Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery

OBJECTIVES: We attempted to determine the relative risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG). BACKGROUND: Due to an expanding population of patients with surgically treated coronary artery disease and the natural progression of atherosclerosis, an increasing number of patients with previous CABG require repeat revascularization procedures. Although there are randomized comparative data for CABG versus medical therapy and, more recently, versus PTCA, these studies have excluded patients with previous CABG. METHODS: We retrospectively analyzed data from 632 patients with previous CABG who required either elective re-CABG (n = 164) or PTCA (n = 468) at a single center during 1987 through 1988. The PTCA and re-CABG groups were similar with respect to gender (83% vs. 85% male), age > 70 years (21% vs. 23%), mean left ventricular ejection fraction (46% vs. 48%), presence of class III or IV angina (70% vs. 63%) and three-vessel coronary artery disease (77% vs. 74%). RESULTS: Complete revascularization was achieved in 38% of patients with PTCA and 92% of those with re-CABG (p < 0.0001). The in-hospital complication rates were significantly lower in the PTCA group: death (0.3% vs. 7.3%, p < 0.0001) and Q wave myocardial infarction (MI) (0.9% vs. 6.1%, p < 0.0001). Actuarial survival was equivalent at 1 year (PTCA 95% vs. re-CABG 91%) and 6 years (PTCA 74% vs. re-CABG 73%) of follow-up (p = 0.32). Both procedures resulted in equivalent event-free survival (freedom from dealth or Q wave MI) and relief of angina; however, the need for repeat percutaneous or surgical revascularization, or both, by 6 years was significantly higher in the PTCA group (PTCA 64% vs. re-CABG 8%, p < 0.0001). Multivariate analysis identified age > 70 years, left ventricular ejection fraction < 40%, unstable angina, number of diseased vessels and diabetes mellitus as independent correlates of mortality for the entire group. CONCLUSIONS: In this nonrandomized series of patients with previous CABG requiring revascularization, an initial stategy of either PTCA or re-CABG resulted in equivalent overall survival, event-free survival and relief of angina. PTCA offers lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and a greater need for subsequent revascularization procedures.     

One-year outcomes of diabetic versus nondiabetic patients with non-Q-wave acute myocardial infarction treated with percutaneous transluminal coronary angioplasty

Risk factors and outcomes associated with non-Q-wave myocardial infarction (MI) in diabetics and nondiabetics were analyzed for 376 consecutive patients, 77 with diabetes (20%) and 299 nondiabetics (80%), who had non-Q-wave MI and had percutaneous transluminal coronary angioplasty (PTCA) performed before discharge from hospital during the period from January 1992 to February 1996. Diabetics were slightly older (64 +/- 10 years vs 61 +/- 12 years, p <0.053), had more prior coronary artery bypass grafting (CABG) surgery (27% vs 12%, p <0.001), and hypertension (77% vs 49%, p <0.001). There was no significant difference in unstable angina, saphenous vein graft PTCA, single versus multiple vessel disease, or history of MI. PTCA success rates for diabetics versus nondiabetics were similar (96% vs 97%, p = NS). In-hospital complications such CABG, recurrent MI, repeat PTCA, stroke, and death were not statistically significant between the 2 groups. At 1-year follow-up, survival in diabetics (92%) was similar to nondiabetics (94%, p = NS), although event-free survival (PTCA, CABG, MI, death) was worse in diabetics (55% vs 67% for nondiabetics, p <0.05). Although diabetic patients with non-Q-wave MI represent a cohort with more risk factors for poor outcome, aggressive in-hospital revascularization with PTCA results in an excellent short-term outcome as well as 1-year survival similar to the nondiabetic patients. However, total events at 1-year follow-up are more common in the diabetic patients, suggesting that more aggressive screening and therapy in follow-up may be warranted, and that a diabetic with non-Q-wave MI will require increased utilization of cardiovascular resources in the first year after the event.     

Late results of percutaneous transluminal coronary angioplasty of two or more major native coronary arteries

Of 613 consecutive patients with multivessel coronary artery disease (CAD) undergoing revascularization, 521 patients (85%) underwent primary management with percutaneous transluminal coronary angioplasty (PTCA). To examine long-term outcome in a series of patients often referred for coronary artery bypass graft (CABG) surgery, all patients undergoing multivessel dilations were identified for late follow-up analysis (n = 161). Mean age was 65 years; 54 patients (34%) were women. Four hundred fifty-five of 502 lesions (90.6%) were successfully dilated. Major in-hospital procedural complications occurred in 6 patients (3.7%), including death in 3 (1.9%), nonfatal Q-wave myocardial infarction in 2 (1.2%), and CABG in 1 (0.6%). Final follow-up data were available in 159 patients (99%) at a mean of 39 +/- 18 months. Including in-hospital events, actuarial 3-year survival was 93%, and 3-year infarct-free survival was 90%. At final follow-up, 143 of 146 patients alive (98%) were angina free. Crossover to CABG was required in 25 patients (16%). Repeat PTCA was performed in 67 patients (42%) (mean 1.7 PTCAs/patient, range 1 to 7). PTCA is an effective therapeutic alternative in the management of most patients with multivessel CAD requiring revascularization. A strategy using multiple repeated PTCA procedures when necessary results in prolonged infarct-free survival, with long-term freedom from angina and limited crossover to CABG.     

An evaluation of the use made of cosmetic and functional prostheses by unilateral upper limb amputees

PURPOSE: To review the available data on the treatment of chronic stable angina and formulate a rational approach to the use of pharmacologic therapy, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft surgery (CABG). DATA SOURCES: A MEDLINE search of English-language literature published between 1976 and 1996 and the bibliographies of relevant articles. STUDY SELECTION: Primary research articles, meta-analyses, and meeting abstracts related to the management of chronic stable angina with an emphasis on comparisons of medical therapy, PTCA, and CABG. DATA EXTRACTION: Three trials comparing medical therapy with PTCA, seven trials comparing medical therapy with CABG, and nine trials comparing PTCA with CABG. DATA SYNTHESIS: Low-risk patients with single-vessel coronary artery disease and normal left ventricular function had greater alleviation of symptoms with PTCA than with medical treatment; mortality rates and rates of myocardial infarction were unchanged. In high-risk patients (risk was defined by severity of ischemia, number of diseased vessels, and presence of left ventricular dysfunction), improvement of survival was greater with CABG than with medical therapy. In moderate-risk patients with multivessel coronary artery disease (most had two-vessel disease and normal left ventricular function), PTCA and CABG produced equivalent mortality rates and rates of myocardial infarction. CONCLUSIONS: In low-risk patients, a strategy of initial medical therapy is reasonable. In moderate-risk patients, PTCA and CABG produce similar mortality rates and rates of myocardial infarction but PTCA-treated patients require more revascularization procedures. In high-risk patients, CABG is usually preferred.     

Ischemic heart disease in the elderly: the role of coronary angioplasty and coronary artery bypass grafting

Management of ischemic heart disease in the elderly is complex. Invasive therapies such as percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) are associated with significant morbidity and mortality. The short-term advantage of PTCA is that its associated noncardiac morbidity and mortality are less than that of CABG, particularly in the incidence of stroke. Unfortunately, PTCA revascularization is less complete and less durable than CABG revascularization. The advantages of CABG are that cardiac revascularization is more complete, the result is more durable, and long-term results are improved over those of PTCA. Conversely, the initial morbidity and mortality are higher for CABG and are adversely affected by factors such as recent myocardial infarction, lung disease, and renal failure. We provide an overview of the results and outcomes of PTCA and CABG in the elderly, as well as suggestions for management.     

Myocardial revascularisation in elderly patients with refractory or unstable angina and advanced coronary disease

BACKGROUND: Elderly patients with ischaemic heart disease are often treated more conservatively and for longer than younger patients, but this strategy may result in subsequent invasive intervention of more advanced and higher risk coronary disease. METHODS: We performed a retrospective analysis of 109 patients aged > or = 70 years (mean age 74 years, 66% men), who presented with angina refractory to maximal medical treatment or unstable angina over a 2-year period (1988-1990), to compare the relative risks and benefits of myocardial revascularisation [coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA)] in this higher-risk age group. RESULTS: Sixty patients underwent CABG and 49 patients PTCA. There were eight periprocedural deaths in total (six in the CABG group, and two in the PTCA group, P = 0.29). Six patients in the CABG group suffered a cerebrovascular accident (two fatal). Acute Q-wave myocardial infarction occurred in one patient in the CABG group and in two patients in the PTCA group. The length of hospital stay was longer for the CABG group (CABG group 11.4 +/- 5.4 days, range 7-30 days, PTCA group 7.4 +/- 7.6 days, range 1-39 days, P = 0.01). Outcome was assessed using the major cardiac event rate (MACE; i.e. the rate of death, myocardial infarction, repeat CABG or PTCA). The cumulative event-free survival in the CABG group in 1, 2 and 3 years was 87, 85 and 85%, respectively. In contrast, in the PTCA group it was 55, 48 and 48% (P = 0.0001). Age, sex, number of diseased vessels, degree of revascularisation and left ventricular function were not predictive of the recurrence of angina in both groups. Actuarial survival (total mortality, including perioperative mortality) was lower at 1 year in the CABG group due to the higher perioperative mortality, but similar in both groups after the second year (P = 0.62). CONCLUSIONS: Elderly patients with refractory or unstable angina who are revascularised surgically have a better long-term outcome (less frequent event rate of the composite end-point--myocardial infarction, revascularisation procedures and death) compared with those who are revascularised with PTCA. This benefit is been realised after the second year. Total mortality is similar in both groups after the second year. Therefore elderly patients who are fit for surgery should not be denied the benefits of CABG. PTCA may be regarded as a complementary and satisfactory treatment, especially for those whose life expectancy is limited to less than 2 years. The use of stents may improve outcome in the PTCA group and this needs to be evaluated.     

Extensive endarterectomy of the left anterior descending coronary artery combined with coronary artery bypass grafting

BACKGROUND: Complete revascularization of a diffusely diseased left anterior descending (LAD) coronary artery can be accomplished by extensive endarterectomy in conjunction with coronary artery bypass grafting (CABG). The present study was designed to assess the safety of the procedure, and which techniques lead to the best short- and long-term results. METHODS: Between January 1990 and October 1994 106 patients underwent extensive open endarterectomy of the LAD coronary artery combined with CABG at our institution. This group constituted 4.9% of all patients undergoing CABG during this period. The mean age of those studied was 64.4 +/- 9.2 years and 92% were male. In 22 patients (21%) the procedure was a repeat CABG and 12% had had percutaneous transluminal coronary angioplasty prior to the operation. Ninety-one per cent of the patients were in Canadian Cardiovascular Society (CCS) angina class 3 or 4, 91% had three-vessel disease and 36% had unstable angina at the time of surgery. The mean preoperative left ventricular ejection fraction was 53.6 +/- 14.9% (range, 15-80%). The internal mammary artery (IMA) was used to bypass the LAD coronary artery in 40 patients (38%) and a saphenous vein graft (SVG) was used in 66 patients. In 25 of the IMA bypass group an additional venous patch was used (IMA+P). RESULTS: The overall mortality rate was 9.4% (10 patients), including seven immediate postoperative deaths. When the IMA was used as a conduit the mortality rate was only 5.0%. There were seven (6.6%) postoperative non-fatal myocardial infarctions. There was a low incidence of other postoperative complications, similar to that following CABG without endarterectomy performed during the same period. Multivariate analysis identified emergency operation, two-vessel endarterectomy and female sex as independent risk factors for mortality. Upon follow-up study of 94 hospital survivors (98%), at a mean of 26.5 months (range, 1-48 months), all endarterectomy patients were in CCS class 1 or 2. Seventy-eight patients (83%) had an excellent postoperative exercise tolerance and the left ventricular function was preserved. The 4-year survival rates were 88% and 96% and the cardiac event-free survival rates were 74% and 87% in the SVG and IMA groups respectively. CONCLUSIONS: Complete revascularization of the diffusely diseased LAD coronary artery can be accomplished by adjunctive open endarterectomy with a degree of operative risk (mortality 9% and incidence of non-fatal myocardial infarction 7%). The immediate and medium-term results are improved when the IMA is used as a conduit, with or without additional venous patch. Independent risk factors for mortality were two-vessel endarterectomy, female sex and emergency operation. The long-term results revealed an overall survival rate of 92% and a cardiac event-free survival rate of 79% at 4 years, as well as excellent functional results.     

A study on the cost-effectiveness of coronary revascularization: introducing the simultaneous mimic health status model

An econometric model is presented to compare the cost-effectiveness of two alternative procedures, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG), for the treatment of multivessel coronary artery disease. This study utilizes the MIMIC (multiple indicator multiple cause) health model in a simultaneous equation system to analyse Emory Angioplasty Surgery Trial (EAST) data. This method eliminates the possibility of endogeneity bias, which may have affected the results of previous cost-effectiveness analyses on this topic. The empirical results indicate that neither procedure proves more cost-effective at 3 year follow-up.     

Effect of coronary angioplasty on precordial QT dispersion

Dispersion of the QT interval is a measure of inhomogeneity of ventricular repolarization. Because ischemia is associated with regional abnormalities of conduction and repolarization, we hypothesized that the surface electrocardiographic interval dispersion would increase in patients with symptomatic coronary artery disease in the absence of myocardial infarction and that successful revascularization would reduce QT interval dispersion. Thirty-seven consecutive patients with ischemia due to 1-vessel coronary artery disease without prior myocardial infarction who underwent percutaneous transluminal coronary angioplasty (PTCA) were evaluated. Standard 12-lead electrocardiograms were performed 24 hours before, 24 hours after, and late (>2 months) after PTCA. Precordial QT interval dispersions were determined from differences in the maximum and minimum corrected QT intervals. Mean QT interval dispersion before PTCA was 60 +/- 9 ms, immediately after PTCA 23 +/- 14 ms (p <0.001), and late after PTCA 29 +/- 18 ms (p <0.001 vs before PTCA). The shortest precordial QT interval increased immediately after PTCA (367 +/- 40 vs 391 +/- 39 ms; p <0.02) and then remained stable late after PTCA (376 +/- 36 ms, p = NS vs immediately after PTCA). Symptomatic recurrent ischemia in 8 patients with documented restenosis increased QT interval dispersion (56 +/- 15 ms [p <0.01] vs 25 +/- 14 ms immediately after PTCA), which decreased again after successful repeat PTCA (22 +/- 13 ms [p <0.01] vs before the second PTCA). QT interval dispersion decreases after successful coronary artery revascularization and increases with restenosis. Therefore, QT interval dispersion may be a marker of recurrent ischemia due to restenosis after PTCA.     

Appropriateness of indicating aortocoronary bypass and coronary angioplasty: results of an observational prospective study in the Lombardy region. Gruppo Interdisciplinare Valutazione Appropriatezza Rivascolarizzazione Coronarica

OBJECTIVE: Most studies on the appropriateness of cardiac revascularization procedures have been aimed at detecting "overuse" (ie when patients get a procedure without a clear indication), while little attention has been paid yet to "underuse" (when patients who could benefit from a procedure do not get it). This study was planned to assess the extent of over- and underuse of revascularization procedures in northern Italy. METHODS: A multidisciplinary panel of experts convened by the Italian Association of Hospital Cardiologists (ANMCO) rated the appropriateness of 898 "theoretical indications" for coronary artery by-pass grafting (CABG) and percutaneous transluminal angioplasty (PTCA) using the RAND Corporation methodology. Standardized information has been collected on a consecutive sample of patients in the Lombardy region and identified during performance of a coronary angiogram at one of the services belonging to the GISE (Gruppo Italiano Studi Emodinamica) network. Out of the 2718 consecutive patients undergoing a coronary angiogram during the recruitment period (February-May 1995), a total of 1821 (70%) were eligible for the appropriateness study. RESULTS: Indication for CABG were appropriate in 565 (80%) patients, uncertain in 111 (16%) and inappropriate in 25 (4%). Corresponding values for PTCA were: 40% (n = 262), 46% (n = 300) and 14% (n = 90). Among the 394 to whom a medical therapy was recommended after angiography, the indication was considered appropriated in only 14% (n = 57) and uncertain for 30% (n = 117). For the remaining 220, the indication was considered inappropriate, suggesting that according to the panel criteria, 56% of the patients should have received a revascularization procedure (either a CABG or PTCA) instead. CONCLUSIONS: These results suggest that underuse of revascularization procedures represents a substantial health care problem in Lombardy region, at least with reference to the period covered by this study. The study in itself does not make it possible to understand whether these results reflect a structural shortage of services (limited accessibility and/or unprioritized waiting lists) or a more general quality-of-care problem. The study protocol now foresees a follow-up for 9 months after the index angiogram to assess the eventual utilization pattern of CABG/PTCA.     

Diagnosing left lower lobe pneumonia: usefulness of the ''spine sign'' on lateral chest radiographs

Percutaneous cardiopulmonary assist devices (PCPS) have become available in interventional cardiology within recent years. These tools offer the opportunity of performing percutaneous transluminal coronary angioplasty (PTCA) in high-risk patients characterized by significant stenoses of several coronary arteries and a poor left ventricular function. It is unclear for which patients PCPS are necessary and which patients will profit by PTCA as compared to coronary artery bypass grafting (CABG). Therefore, the anticipated risk of CABG and of PTCA without assist devices was calculated according to risk scores and compared with our results of assisted PTCA. In addition the long-term survival rate was investigated. In 35 patients (mean 65.5 years of age, 12 females, 23 males), we performed PTCA concomitant with the use of cardiac assist devices. The indications for the use of a cardiac assist device were severely impaired LV function (EF 30% +/- 8.9%) in combination with significant coronary artery disease (2.7 +/- 0.3 vessels) and a significant supply area of the vessel to be dilated. In 6 patients, PCPS was started before coronary angioplasty because of hemodynamic instability. In 21 cases, PCPS was on a standby basis without being connected to the patient's circulation. In 8 patients, a left heart assist device, the 14F-Hemopump, was inserted percutaneously. The patients were analyzed using risk scores of angioplasty and of coronary bypass graft surgery. The calculated risk of hemodynamic compromise during PTCA according to the risk scores was more than 50%. The anticipated risk of a fatal outcome following CABG would have been 19.8%. PTCA was performed on an average of 2.0 coronary arteries per patient and was successful in 85%. We observed a decline in angina pectoris classification (CCS) from 3.5 to 1.6. An average reduction of 1.1 NYHA class was achieved. The in-hospital mortality was 8.6% (3 patients: 1 x sepsis, 1 x early reocclusion, 1 x cerebral embolism). At 24 months follow-up, a re-PTCA was necessary in four cases because of restenosis. In the remainder, NYHA and CCS class were stable during the follow-up period. An additional five patients died during the first year and two patients in the second year. We conclude that PTCA with the use of a cardiac assist device shows favorable short-term results in a subset of patients with extended coronary artery disease and severely impaired LV function who are not suitable for nonsupported PTCA or CABG due to their risk profile. However, the long term results are not satisfying and stress the need for complete revascularisation with CABG once the patient's condition is stabilized by means of supported PTCA.     

Aortic valve replacement after previous coronary artery bypass grafting

BACKGROUND: As the population ages, an increasing number of patients with previous coronary artery bypass grafting (CABG) will require subsequent aortic valve replacement (AVR). This study examined outcome of AVR after previous CABG and reviewed possible indications for valve replacement at the time of initial myocardial revascularization. METHODS: Between March 1975 and December 1994, 145 patients had AVR after previous CABG. Sixty-three patients (43%) had their initial CABG elsewhere. Reoperation for AVR was the second cardiac procedure in 137 patients and the third in 8. Redo CABG with AVR was done in 66 (46%). There were 118 men and 27 women. The mean age at CABG was 64 +/- 7.9 years; for AVR this was 71 +/- 7.6 years. RESULTS: In 2 young patients accelerated calcific aortic stenosis occurred in the setting of renal failure. Significant aortic stenosis did not appear to be addressed at initial CABG in 3 patients. Transaortic valvular gradient, as measured by cardiac catheterization, increased by 10.4 +/- 7.0 mm Hg/y. Twenty-four patients (16.6%) died. The mortality for AVR alone or for AVR + redo-CABG was 15 of 125 patients (12%). For patients having more complicated procedures, the mortality was 9 of 20 (45%). Nine patients (6.2%) suffered a postoperative cerebrovascular accident. Low preoperative ejection fraction measured by echocardiography, sternal reentry problems, complexity of operation, and prolonged cross-clamp and bypass times were significant factors associated with mortality. Age at AVR, interval between operations, the extent of underlying native coronary artery disease, the state of the previously placed bypass conduits, and methods of myocardial preservation were not significant predictors of operative mortality. On multivariate analysis there was only one significant value: prolonged cross-clamp time. CONCLUSIONS: Aortic valve replacement after previous CABG is associated with a mortality that is higher than that seen after repeat CABG or repeat AVR. It seems prudent, therefore, to use liberal criteria for AVR in those patients who require coronary revascularization and who, at the same time, have mild or moderate aortic valve disease.     

Left main coronary artery stenosis following aortic valve replacement using a solid coronary perfusion catheter: report of two cases

We experienced two cases of iatrogenic left main coronary artery stenosis (IOCS) following double (aortic and mitral) valve replacement (DVR). The solid coronary perfusion catheter may attribute IOCS, with grave consequence. There have been no IOCS since the time we exchanged a solid catheter for a soft one. One case, she was successfully treated percutaneous transluminal coronary angioplasty (PTCA), because she developed angina pectoris about 5 years after PTCA. But she developed angina pectoris again and angiographically left main coronary was severe stenotic. So she was undergone aorto coronary bypass grafting (CABG) to the left anterior descending. The other case, he developed angina pectoris about 3 months after DVR. He was treated with PTCA. Angiographically left mine coronary artery stenosis reduced 50% from 90%. Generally the treatment of IOCS is CABG, but we performed PTCA for 2 patients. Because we thought it was very hazardous for us to perform them open heart surgery. When it is very hazardous to perform patients open heart surgery, they need to be performed PTCA.     

Percutaneous transluminal coronary angioplasty in patients with multivessel coronary disease: does complete revascularization improve the long-term survival?

The influence of complete revascularization on long-term outcome of patients with multivessel coronary artery disease undergoing percutaneous transluminal coronary angioplasty (PTCA) was determined by analysis of 10-year survival in 167 consecutive patients treated at Juntendo University Hospital during 1984-1993. Forty-nine patients were completely revascularized and 118 had incomplete revascularization according to the anatomical classification. Among patients with anatomically incomplete revascularization, 56 were categorized as functionally adequate revascularization and 62 as functionally inadequate revascularization according to Faxon's criteria. Baseline characteristics showed incompletely revascularized patients had a higher incidence of prior myocardial infarction triple-vessel disease and/or chronic total occlusion in at least one lesion. The 10-year survival was slightly better in patients with complete (100%) than in those with incomplete revascularization (79%), but not statistically significant (p = 0.089). Event-free survival was not significantly different between the two groups. However, the need for coronary artery bypass surgery was higher in the incomplete revascularization group than that in the complete revascularization group (100% vs 81%, p = 0.013). The influence of the degree of functional revascularization on outcome was not clear in the present study. Long-term survival appeared to be better in patients with complete revascularization than that in patients with incomplete revascularization, but even in the latter, coronary artery bypass grafting in the later period could improve outcome. The effect of functional revascularization status should be further investigated in a larger population.     

Isolation of human intestinal defensins from ileal neobladder urine

Restenosis is a major limitation of percutaneous transluminal coronary angioplasty (PTCA). In this study, we assessed the impact of restenosis on PTCA with reference to coronary angioplasty bypass grafting (CABG). In the Coronary Angioplasty versus Bypass Revascularisation Investigation (CABRI) PTCA population, those who had restenosis were defined as those needing a second revascularization at a site revascularized at the initial procedure. The 1-year clinical outcome of the nonrestenotic group (n=437) was compared with those who underwent CABG (n=453). There was no difference in deaths. In the nonrestenotic PTCA group, the incidence of more infarctions was insignificant (relative risk [RR] 1.9, 95% confidence intervals [CI] 0.96 to 3.75, p=0.064), there was a much greater need for repeat revascularization (RR 8.6, CI 5.14 to 14.41, p <0.0005), and patients had a poorer angina status (RR 1.46, CI 1.01 to 2.13, p=0.046). Using 2 measures of coronary disease, the degree of pre- and postrevascularization disease was compared between groups. There were no differences in prerevascularization disease. However, using either measure, residual postrevascularization disease was more frequent in the nonrestenotic PTCA group. Restenosis only partially accounts for the greater morbidity seen after PTCA, compared with CABG, in multivessel disease. The greater likelihood of residual disease post-PTCA may contribute to this greater morbidity.     

Intraocular lens materials and styles: a review

OBJECTIVE: To compare criteria for coronary revascularization developed by the expert panel process and by decision analysis. METHOD: We reviewed the medical records of 3080 chronic stable angina patients who either underwent coronary artery bypass graft surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA) and determined the agreement between appropriateness ratings made by two expert physician panels, one from the United States and the second from The Netherlands. We also evaluated the agreement between these panels' appropriateness ratings and a decision analytic model's effectiveness categories. RESULTS: There was poor agreement between U.S. and Dutch panel appropriateness ratings for PTCA (kappa = 0.03) and slight agreement for bypass surgery (kappa = 0.18). Dutch ratings had substantial agreement with the decision analytic models effectiveness categories for both PTCA and CABG (kappa = 0.83 and 0.79, respectively) whereas there was no systematic agreement between U.S. ratings and the decision analytic model for PTCA and poor agreement for CABG (kappa = 0.00 and 0.18, respectively). CONCLUSIONS: Although the level of agreement between expert panels and decision analysis on when a procedure is appropriate or effective may vary by procedure and the strength of the scientific evidence, we found that Dutch physicians agree much more strongly with decision analysis than U.S. physicians.     

Health service costs of coronary angioplasty and coronary artery bypass surgery: the Randomised Intervention Treatment of Angina (RITA) trial

For some patients with coronary artery disease, percutaneous transluminal coronary angioplasty (PTCA) is an alternative to coronary artery bypass grafting (CABG). We report comparative health service costs of these interventions within the Randomised Intervention Treatment of Angina (RITA) trial. Medications were costed at published UK prices; other resource use was costed with a set of unit costs estimated at two recruiting centres to the RITA trial, one in London and one outside. Over 2-year follow-up of 1011 patients, the estimated mean additional cost for those randomised to CABG compared with PTCA was 1050 pounds (95% CI 621 pounds-1479 pounds), with unit costs from the non-London centre, and 1823 pounds (1202 pounds-2444 pounds), with unit costs from the London centre. The initial average cost of treating a patient randomised to PTCA is about 52% of that of CABG, but after 2 years this increased to about 80% because of the greater need for subsequent interventions. The balance of advantage between PTCA and CABG may change after several years: funding has been obtained to continue RITA follow-up for 10 years. However, on the basis of patients' status at 2 years, the cost advantages of PTCA cannot be ignored. Further research is necessary to assess whether the advantage of PTCA in terms of cost is translated into one of cost-effectiveness.     

Acute angiographic and clinical results of long balloon percutaneous transluminal coronary angioplasty and adjuvant stenting for long narrowings

Historically, long coronary artery stenoses undergoing percutaneous transluminal coronary angioplasty (PTCA) are reported to have reduced procedural and clinical success in comparison with shorter lesions. The efficacy of long balloons (30 or 40 mm) in long lesions was evaluated. Eighty-two patients had 84 PTCA procedures with a primary long balloon. In all, 86 lesions were available for analysis. Data were collected prospectively on standard PTCA procedure forms. Coronary angiograms were reviewed and measured with digital calipers. Hospital charts were examined for complications. PTCA was performed in the left anterior descending artery in 44 cases (51%), the right coronary artery in 29 (34%) and the circumflex artery in 13 (15%). With the use of a modified classification system, 47 lesions (55%) were class C, 24 (28%) were class B2 and 15 (17%) were class B1. Mean lesion length was 22 +/- 11 mm (range 10 to 72), and 38 lesions (44%) were > or = 20 mm. Twelve patients received an intracoronary stent. The long balloon alone produced angiographic success (< 50% residual stenosis) in 77 lesions (90%). Angiographic success was achieved ultimately in all stenoses, using a stent in 7 patients and a short balloon in 2. There were 2 deaths (2%) and 1 Q-wave myocardial infarction (1%). One patient needed coronary artery bypass surgery. Clinical success without death, Q-wave infarction or bypass surgery was achieved in 83 of 86 procedures (97%). In conclusion, the use of long PTCA balloons with adjuvant stenting produced excellent results in these long stenoses. Lesion length was not a precursor of poor angiographic or clinical outcome.     

Heart interventions in Switzerland 1996

For the year 1996, as for the previous 11 years, a survey of cardiac invasive and surgical procedures in Switzerland was carried out by a standardised questionnaire. At the 25 Swiss centres (10 public non-university, 10 private and 5 university centres) a total of 12,183 coronary revascularisation procedures were performed, 60% by percutaneous transluminal coronary angioplasty (PTCA). Of all PTCAs, 88% were single vessel interventions. PTCA for ongoing infarction accounted for 6% of all PTCAs. The use of coronary stents has increased to 50% of all angioplasties. Other interventions like directional atherectomy and rotablations have lost ground (0.4%, 35 cases). Only 22 interventions (0.2%) with intracoronary laser devices were recorded. Among the new diagnostic tools, only coronary ultrasound (233 cases) and Flowire (147) have been used regularly. Percutaneous balloon valvuloplasties (60 cases) and catheter closure of congenital shunt defects (42 cases) remained rare. Procedure related mortality for PTCA was 0.6%, infarction occurred in 1.0% and emergency coronary artery bypass grafting (CABG) became necessary in 0.4%. The total number of CABGs (4,463) slightly decreased. Among the 2,677 non-coronary operations, 48% were performed for valve disease and 51% for congenital heart disease. Heart transplantation was performed in 41 patients (1%). Half of the interventional catheter procedures were performed at the 5 university centres whereas the majority of CABGs were carried out at private centres. Four centres performed diagnostic procedures, exclusively. In-house surgical stand-by for PTCA was available in 17 of the 21 interventional centres.     

Predictors of CABG within one year of successful PTCA: a retrospective, case-control study

BACKGROUND: We previously have established characteristics predictive of the need for coronary artery bypass grafting (CABG) over many years after successful percutaneous transluminal coronary angioplasty (PTCA). In this study, we examined the factors associated with the need for CABG within 1 year of successful PTCA, and the recent impact of newer, catheter-based technologies. METHODS: From January 1982 through December 1995, 234 patients underwent CABG within 1 year of a successful "index" PTCA at our hospital. Emergency operations within 12 hours of index PTCA were excluded. These cases were matched with 234 controls who underwent a successful index PTCA but did not require a subsequent CABG during the next year. Cases were matched by the date of their index PTCA, and 1-year follow-up was complete for all patients. RESULTS: Before index PTCA there were no differences between the groups in terms of age, sex, diabetes, prior myocardial infarction, ejection fraction, duration of anginal symptoms, hypertension, hyperlipidemia, family history, or obesity (all nonsignificant). At index PTCA the cases had a greater mean number of lesions measuring 70% or greater compared with the controls (2.8 versus 1.8, respectively; p < 0.0001). The cases were more likely to have critical (70% or greater) proximal left anterior descending artery, proximal first obtuse marginal artery, and right posterior descending artery stenoses. The use of stents or atherectomy devices was not significantly more common among the controls (21% of controls versus 17.1% of cases; p = 0.35). Complete revascularization was achieved in significantly fewer of the cases than the controls (91 versus 156, respectively; p < 0.0001). The cases underwent CABG at a mean of 3 months (86% within 6 months) after PTCA. Among those who had a diagnostic catheterization, 52% of the patients had both restenosis of a dilated lesion and progression of other disease. Only 5 of 75 patients who had restenosis of a dilated lesion had a stent or an atherectomy device used at index PTCA. Of note, 13% (30 of 234) required an emergency operation, with an overall operative mortality rate of 3% (7 of 234). CONCLUSIONS: Although the likelihood of local restenosis is decreased by newer interventional techniques, the need for CABG within 1 year after successful PTCA is not diminished. The number of critical lesions and their location are the best predictors of the need for early CABG. If early post-PTCA CABG is to be avoided, patients who cannot be completely revascularized by PTCA should be revascularized by CABG.