RESUMEN
OBJECTIVES: This multicenter study sought to evaluate the short-term efficacy and safety of prolonged, low dose, direct urokinase infusion in recanalization of chronically occluded saphenous vein bypass grafts in a large sample of patients, as well as to determine the 6-month patency rates for this procedure. BACKGROUND: Patients with chronically occluded aortocoronary vein grafts and uncontrolled angina pectoris have limited options for therapy. Previous work has shown that chronically occluded vein grafts can be recanalized by thrombolysis. METHODS: A coaxial infusion of urokinase (100,000 U/h) was given directly into occluded vein grafts in 107 patients. Balloon angioplasty was performed after lysis was achieved. Patients were discharged with warfarin and aspirin therapy. Six-month clinical follow-up data were obtained, and repeat angiography was encouraged. RESULTS: Initial patency was achieved in 74 patients (69%). Mean duration of infusion was 25.4 h, and mean urokinase dosage was 3.70 million U. Acute adverse events included acute myocardial infarction in 5 patients (5%), enzyme level elevation in 18 (17%), emergency coronary artery bypass graft surgery in 4 (4%), stroke in 3 (3%) and death in 7 (6.5%). Recanalization was unsuccessful in all seven patients who died. Six-month follow-up angiograms were obtained for 40 patients (54%), 16 of whom maintained a patent graft (40%). Angina was present in 13 patients with successful (22%) and 12 with unsuccessful (71%) recanalization at 6-month follow-up. CONCLUSIONS: Chronically occluded aortocoronary vein grafts can be recanalized in approximately 70% of appropriately selected patients. Complications are similar to those observed with repeat operations. Clinical follow-up shows an improvement in angina. This procedure is intended for patients with only one occluded vein graft. Strict adherence to the protocol will improve patency and reduce complications.
Asunto(s)
Puente de Arteria Coronaria , Oclusión de Injerto Vascular/tratamiento farmacológico , Activadores Plasminogénicos/administración & dosificación , Vena Safena/trasplante , Activador de Plasminógeno de Tipo Uroquinasa/administración & dosificación , Grado de Desobstrucción Vascular/efectos de los fármacos , Angioplastia Coronaria con Balón , Causas de Muerte , Trastornos Cerebrovasculares/etiología , Angiografía Coronaria , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/complicaciones , Oclusión de Injerto Vascular/mortalidad , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/etiología , Cooperación del Paciente , Recurrencia , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
This report describes a single site experience as part of a multicenter clinical trial with high-speed rotational atherectomy in human coronary arteries. A total of 108 patients with 143 lesions had interventions, were grouped by success or failure, and were analyzed by patient, lesion, and procedural variables. Satisfactory results were achieved in 131 of 143 lesions (92%) and 99 of 108 (92%) patients. Neither patient-related variables (age, gender, diabetes, hypertension, cigarette use, restenosis, previous myocardial infarction, and left ventricular function) nor lesion characteristics (length, ostial or bifurcation location, calcification, lesion classification, and coronary location) were predictive of poor outcome. Tears, acute closure, percentage stenosis after rotational atherectomy and after adjunctive balloon angioplasty were the procedural variables that were statistically associated with outcome by univariate methods. Multivariate analysis isolated postintervention residual stenosis as the only variable that was statistically different between groups. Serious complications included one death in the catheterization laboratory, one Q-wave myocardial infarction, three non-Q myocardial infarctions, and three emergency coronary bypass operations for sustained vessel closure. One patient required emergency surgery for a pacing wire perforation not related to the use of the device. The potential benefits of high-speed rotational atherectomy include increased safety in complex lesions, the ability to address lesions not amenable to balloon techniques, and the possibility of reducing the incidence of restenosis.
Asunto(s)
Aterectomía Coronaria/métodos , Angioplastia Coronaria con Balón , Arritmias Cardíacas/etiología , Aterectomía Coronaria/efectos adversos , Aterectomía Coronaria/instrumentación , Terapia Combinada , Enfermedad de la Arteria Coronaria/patología , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/terapia , Vasos Coronarios/lesiones , Vasos Coronarios/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etiología , Recurrencia , Rotación , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
We describe two cases of high speed rotational atherectomy performed in patients with anomalous coronary anatomy. These procedures are performed with standard equipment requiring no modifications using a percutaneous femoral approach. We feel these cases clearly illustrate the facile application of this new technology to unusual anatomical situations.