Angiographic studies have demonstrated that maximal lumen loss after angioplasty occurs in the first 6 months, with no further significant loss up to 3 years after the procedure.(1,2) Serial angiographic studies performed up to 1 year after stent implantation have demonstrated that lumen loss after stenting also reaches its maximum in the first 6 months.(3,4) There is a paucity of data, come after stent implantation. This study was undertaken to determine whether there were changes in endovascular dimensions >6 months after stent implantation.

OBJECTIVE:To present a comparative analysis of the immediate and short term experience of stent implantation as the initial treatment for failed angioplasty (immediate stenting) with the staged approach of prolonged inflation with a perfusion balloon followed by stent implantation if prolonged inflation was unsuccessful (secondary stenting).DESIGN:Retrospective analysis of the outcome of 90 consecutive patients from a single institution undergoing one of these treatment strategies for failed angioplasty.INTERVENTIONS AND MAIN RESULTS:The initial treatment for failed angioplasty was prolonged inflation with a perfusion balloon in 59 and immediate stent implantation in 31 patients. Angiographic success (less than 50% residual and normal flow) was achieved in 24 of 59 (41%) with the perfusion balloon (mean duration of inflation 12.2 +/- 8.3 mins) and in 30 of 31 (97%) with immediate stent implantation (P = 0.0001). Of the 35 patients in whom the perfusion balloon was unsuccessful secondary stenting was attempted in 27, with angiographic success in 24 (89%). Stent thrombosis occurred in four (13%) of the immediate stent group and in three (13%) of the secondary stent group. Acute ischemia compatible with vessel occlusion occurred in one (4%) of the perfusion balloon alone group following an initially successful result. One month following the procedure, 23 (72%) of the patients treated with perfusion balloon alone, 26 (84%) of the immediate stent group and 21 (78%) of the secondary stent group had a successful outcome and were free from major complications.CONCLUSION:Immediate stent implantation and the staged approach of prolonged inflation with a perfusion balloon followed by secondary stent implantation if prolonged inflation was unsuccessful yielded similar results.

Background: Restenosis is the main limitation of long-term success after coronary angioplasty Intracoronary stent implantation may reduce restenosis by producing a larger initial lumen and eliminating recoil. The objective of this study was to determine the frequency of and features associated with restenosis after elective single Palmaz-Schatz stent implantation in de-novo lesions in native vessels. Methods Eighty consecutive patients were studied. Angiographic follow-up was performed in 79 out of 80 (99%) 6.5 $$ 3.4 months after the procedure. Angiographic measurements were performed using an automated computerized quantitative angiographic analysis system. Results: Restenosis ($$50% stenosis) at follow-up occurred in 26 out of 79 patients (33%). The frequency of complex lesion morphology was higher (50% versus 19% American College of Cardiology/American Heart Association classification B2; P= 0.005). the reference vessel diameter larger (3.0$$0.5 mm versus 2.8 $$0.6 mm, P=0.049), and the lesion length longer (10.9$$3.5mm versus 8.5$$3.5mm. P=0.009) in the restenosis group compared with the non-restenosis group. The population was divided into three groups according to the reference vessel diameter: (1) greater than 3.0mm (n = 27), (2) 2.5–3.0mm (n = 29), and (3) less than 2.5mm (n = 22). One patient was excluded from this subgroup analysis because of difficulty in determining the reference vessel diameter before the procedure. The restenosis rates were 52%. 37%. and 11%. respectively, for the three groups (P=0.02). The relative acute gain was greater in the smaller vessels. (0.66 in the < 2.5 mm vessels. 0.53 in the 2.5–3.0 mm vessels, and 0.48 in the > 3.0 mm vessels; P- 0.006). This was associated with a relative oversizmg of the final stent balloon in the smaller vessels (balloon-to-vessel ratio of 1.33 in the vessels < 2.5 mm diameter, 1.16 in the 2.5–3.0 mm vessels, and 0.98 in the > 3.0mm vessels; P= 0.001). Conclusion: The frequency of restenosis in single electively implanted Palmaz-Schatz stents in de-novo lesions in native vessels was 33%. The degree of restenosis was lower in smaller vessels, in which a better initial result was associated with relative oversizmg of the final stent balloon. More aggressive dilation within the stented segment may result in a lower restenosis rate.

BACKGROUND Observational studies have suggested that prolonged balloon inflation during coronary angioplasty is associated with a high clinical success rate. This randomized clinical trial sought to evaluate the impact of primary gradual and prolonged inflations versus standard short dilatations in patients undergoing elective angioplasty. METHODS AND RESULTS In phase 1 of the study, patients were randomized to receive two to four standard (1 minute) dilatations or one or two prolonged (15 minutes) dilatations after a perfusion balloon had been placed across a single target lesion. Patients with unsuccessful angiographic appearance after phase 1 dilatations had further dilatations in phase 2. Patients were followed for 6 to 12 months after the procedure. Of 478 patients, 242 received a median of one prolonged dilatation of 15 minutes' duration, and 236 received three dilatations for a median of 1 minute. Patients assigned to prolonged dilatations had a higher success rate (< or = 50% residual visual stenosis) (95% versus 89%; P = .016), less severe residual stenosis by quantitative angiography (median [25th and 75th percentiles], 35% [26%, 42%] versus 38% [30%, 46%]; P = .001), and a lower rate of major dissections (3% versus 9%; P = .003) at the end of phase 1. A total of 114 patients had further dilatations in phase 2-43 in the prolonged arm and 71 in the standard arm. The final procedural success rate was 98% with both primary dilatation strategies, which included additional maneuvers such as prolonged dilatations in the patients randomized to the primary standard dilatation. Overall, 320 of 416 patients (77%) who were discharged after a successful procedure without any in-hospital event (death, myocardial infarction, coronary artery bypass graft surgery, abrupt closure, or repeat angioplasty in target vessel) returned for follow-up angiography. The restenosis rate (> 50% residual visual stenosis) was 44% (95% confidence interval, 37% to 52%) in the prolonged dilatation group and 44% (36% to 52%) in the standard dilatation group. The primary angiographic end point of failure at the end of phase 1, abrupt closure, or restenosis throughout the study period was similar in both groups (prolonged, 51%; standard, 49%; P = .62). The secondary end point of absence of clinical events (death, nonfatal myocardial infarction, coronary artery bypass graft surgery, or repeat angioplasty in target vessel) also was similar (prolonged, 66%; standard, 74%; P = .15). CONCLUSIONS Primary gradual and prolonged dilatations caused less arterial trauma with a modestly larger arterial lumen compared with standard dilatations. This initial improvement in angiographic appearance did not lead to a significant reduction in restenosis or clinical adverse events during follow-up.

Prolonged inflation with perfusion balloons is commonly used in failed angioplasty. The objective of this study was to determine the angiographic outcome of 59 consecutive patients treated with prolonged inflation with perfusion balloons as the primary treatment for failed angioplasty. Angiographic success (< 50% stenosis and normal flow) was achieved in 41%. Angiographic success was greater in the left anterior descending coronary artery (67% versus 33% for non-left anterior descending involvement, P = .044) and was less in complex dissections (25% versus 75% for no dissection or simple dissections, P = .025). Angiographic deterioration occurred in 37.5% of the successful group and 77% of the unsuccessful group (P = .002) and was more frequent in the right coronary artery (88% versus 50% for non-right coronary involvement, P = .007) and complex dissections (92% versus 38% for no dissection or simple dissections, P = .0001). Thus, in a group of patients with unsuccessful outcome following conventional balloon angioplasty, success with the perfusion balloon was modest. Furthermore, angiographic deterioration was frequently observed following unsuccessful prolonged inflation.

The results of Palmaz-Schatz stent implantation in failed angioplasty in 60 consecutive patients were compared with those of elective stent implantation in 100 consecutive patients. Stent implantation was successful in all of the failed group and in 99% of the elective. Stent thrombosis occurred in 16.7% of the failed group and 2% of the elective (p = 0.001). In the failed angioplasty group, stent thrombosis was associated with a greater frequency of preprocedure complex morphology (40% vs 12% in the nonthrombosis group, p = 0.05), persistent uncovered dissection after stenting (60% vs 14%, p = 0.004), and greater residual stenosis (39.9% ± 25.3% vs 24.9% ± 13.08%, p = 0.008) after stenting. Vessel patency was reestablished by angioplasty in 5 of 10 with stent thrombosis. Of these 5 patients, however, 2 suffered repeat stent thrombosis; 1 died suddenly four months later; and restenosis occurred in the remaining 2. Follow-up angiography was performed in 98% of the elective group at 6.3 ± 2.6 months and 96% of the failed angioplasty group at 6.4 ± 2.1 months. Restenosis (≥50% stenosis) occurred in 32% of the elective group and 50% of the failed angioplasty group (p = 0.041). Multiple logistic regression analysis identified multiple stent implantation (F = 6.75, p = 0.01) and triple-vessel disease (F = 3.46, p = 0.06) as independent positive predictors of restenosis. In conclusion, stent implantation in cases of failed angioplasty could be performed with a success similar to that of elective stent implantation but was associated with a greater frequency of stent thrombosis and restenosis.

We report the immediate safety, efficacy, and 6-month angiographic follow-up after elective implantation of the Palmaz-Schatz stent (Johnson & Johnson Interventional Systems, Warren, N.J.) in the first 100 consecutive patients at a single center. Patients with suitable cardiac anatomy and no contraindications to anticoagulation were prospectively entered into the study. One hundred two stents were successfully implanted in 99 patients. The mean diameter stenosis was 70% ± 11% before implantation and was reduced to 20% ± 11% after stent implantation. There were no deaths, Q-wave myocardial infarcts, urgent bypass operations, or strokes during the procedure or follow-up period. Stent thrombosis occurred in two patients; in both vessel patency was successfully accomplished by ballon angioplasty. There were three gastrointestinal hemorrhages, two of which required transfusion. Angiographic follow-up was performed in 98% of patients at 6.3 ± 2.6 months after the procedure. Restenosis (≥50% stenosis within or immediately adjacent to the stent) occurred in 32%. Stent restenosis was associated with male sex (36% vs 7% for female subjects; p = 0.03) and stent implantation in a restenosis lesion (47% vs 25% for de novo lesions; p = 0.03); it was inversely associated with current cigarette smoking (0% vs 36% for nonsmokers; p = 0.02). In conclusion, the Palmaz-Schatz stent can be electively implanted with high success and low complication rates. The restenosis rate appears to be similar to that of balloon angioplasty.

Attempted coronary angioplasty of a right coronary artery sub-total occlusion was unsuccessful due to failure to cross the lesion with the dilatation catheter. Both fixed-wire and over-the-wire systems were tried. Coronary rotational ablation was successful in reducing the stenosis and allowing successful angioplasty.

Angioplasty of right internal mammary artery grafts may present problems because of the variable origin of the mammary artery and its angulation from the subclavian artery. We report a case of successful angioplasty using a custom designed guide catheter, after failed attempts using conventional guide catheters.

Abrupt closure of a dominant right coronary artery occurred in a patient 1 h post coronary angioplasty. Angiography revealed a long spiral dissection involving the mid to distal segment of the right coronary artery. Four intracoronary balloon expandable stents were deployed to 'tack up' the dissection and recanalize the occluded artery. Six month follow-up angiography revealed continued patency of the stented segment. Balloon expandable stents may be an effective alternative to coronary bypass surgery in the treatment of acute closure following coronary angioplasty.

With the number of outpatient cardiac catheterizations increasing, much attention has recently been focused on the use of 5 French catheters for cardiac catheterization and selective coronary angiography. However, there are few reports in the literature regarding the technical aspects of their use or the quality of cineangiograms obtained. We reviewed our experience with these catheters in our first 100 consecutive cases. All cineangiograms were diagnostic, though 9% were deemed only of fair quality (incomplete luminal filling in some frames) by two experienced observers. Technical problems encountered with the use of these catheters included instability of the right Judkin's catheter in the right coronary ostium owing to high torquability, streaming of contrast during left coronary injections, and difficulty entering the left ventricle with a pig-tail catheter.