group I). We conclude that despite the changing profiles of patients undergoing PTCA, which include older patients with more extensive coronary artery disease and lower ejection fractions, operative results after emergent coronary artery bypass grafting for failed PTCAs remain unchanged.

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Brief reportTransluminal catheter reperfusion: A new technique to reestablish blood flow after coronary occlusion during percutaneous transluminal coronary angioplasty

Abstract

Am J Cardiol

JACC

Percutaneous transluminal coronary angioplasty: report of complications from the National Heart, Lung, and Blood Institute PTCA Registry

Circulation

Brief report
Transluminal catheter reperfusion: A new technique to reestablish blood flow after coronary occlusion during percutaneous transluminal coronary angioplasty