Mechanical debulking versus balloon angioplasty for the treatment of true bifurcation lesions

OBJECTIVES: The purpose of this study was to compare the immediate angiographic and long-term results of debulking versus balloon angioplasty for treatment of true bifurcation lesions. BACKGROUND: Previous studies have shown true bifurcation lesions to be a high risk morphological subset for percutaneous transluminal coronary angioplasty (PTCA). Although atherectomy devices have been used to treat bifurcation lesions, no studies have compared the outcomes of these alternative treatment modalities. METHODS: Between January 1992 and May 1997, we treated 70 consecutive patients with true bifurcation lesions (defined as a greater than 50% stenosis in both the parent vessel and contiguous side branch) with conventional PTCA (n = 30) or debulking (with rotational or directional atherectomy) plus adjunctive PTCA (n = 40). Paired angiograms were analyzed by quantitative angiography, and clinical follow-up was obtained in all patients. RESULTS: Acute procedural success was 73% in the PTCA group and 97% in the debulking group (p = 0.01). Major in-hospital complications occurred in two patients in the PTCA group and one in the debulking group. Treatment with atherectomy plus PTCA resulted in lower postprocedure residual stenoses than PTCA alone (16+/-15% vs. 33+/-17% in the parent vessel, and 6+/-15% vs. 39+/-22% in the side branch; p < 0.001 for both comparisons). At 1 year follow-up, the incidence of target vessel revascularization (TVR) was 53% in the PTCA group as compared with 28% in the debulking group (p = 0.05). Independent predictors of the need for repeat TVR were side branch diameter >2.3 mm, longer lesion lengths, and treatment with PTCA alone. CONCLUSIONS: For the treatment of true bifurcation lesions, atherectomy with adjunctive PTCA is safe, improves acute angiographic results, and decreases target vessel revascularization compared to PTCA alone. The benefits of debulking for bifurcation lesions were especially seen in lesions involving large side branches.     

The oxidative metabolism of catecholamines in the brain: a review

The EBI (BARD-XT, C.R. Bard, Murray Hill, NJ) stent is a new radiopaque balloon expandable coronary stent with high resistance to external radial forces. It does not shorten significantly with expansion and allows stent implantation in bifurcation lesions. A total of 28 EBI stents were implanted in 23 lesions in 21 patients. Indications for stent implantation were acute closure in 1, threatened closure in 15, and electively in 7 lesions. In 2 cases, the lesion involved a bifurcation where a stent was implanted in both vessels. All patients received aspirin and ticlopidine. No anticoagulant therapy was given. The stenting procedure was successful in 22 of 23 lesions. No complications occurred with the exception of 1 patient with a thrombotic reocclusion within 1 hr after stent implantation and 1 patient with a temporary occlusion of a side branch. The mean minimal luminal diameter (MLD) increased from 0.74+/-0.46 mm before balloon dilatation to 1.27+/-0.62 mm before stent implantation and 2.32+/-0.57 mm after stent implantation. Percent stenosis decreased from 71+/-19% before angioplasty to 46+/-25% after angioplasty to 5+/-8% after stent implantation. MLD at the time of follow-up angiography after 4 months was 1.98+/-0.77 mm and percent stenosis was 26+/-21%. Restenosis of more than 50% occurred in 2 lesions. In these lesions, a second percutaneous transluminal coronary angioplasty was performed. Advantages of this stent are its flexibility together with an acceptable radial strength as well as enabling radiopacity without obscuring the arterial lumen. Stenting of bifurcation lesions is possible.     

Adult moyamoya disease progressing from unilateral to bilateral involvement

The effect of domestically-manufactured excimer laser with adjunctive balloon angioplasty in achieving revascularization and reduction of residual stenosis was assessed. 20 femoral arteries with thrombosis and occlusion from 12 dogs were subject to angiography. At first excimer laser angioplasty was done followed by balloon angioplasty. The diameter and residual stenosis of revascularized vessel were measured. The result showed that 17 out of 20 vessels (85%) were revascularized. The diameter of revascularized vessel by excimer laser were 1.22 +/- 0.14 mm, while residual stenoses were 54% +/- 5%. After adjunctive balloon angioplasty the diameter and residual stenoses were 2.04 +/- 0.16 mm and 20% +/- 7% respectively (P < 0.05 and P < 0.01). Complication in form of vasoperforation occurred in 3/20 vessels (15%). It is concluded that China- manufactured excimer laser angioplasty is effective when used for revascularization. While the reduction of narrowing and residual stenoses was enhanced after adjunction of balloon angioplasty. This method can be employed in treating peripheral occlusive disease effectively and safely.     

Are directional coronary atherectomy and Palmaz-Schatz stent more efficacious than conventional balloon angioplasty for treating de novo coronary artery lesions?

It is unclear whether new devices such as directional coronary atherectomy (DCA) or Palmaz-Schatz stent implantation improve long-term outcomes compared with conventional balloon angioplasty in patients with stable angina and de novo coronary artery lesions of type A or type B except for complete occlusive lesions investigated by the American College of Cardiology/American Heart Association task force on percutaneous transluminal coronary angioplasty. A total of 146 patients with stable angina and simple lesions were assigned to either conventional balloon angioplasty (62 patients), DCA (50 patients), or Palmaz-Schatz implantation (34 patients). The acute results and late outcomes were assessed by coronary angiography. The results of the three procedures were similar with respect to procedural success and complications. Patients who underwent stenting or DCA had a larger immediate increase in the diameter of the lumen and a larger luminal diameter immediately after the procedure than those who underwent balloon angioplasty. At six months follow-up, the patients treated by stenting continued to have a larger luminal diameter and a lower rate of restenosis than those treated with balloon angioplasty (2.30 +/- 0.66 vs 1.85 +/- 0.83 mm, p < 0.005; 5.9% vs 29%, p < 0.05) and DCA (2.30 +/- 0.66 vs 1.90 +/- 0.96 mm, p < 0.05; 5.9% vs 24%, NS). The patients treated with balloon angioplasty had a smaller late loss than those treated with DCA or Palmaz-Schatz stent. The patients treated with DCA had a larger loss index than those treated with balloon angioplasty or Palmaz-Schatz stent. Stenting was a significant factor in decreasing the rate of restenosis by logistic regression analysis, compared with balloon angioplasty. The angiographic outcomes were better in patients who received a stent than in those who received other treatments. This study suggests that even lesions stable for treatment by balloon angioplasty and DCA can also be treated with Palmaz-Schatz stents.     

Recurrent group B streptococcal arthritis

We present a patient with renal artery stenoses due to fibromuscular dysplasia involving the point of arterial bifurcation that we could successfully dilate with percutaneous transluminal angioplasty. We used the kissing balloon technique to prevent possible complications of percutaneous transluminal renal angioplasty (PTRA), including occlusion of the other branch while dilating one branch. The kissing balloon technique worked well for PTRA of the arterial bifurcation.     

Elective stenting of carotid artery stenosis in patients with severe coronary artery disease

AIMS: To evaluate the feasibility and safety of elective carotid stent implantation in patients with carotid stenoses and concomitant coronary artery disease, as an alternative to combined carotid and coronary surgery. METHODS: We treated 50 patients with >70%, stenoses in 53 carotid arteries with balloon angioplasty followed by elective stent implantation. All patients had severe coronary artery disease, and/or mitral insufficiency, aortic stenosis, rhythm disorders or generalized arteriosclerosis. In three patients the opposite carotid artery was occluded; nine patients had bilateral stenoses of which two received stents bilaterally. RESULTS: Fifty-six successful stent implantations (42 Wallstents, eight BeStents, two AVE-Microstents, one Palmaz Schatz stent, three Sito stents) were performed, reducing the baseline percent stenosis from 78 +/- 18%, to 13 +/- 11%. Complications included three transient ischaemic attacks, one minor and one major stroke. Follow-up was available for 46 patients over a mean of 10 months. Three asymptomatic restenoses and one deformation of a BeStent occurred. CONCLUSION: Our preliminary results indicate that carotid artery stenting in patients with concomitant severe coronary artery disease is feasible, safe, and may be an alternative to combined carotid and coronary surgery.     

Paratesticular sarcoma: apropos of a case with a 19-year evolution

In young children with renal artery stenosis the applicability of percutaneous transluminal angioplasty is limited by the small vessel size. We report our experience in a 15-month-old girl with severe hypertension, who underwent successful balloon dilatation of a tight renal artery stenosis caused by fibromuscular dysplasia. The procedure was performed using the guided co-axial balloon catheter technique with a 6 F right coronary Judkins catheter, a 0.014" guidewire and a 2 mm coronary artery balloon dilatation catheter. Antihypertensive medication was discontinued 6 weeks after the procedure. During a follow up period of 11 months, Doppler sonography revealed no evidence of recurrent renal artery stenosis. CONCLUSION: Percutaneous transluminal angioplasty of renal artery stenosis can be performed safely in young children using equipment originally designed for treatment of coronary artery stenosis in adults.     

Bovine endometrial retinol-binding protein secretion, messenger ribonucleic acid expression, and cellular localization during the estrous cycle and early pregnancy

OBJECTIVES: We assessed the safety and efficacy of stent placement in patients with poorly controlled hypertension and renal artery stenoses, which are difficult to treat with balloon angioplasty alone. BACKGROUND: Preliminary experience with stent placement suggests improved results over balloon angioplasty alone in patients with atherosclerotic renal artery stenosis. METHODS: Balloon-expandable stents were placed in 100 consecutive patients (133 renal arteries) with hypertension and renal artery stenosis. Sixty-seven of the patients had unilateral renal artery stenosis treated and 33 had bilateral renal artery stenoses treated with stents placed in both renal arteries. RESULTS: Angiographic success, as determined by quantitative angiography, was obtained in 132 (99%) of 133 lesions. Early clinical success was achieved in 76% of the patients. Six months after stent placement, the systolic blood pressure was reduced from 173 +/- 25 to 147 +/- 23 mm Hg (p < 0.001); the diastolic pressure from 88 +/- 17 to 76 +/- 12 mm Hg (p < 0.001); and the mean number of antihypertensive medications per patient from 2.6 +/- 1 to 2.0 +/- 0.9 (p < 0.001). Angiographic follow-up at a mean of 8.7 +/- 5.0 months in 67 patients revealed restenosis (>50% diameter narrowing) in 15 (19%) of 80 stented vessels. CONCLUSIONS: Renal artery stenting is an effective treatment for renovascular hypertension, with a low angiographic restenosis rate. Stent placement appears to be a very attractive therapy in patients with lesions difficult to treat with balloon angioplasty such as renal aorto-ostial lesions and restenotic lesions, as well as after a suboptimal balloon angioplasty result.     

Cytochrome P450 2E1 mRNA in the rat prostate: detection and quantitation by competitive reverse transcription and polymerase chain reaction

Conventional balloon angioplasty treatment of aorto-ostial stenoses in native coronary arteries and saphenous vein grafts is associated with a low primary success rate, a high complication rate and a high incidence of restenosis. The short-term outcome of Palmaz-Schatz stent implantation in aorto-ostial lesions was compared with that of balloon angioplasty. Thirteen patients underwent stent implantation for 13 de novo lesions (four in the left main coronary trunk, two in the right coronary artery, seven in the vein graft) between January 1994 and December 1995. Fourteen patients underwent balloon angioplasty for 14 de novo lesions (five in the left main coronary trunk, four in the right coronary artery, five in the vein graft between January 1986 and April 1992. Both groups had similar clinical characteristics. Initial success was obtained in all patients in the stent group, compared with 71% of the balloon angioplasty group. Insufficient dilation was the main cause for such failure in the balloon angioplasty group. Baseline reference diameters were similar (3.40 +/- 0.65 mm in the stent group vs 3.36 +/- 0.42 mm in the balloon angioplasty group) and there was no difference in baseline minimal luminal diameter (1.41 +/- 0.74 vs 1.08 +/- 0.56 mm). Minimal luminal diameter was significantly greater in the stent group than in the balloon angioplasty group at both post-procedure and follow-up examinations (post: 3.36 +/- 0.58 vs 2.69 +/- 0.45 mm, p < 0.01; follow-up: 2.33 +/- 0.96 vs 1.52 +/- 0.68 mm, p < 0.05). There was no subacute occlusion in either group. The overall angiographic restenosis rate (> 50% stenosis) was lower in the stent group (17%) than in the balloon angioplasty group: the restenosis rates of native lesions were 0% in the stent group and 40% in the balloon angioplasty group; those of saphenous vein graft lesions were 33% in the stent group and 50% in the balloon angioplasty group. Although the number of patients was limited, these results suggest that Palmaz-Schatz stent implantation may be a safe and effective strategy for treating aorto-ostial lesions in both native coronary arteries and saphenous vein grafts.     

Excimer laser angioplasty versus balloon angioplasty in functional and total coronary occlusions

Registries of excimer laser coronary angioplasty have reported good results in the treatment of complex coronary artery disease, including total or subtotal coronary occlusions. One hundred three patients (103 lesions) with a functional or total coronary occlusion were included in a randomized trial (Amsterdam-Rotterdam [AMRO] trial, total of 308 patients), 49 patients were allocated to laser angioplasty and 54 patients to balloon angioplasty. The primary clinical end points were death, myocardial infarction, coronary bypass surgery, or repeated coronary angioplasty of the randomized segment during a 6-month follow-up period. The primary angiographic end point was the minimal lumen diameter at follow-up in relation to the baseline value (net gain), as determined by an automated contour-detection algorithm. Laser angioplasty was followed by balloon angioplasty in all procedures. The angiographic success rate was 65% in patients treated with excimer laser-assisted balloon angioplasty compared with 61% in patients treated with balloon angioplasty alone. No deaths occurred. There were no significant differences between the laser angioplasty group and the balloon angioplasty group in the incidence of myocardial infarctions (1 patient vs 3, respectively, p = 0.36), coronary bypass surgery (4 patients vs 2, respectively, p = 0.34), repeat angioplasty (10 patients vs 8, respectively, p = 0.46) or primary clinical end point (15 patients vs 12, respectively, p = 0.34). The net gain in minimal lumen diameter and restenosis rate (>50% diameter stenosis at follow-up) were 0.81 +/- 0.74 mm and 66.7%, respectively, in patients treated with laser angioplasty compared with 1.04 +/- 0.68 mm and 48.5%, respectively, in patients treated with balloon angioplasty (p = 0.59 and p = 0.15, respectively). Excimer laser-assisted balloon angioplasty demonstrated no benefit over balloon angioplasty with respect to initial and long-term clinical and angiographic outcome in the treatment of patients with functional or total coronary occlusions of >10 mm in length.     

Bronchoscopic balloon dilatation in the combined management of postintubation stenosis of the trachea in adults

Bronchoscopic balloon dilatation (BBD) using angioplasty balloon catheters has been employed successfully in the treatment of tracheobronchial stenoses in children and has worked with variable success in adults with bronchial stenosis. In adults with tracheal stenosis, BBD only has been reported anecdotally. In this study, experience with BBD using a valvuloplasty balloon catheter in the combined treatment (with Nd-YAG laser photoresection and stenting) of severe benign postintubation tracheal stenoses in three adults is delineated. BBD was particularly successful in establishing tracheal patency when laser photoresection was contraindicated or was too dangerous; BBD allowed easy insertion of tracheal stents and the "opening" of folded silicone stents. BBD is a simple, inexpensive, safe, and efficient adjunct in the combined treatment of severe postintubation rigid tracheal stenosis in selected adults.     

Infection control for the dying

The data on 36 patients who had undergone coronary angiography (CAG) and/or transluminal balloon angioplasty (TBAP) again after successful TBAP were analyzed. Twenty four patients were found to develop restenosis (n = 26), 80 and 92% of patients having them within the first 6 and 12 months after successful TBAP, respectively. Restenosis were demonstrated to be of almost the same degree and extent as the baseline stenoses; however, after repeated TBAP there was a slight reduction in the extent of residual stenosis as compared with the first TBAP (15.9 +/- 16.1% and 30.8 +/- 16.6%, respectively), though this difference was insignificant. At baseline, 42% of dilated stenoses were complicated and/or eccentric, while restenosis were eccentric in 16% of cases (p < 0.05) and complicated in 21% (p < 0.05). Thus, restenoses are X-ray morphologically more favourable for TBAP.     

Coronary stenosis progression differs in patients with stable angina pectoris with and without a previous history of unstable angina

OBJECTIVES: To compare the evolution of stenoses responsible for acute coronary events with those not associated with acute coronary syndromes. METHODS AND RESULTS: We prospectively studied angiographic stenosis progression in 190 stable angina patients, with single vessel disease, who were awaiting non-urgent coronary angioplasty. Sixty four patients had a previous history of unstable angina (Group 1) and 126 patients had no history of unstable angina (Group 2). Culprit stenoses were classified as "complex' or "smooth'. At restudy, 8 +/- 4 months after the first angiogram, 12 of 63 culprit stenoses in Group 1 had progressed and seven of 125 in Group 2 (19% vs 6%, P = 0.0044). Thirteen of 68 complex culprit stenoses had progressed, compared with only 6 of 120 smooth culprit stenoses (19% vs 5%, P = 0.003). Coronary events occurred in 12 Group 1 patients and nine Group 2 patients (P = 0.02). CONCLUSIONS: In patients with stable angina, stenoses associated with previous episodes of unstable angina are more likely to progress than stenoses not associated with previous unstable angina. Unstable coronary atherosclerotic plaques, even those that have been clinically stable for more than 3 months, may retain the potential for rapid progression to total occlusion.     

Comparisons of three simple nutritional assessments applied to patients with oral and maxillofacial malignancies

Percutaneous balloon angioplasty was used to dilate inferior vena cava (IVC) stenosis in 12 patients with Budd Chiari syndrome. There were seven men and five women, aged 32.8 +/- 8.5 years. Angioplasty was performed using balloon 18-20 mm in diameter. In eleven (91.6%) patients, IVC could be successfully dilated. In these eleven patients, the caval diameter at the site of stenosis increased from 2.3 +/- 1.5 to 13.1 +/- 2.8 mm (p < 0.001), the mean IVC pressure decreased from 28.2 +/- 4.1 to 10.5 +/- 3.4 mmHg (p < 0.001) and the gradient across the stenosis decreased from 23.1 +/- 2.2 to 4.2 +/- 1.9 mmHg (p < 0.001). There was appreciable clinical improvement after angioplasty. On a mean followup of 10.8 (3-18) months four (36.4%) patients had restenosis which could be successfully dilated again. These results suggest that balloon dilatation of inferior vena cava stenosis is safe and effective, however, recurrence is common and needs redilatation.     

Coronary flow analysis during autoperfusion angioplasty

BACKGROUND: Autoperfusion balloons are available for the protection of the myocardium during balloon angioplasty. The aortic pressure is the driving force that delivers blood to the distal vessel during balloon inflation. Autoperfusion balloons can achieve sufficient flow rates in vitro. The use of these devices is recommended in high-risk patients in danger of haemodynamic collapse during balloon inflation. The quantity of the distal blood flow during balloon inflation in vivo is still unknown. OBJECTIVES: To measure distal coronary perfusion using Doppler guidewires during percutaneous transluminal coronary angioplasty (PTCA) with autoperfusion balloons. METHODS: Coronary flow velocity was measured with 0.014-inch Doppler guidewires bypassing the autoperfusion balloon in eight patients undergoing elective PTCA (degree of stenosis 74 +/- 7.2%). We used balloons with diameters of 3.0 and 3.5 mm. The coronary diameter at the location of the flow measurements was obtained by quantitative angiography in two planes. Coronary blood flow was calculated as the luminal area multiplied by the average peak flow velocity of the Doppler wire divided by 2. Coronary flow velocity reserve was measured before and after angioplasty by intracoronary injection of adenosine. RESULTS: Coronary blood flow was 35 +/- 11.6 ml/min before PTCA. During average inflation times of 4.6 +/- 0.9 min, coronary blood flow was 19 +/- 3.8 ml/min (P = 0.002) after withdrawing the guidewire in the autoperfusion balloon. Five minutes after angioplasty it increased to 42 +/- 13.5 ml/min (P < 0.001). Four patients had electrocardiographic changes during balloon inflation; three patients reported chest pain. One patient required a stent because of a local dissection. To achieve satisfactory angiographic results (residual stenosis 11 +/- 8.5%), we performed 2.1 +/- 0.78 inflations on average with a cumulative inflation time of 8.8 +/- 3.35 min. Coronary flow velocity reserve increased from 1.3 +/- 0.20 to 2.2 +/- 0.22 (P < 0.001). CONCLUSIONS: Using the autoperfusion balloon we measured a coronary blood flow during angioplasty of 56 +/- 10.3% of the distal perfusion before PTCA. In high-risk patients dependent on adequate coronary perfusion, autoperfusion balloons are not able to provide sufficient distal coronary blood flow during balloon inflation. In these patients active coronary or circulatory support devices are recommended.     

Directional coronary atherectomy for the treatment of Palmaz-Schatz in-stent restenosis

Management of in-stent restenosis has become a significant challenge in interventional cardiology. The results of balloon angioplasty have been disappointing due to the high recurrence of restenosis at follow-up. Debulking of the restenotic tissue within the stents using directional coronary atherectomy (DCA) may offer a therapeutic advantage. We report the immediate clinical and angiographic outcomes and long-term clinical follow-up results of 45 patients (46 lesions), mean age 63+/-12 years, 73% men, with a mean reference diameter of 2.9+/-0.6 mm, treated with DCA for symptomatic Palmaz-Schatz in-stent restenosis. DCA was performed successfully in all 46 lesions and resulted in a postprocedural minimal luminal diameter of 2.7+/-0.7 mm and a residual diameter stenosis of 17+/-10%. There were no in-hospital deaths, Q-wave myocardial infarctions, or emergency coronary artery bypass surgeries. Four patients (9%) suffered a non-Q-wave myocardial infarction. Target lesion revascularization was 28.3% at a mean follow-up of 10+/-4.6 months. Kaplan-Meier event-free survival (freedom from death, myocardial infarction, and repeat target lesion revascularization) was 71.2% and 64.7% at 6 and 12 months after DCA, respectively. Thus, DCA is safe and efficacious for the treatment of Palmaz-Schatz in-stent restenosis. It results in a large postprocedural minimal luminal diameter and a low rate of both target lesion revascularization and combined major clinical events at follow-up.     

Dietary and non-dietary factors associated with iron status in a cohort of Danish adults followed for six years

PURPOSE: Suboptimal distal coronary flow reserve after successful balloon angioplasty has been attributed to angiographically unrecognized inadequate lumen expansion, and adjunct coronary stenting has been shown to improve coronary flow reserve. The aim of this study was to investigate whether myocardial fractional flow reserve (FFRmyo) would increase further after coronary stenting compared with balloon angioplasty alone in the same patient group. METHODS: FFRmyo and quantitative coronary angiography were obtained before and after pre-stent balloon dilation, and again after stent placement in 11 patients (7 left anterior descending artery, 3 right coronary artery and 1 left circumflex artery). FFRmyo was calculated as the ratio of Pd/Pa during intracoronary adenosine 5'-triphosphate (50 micrograms and 20 micrograms in the left and right coronary arteries, respectively)-induced maximum hyperemia, where Pd represents mean distal coronary pressure measured by a 2.1 Fr infusion catheter and Pa represents mean aortic pressure measured by the guiding catheter. RESULTS: Percent diameter stenosis significantly decreased after balloon angioplasty (74% +/- 15% vs 37% +/- 17%, p < 0.001), and decreased further after stent placement (18% +/- 10%, p < 0.001 vs baseline and balloon angioplasty). FFRmyo after coronary stenting (0.85 +/- 0.09) was significantly higher than that at baseline (0.51 +/- 0.16, p < 0.001) and after balloon angioplasty (0.77 +/- 0.11, p < 0.05). There was a significant correlation between angiographic variables and FFRmyo. The increase in lumen dimensions after coronary stenting was followed by a further significant improvement of FFRmyo. CONCLUSION: These results suggest that coronary stenting may provide a more favorable functional status and lumen geometry of residual coronary stenosis compared with balloon angioplasty alone.     

Reduced visual acuity in elderly people: the role of ergonomics and gerontechnology

Branch pulmonary artery stenosis is a common problem in pediatric cardiology. Treatment has included surgery, balloon angioplasty, and balloon expandable stent placement. It was the purpose of this investigation to demonstrate the cost-effectiveness of each of these modes of treatment. From 1983 to 1994 there were 30 patients admitted for treatment of branch pulmonary artery stenosis only. Data included age at procedure, sex, primary diagnosis, acute and intermediate term success, and complications. Acute success was defined by results at the end of the procedure where intermediate term (IT) success was defined by results at follow-up. Success of a procedure was defined by at least one of the following: an increase in vessel diameter by >/=50% of predilation diameter, a decrease in right ventricular to left ventricular or aortic systolic pressure ratio by >/=20%, or a decrease in peak to peak pressure gradient by >/=50%. The procedure was considered a failure if the previously mentioned criteria were not met or if the patient required a second procedure for the same stenosis. The expense of the procedure (estimated by using the patient charges) were collected from the time of the procedure until December 1994. Because of differing lengths of follow-up, the patients were analyzed separately for procedures and outpatient charges. The total charges were corrected to 1994 dollars using the Medical Consumer Price Index. Thirty patients had 46 separate procedures (12 patients had >1 procedure and 3 had >2 procedures). There were 13 surgeries, 13 balloon angioplasties, and 20 stents. Stents were the most successful (90% acute and 85% IT), but were not statistically superior to surgery (62% acute and IT). Balloon angioplasty was significantly less successful as compared with stents (31% acute and 23% IT), and was not statistically different from surgery over the acute and intermediate term. The charge data showed balloon angioplasty was the least expensive followed by stents and then by surgery. The average total charges per procedure, including outpatient charges, were: surgery $58,068 +/- $4372 (standard error), balloon $21,893 +/- $5019, stents $33,809 +/- $3533 (p < 0.001); excluding outpatient charges: surgery $52,989 +/- $3649, balloon $15,653 +/- $1691, and stents $29,531 +/- $2241 (p < 0.001). Average total charges per patient, including all procedure types and grouped by initial procedure, were: surgery $53,707 +/- $6388, balloon $50,040 +/- $8412, and stent $34,346 +/- $3488 (p = 0.047). Stents were at least as effective as surgery and were more effective than balloon angioplasty in both acute and intermediate term follow-up. Balloon angioplasty was least expensive per procedure but was also least effective. Therefore, intravascular balloon expandable stents are the most cost-effective means available in the treatment of branch pulmonary artery stenosis.     

Prediction of incontinence following low anterior resection for rectal carcinoma

We evaluated the long-term angiographic outcome of balloon angioplasty by comparing original and follow-up target coronary narrowing. Rather than using restenosis to determine outcome, as in most angioplasty studies, we took an unusual approach and analyzed outcome in terms that are commonly used in progression and regression studies after medical interventions. Quantitative angiographic measurements were undertaken in 315 narrowings with an initial diameter stenosis <90% before and after angioplasty and at follow-up. Angiographic deterioration (>10% increase in follow-up diameter stenosis) was identified in 44 (14%) narrowings. Angiographic deterioration was not influenced by age, sex, risk factors, lipid profile, or the indication for angioplasty. Deterioration was also not predicted by the severity, length, or the location of the narrowing. The deteriorating narrowings had a higher recoil after dilatation compared with narrowings with angiographic improvement (21% +/- 31% vs 12% +/- 17%, p = 0.006); the residual stenosis after angioplasty was therefore higher. The late loss was also significantly increased compared with narrowings with angiographic improvement (65% +/- 26% vs 8% +/- 24%, p < 0.001). We conclude that the incidence of angiographic deterioration of coronary disease as a result of restenosis is uncommon but not negligible. Interventional cardiologists should resist the temptation to dilate mild, silent coronary narrowings because the procedure might have an unfavorable angiographic (and probably clinical) effect.     

Serial investigation of balloon angioplasty induced changes in the superficial femoral artery using colour duplex ultrasonography

Percutaneous transluminal balloon angioplasty (PTA) of superficial femoral artery lesions is associated with similar initial success rates in coronary and iliac artery angioplasty but its application is limited by a much higher incidence of restenosis. To improve understanding of the trauma caused to the vessel by balloon angioplasty and the mechanisms contributing to the subsequent processes of healing and restenosis requires serial investigations of the treated arteries in vivo. This paper describes a prospective study using colour duplex ultrasonic imaging to assess arterial changes in 51 patients with atherosclerotic disease undergoing PTA of superficial femoral artery stenoses and occlusions. Each patient was scanned prior to angioplasty and at intervals up to 6 months post-angioplasty. On each scan, measurements were made of the overall vessel and lumen diameters at each site of angioplasty. These measurements indicate that angioplasty improves vessel patency mainly by stretching of the vessel wall, with compression and/or redistribution of the atherosclerotic plaque contributing less than 25% to the improvement of lumen diameter. Serial measurements after angioplasty show complex patterns of change at the angioplasty sites indicating that several mechanisms may be contributing to the processes of vessel healing and subsequent restenosis. Possible mechanisms which could explain the measured changes in overall vessel and lumen diameters are discussed.