Cholesterol embolism: an underdiagnosed clinical entity.
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Arteriosclerosis↗
Biomedical subjects
G DiSciascio
Publications and source records attributed to G DiSciascio.
Angiographic features of left main coronary artery aneurysms.
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Aged↗
Application of coronary angioplasty to the septal perforator arteries.
Significant coronary artery disease affecting the septal perforator arteries can cause anginal pain, rhythm disturbances, or septal infarction. However, since these vessels are usually inaccessible to coronary bypass surgery, there is a tendency among angiographers and angioplasters to overlook lesions of the septal perforator arteries. Our experience suggests that if medical treatment is not sufficient to treat clinical manifestations resulting from septal perforator disease, then coronary angioplasty can be considered a therapeutic alternative for revascularization. We herein present 11 patients who underwent coronary angioplasty of a major septal artery and discuss angiographic and technical aspects of the procedure.
Angina, Unstable↗
Late complications involving the ascending aorta after cardiac surgery: recognition and management.
Pseudoaneurysms and dissecting aneurysms of the ascending aorta after cardiac surgery are uncommon but important complications. Pseudoaneurysms, which result from extravasation of blood into the mediastinum, most commonly occur at the site of aortotomy or aortic cannulation. Infection may play an important role. Dissecting aneurysms after cardiac surgery usually occur at the site of aortic incision or cross clamping, especially in atherosclerotic aortas. Both conditions may be clinically silent but more frequently are seen with significant symptoms. Noninvasive techniques including CT scan, MRI, and echocardiography are very useful in the diagnosis of both complications, with contrast aortography remaining the definitive method. Surgical repair is necessary for dissecting aneurysms and for enlarging and symptomatic pseudoaneurysms, with improving morbidity and mortality.
Aged↗
Coronary collateral recruitment: functional significance and relation to rate of vessel closure.
Studies in animals and humans have demonstrated the anatomic presence and functional significance of coronary collaterals. The extent of collateralization varies among species and among individuals. Collateral vessels are usually adequate for preserving resting regional and global ventricular function in the face of coronary obstruction. During stress, however, collateral supply may be inadequate. Collateral development is a time-dependent process during both the initial occlusion and following transient reflow and reclosure. Therefore when a previously collateralized coronary occlusion is recanalized and then recloses, the extent of the resulting collateral recruitment will depend, at least in part, upon the period of reflow between the two occlusions. The longer the reflow period, the less enhanced will be the collateralization. This is illustrated in the cases presented and has also been demonstrated in animal studies. The exact mechanisms for this recurrent collateral recruitment need further study.
Adult↗
Isolated significant left main coronary artery stenosis: angiographic, hemodynamic, and clinical findings in 16 patients.
Among 21,545 adult patients who underwent consecutive coronary angiography, 16 (0.07%) were found during their coronary arteriography to have a significant isolated stenotic lesion (luminal diameter narrowing of 50% or more) located at the left main coronary artery. The remaining major epicardial coronary arteries and their branches were free of disease. A strong predilection for the isolated lesion to occur at the ostium of the left main artery was found (12 patients). The most common presenting symptom was angina of less than 4 weeks' duration, although one third of the group was asymptomatic. Resting electrocardiograms were normal in 12 patients, while three patients had T wave inversion and another had nonspecific ST-T changes. Eleven patients exhibited severe stenosis, with eight having 70% to 89% stenosis and three having 90% to 95% stenosis. Five patients had 50% to 69% stenosis. No significant differences were found between patients with angina and patients without angina with respect to age, left ventricular end-diastolic pressure, left ventricular ejection fraction, and mean percent stenosis of the obstructive lesion. Despite the severity and the crucial location of the obstructive lesion, most patients with an isolated, significant left main stenosis appear to have a preserved left ventricular ejection fraction, normal wall motion, and no significant alteration of the left ventricular end-diastolic pressure.
Adult↗
Intracoronary recombinant tissue-type plasminogen activator in unstable angina: a pilot angiographic study.
The effectiveness of intracoronary (IC) recombinant thromboplastin activator (rt-PA) was prospectively evaluated in seven patients with unstable angina and complex angiographic lesions or intracoronary filling defects (ICFD). There were four men and three women, with a mean age of 60 years. Three patients had multivessel disease and all patients had rest angina; none had evolving myocardial infarction. All patients were pretreated with aspirin and were given heparin. IC rt-PA was infused at the rate of 1 mg/min to a total of 50 mg, and angiographic changes were observed every 15 minutes. At 50 minutes, angiographic improvement was seen in two patients (28%), one of whom had complete and one of whom had partial resolution of ICFD. In two patients (28%) there was no change in the lesion, and three patients (42%) had worsening of the lesion appearance. In two of the latter, paradoxical closure was observed at the end of the infusion, and was treated successfully with ad hoc emergency angioplasty. This pilot study suggests that IC rt-PA at the dosage used may have variable effects on complex coronary lesions associated with unstable angina, and this may be of relevance in further trials evaluating IC thrombolysis in unstable coronary ischemic syndromes.
Angina, Unstable↗
Coronary angioplasty of diffuse coronary artery disease.
From January 1983 through December 1987, 98 patients underwent angioplasty of at least one diffusely diseased coronary artery. Diffuse coronary disease was described as: group I, narrowing greater than or equal to 50% that involved the entire vessel (40 patients), group II, long lesions greater than or equal to 2 cm in length (39 patients), group III, three or more lesions in the same vessel (19 patients). There were 65 men and 33 women, with a mean age of 60 years; 64 patients (65%) had unstable angina, 23 patients (23%) were diabetic, 31 (32%) had prior myocardial infarctions, and 12 had prior bypass surgery. Multivessel disease was present in 89% of patients. Angioplasty of only the diffusely diseased vessel was performed in 41 patients, and additional vessels were dilated in 57 patients. Overall, of 396 lesions (four per patient) and 197 vessels (two per patient) attempted, success was achieved in 382 lesions (96%) and 187 vessels (95%); angiographic success was achieved in 112 of 120 diffusely diseased vessels (93%). Clinical success was achieved in 91 patients (93%). The overall complication rate (death, myocardial infarction, urgent bypass surgery) was 8% (8 of 98): six patients (6%) had myocardial infarction (one Q wave, five non-Q wave), one patient (1%) had urgent bypass surgery, and two patients (2%) died (one during bypass surgery). The majority of complications (7 of 8 or 87%), including the two deaths, occurred in group I patients, with a 17.5% rate, versus 2.5% in group II and 0% in group III, p less than 0.002.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Absent left main coronary artery: angiographic findings in 83 patients with separate ostia of the left anterior descending and circumflex arteries at the left aortic sinus.
Among 20,332 adult patients who underwent consecutive cardiac catheterization and coronary arteriography, 83 (0.4%) were angiographically identified as having an absent left main coronary artery. The angiographic characteristics of this coronary anomaly include: (1) the presence of two well-separated coronary ostia at the left aortic sinus resulting in separate origin of the left anterior descending and circumflex arteries; (2) an increased incidence of left coronary dominance; (3) a higher (6%) than usual (0.5% to 1.5%) incidence of myocardial bridging; (4) lack of a high incidence of congenital heart anomalies; and (5) an incidence of atherosclerotic coronary artery disease similar to that of patients whose left main artery is intact. In 39% of the patients difficulties in selectively cannulating the separate ostium of the circumflex artery and adequately opacifying this vessel resulted in a need to change the diagnostic catheter size. Recognition of this coronary anomaly is needed to ensure accurate angiographic interpretation and is important for patients undergoing cardiac surgery to selectively perfuse these separate vessels during cardiopulmonary bypass.
Cardiac Catheterization↗
Determinants of 2-year outcome after coronary angioplasty in patients with multivessel disease on the basis of comprehensive preprocedural evaluation. Implications for patient selection. The Multivessel Angioplasty Prognosis Study Group.
BACKGROUND: To assess the likelihood of intermediate-term event-free survival (freedom from death, coronary artery bypass surgery, and myocardial infarction) in patients with multivessel coronary disease undergoing coronary angioplasty, 350 consecutive patients from four clinical sites were carefully evaluated and followed for 22 +/- 10 months. METHODS AND RESULTS: Eight clinical variables were evaluated at the clinical sites, and 23 angiographic variables describing the number, morphology, and topography of coronary stenoses were evaluated at a core angiographic laboratory. Most patients had Canadian Cardiovascular Society class III or IV angina (72%), two-vessel coronary disease (68%), and well-preserved left ventricular function (mean ejection fraction, 58 +/- 12%; range, 18-85%). Follow-up was complete in 99% of patients. At 2 years, event-free survival was 72%, overall survival was 96%, freedom from bypass surgery was 82%, and freedom from nonfatal myocardial infarction without surgery was 96%. Sequential Cox proportional hazards regression analyses allowing stepwise entry of variables prospectively coded as simple, as of intermediate complexity, or as complex found event-free survival to be independently predicted by low Canadian Cardiovascular Society angina class, no diabetes, no proximal left anterior descending stenoses, and the sum of stenosis simplified risk-territory scores of 15 or less. In the absence of class IV angina and these risk factors, 2-year event-free survival was 87% and overall survival was 100%. In the presence of two or more of these risk factors, event-free survival was less than 50%. CONCLUSIONS: Recognition of risk factors for poor long-term outcome in this setting may improve clinical decision making and provide a framework on which to base meaningful subgroup analyses in randomized trials assessing the efficacy of coronary angioplasty.
Angioplasty, Balloon, Coronary↗
Coronary angioplasty of anomalous coronary arteries: notes on technical aspects.
Five patients with significant atherosclerotic lesions of anomalous coronary arteries underwent coronary angioplasty of the anomalous vessel. Four patients had anomalous circumflex artery and 1 had an anomalous right coronary artery. Angiographic and clinical success was achieved in all 5 patients. To ensure adequate equipment selection special consideration should be given to angiographic characteristics of these vessels, such as the orifice configuration, exit angulation, the route the artery traverses and the location of the stenotic lesions. Major determinants for successful angioplasty in these patients are guiding catheter selection and advancement of the balloon catheter to the very proximal portion of the anomalous vessel to subsequently facilitate guide wire advancement. This data indicates that balloon angioplasty can be successfully utilized in patients with significant atherosclerotic disease of anomalous coronary arteries.
Aged↗
Angioplasty of a recently occluded coronary artery bypass graft.
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Aged↗
Clinical and angiographic recurrence following PTCA for nonacute total occlusions: comparison of one- versus five-minute inflations.
To assess potential efficacy of longer inflations to reduce restenosis, 49 patients with nonacute total occlusions were randomized into two groups after successful guide wire passage across the occlusive stenosis. Twenty-one group I patients had all inflations less than 1 minute, while 28 group II patients received at least one inflation of 5 minutes' duration. There was no significant difference between group I and group II patients in mean age (56 +/- 3 versus 57 +/- 2 years), percent male sex (76% versus 68%), or frequency of left anterior descending (LAD) percutaneous transluminal coronary angioplasty (PTCA) (33% versus 32%), p = NS for all. All lesions post PTCA were less than or equal to 50% stenosed and no patient had coronary artery bypass surgery (CABG). Mean post PTCA stenosis was 29 +/- 2% for group I versus 33 +/- 2% for group II, p = NS. Clinical follow-up was available for all patients 8 +/- 0.6 months after PTCA. Recurrent symptoms were present in 8 of 21 (38%) group I patients compared with 12 of 28 (43%) patients in group II, p = NS. Angiographic follow-up was available in 32 patients (65%), with confirmation of restenosis in seven (33%) group I patients and in 11 (39%) group II patients, p = NS. In conclusion, this prospective study suggests that recurrence rates following successful PTCA of nonacute total occlusions is not modified by 5-minute versus 1-minute inflations.
Angiography↗
Acute ventricular septal rupture: perspectives on the current role of ventriculography and coronary arteriography and their implication for surgical repair.
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Acute Disease↗
Multivessel coronary angioplasty early after acute myocardial infarction.
Coronary angioplasty has been applied in patients with recent myocardial infarction, but results of angioplasty of multiple vessels early after myocardial infarction in patients with severe multivessel disease have not been reported. Coronary angioplasty of multiple vessels was performed in 105 patients 0 to 15 days (mean 5 +/- 4) after recent myocardial infarction. There were 77 men (73%) and 28 women (27%), with a mean age of 57 years. All patients had severe multivessel disease, 68% with two vessel and 32% with three vessel disease. Twenty-eight patients (27%) had successful thrombolysis before angioplasty and 70 (67%) had postinfarction angina. Mean left ventricular ejection fraction was 58 +/- 10% and was less than 45% in 13 patients (12%). Angioplasty was attempted in 319 lesions (mean 3 lesions per patient, range 2 to 9) and 252 vessels (mean 2.4 vessels per patient, range 2 to 4), with success in 302 lesions (95%) and 237 vessels (94%); angioplasty was done in two stages in 59 patients (56%). Clinical success was achieved in 102 patients (97%). Complications included myocardial infarction in six patients (5.7%) (one Q wave, five non-Q wave), urgent bypass surgery in two (1.9%) and death in one (0.9%); overall, seven patients (7%) had a major complication. All patients had a follow-up duration greater than 1 year (mean 31 months, range 12 to 73). Clinical recurrence developed in 24 patients (23%), of whom 21 had repeat angioplasty, 1 had bypass surgery and 2 were managed medically. Ten patients (9.8%) had a late infarction and 5 (4.9%) died of cardiac death during the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)
Angioplasty, Balloon, Coronary↗
Coronary angioplasty in patients with severe left ventricular dysfunction.
The applications for coronary angioplasty have greatly expanded and the procedure is now increasingly used in complex and potentially high risk conditions. This report describes the short- and long-term effects of coronary angioplasty in 61 patients with severely depressed left ventricular function (ejection fraction less than or equal to 35%) with unstable or refractory anginal symptoms, or both, in whom revascularization was necessary despite increased risk. In a retrospective analysis of 1,260 patients undergoing angioplasty between January 1985 through December 1987, 61 had an ejection fraction less than or equal to 35%. The common clinical presentation was unstable angina (70%) with or without recent myocardial infarction. Mean left ventricular ejection fraction was 27 +/- 6%. Forty-five patients (74%) had multivessel disease. Clinical success after angioplasty was achieved in 55 patients (90%). Major complications (death, infarction and emergency bypass surgery) occurred in five patients (8.2%), with death in two (3.2%). During long-term (mean 21 +/- 11 months) follow-up study of the 55 patients with successful angioplasty, 13 (23%) died, including 3 of noncardiac causes, and 11 (20%) had clinically symptomatic recurrence. Continued clinical success was present in 39 patients (71%), of whom 28 (51%) were event-free patients and 11 (20%) had clinical recurrence; a successful second angioplasty procedure was performed in 9 because of restenosis. Thus, in patients with depressed left ventricular function, coronary angioplasty can be performed with a short-term success rate comparable to that of routine angioplasty or surgical procedures. However, acute complications are more frequent and the late mortality rate is higher than in patients with less depressed function.
Angina, Unstable↗
Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease. Implications for patient selection. Multivessel Angioplasty Prognosis Study Group.
To assess the likelihood of procedural success in patients with multivessel coronary disease undergoing percutaneous coronary angioplasty, 350 consecutive patients (1,100 stenoses) from four clinical sites were evaluated. Eighteen variables characterizing the severity and morphology of each stenosis and 18 patient-related variables were assessed at a core angiographic laboratory and at the clinical sites. Most patients had Canadian Cardiovascular Society class III or IV angina (72%) and two-vessel coronary disease (78%). Left ventricular function was generally well preserved (mean ejection fraction, 58 +/- 12%; range, 18-85%) and 1.9 +/- 1.0 stenoses per patient had attempted percutaneous coronary angioplasty. Procedural success (less than or equal to 50% final diameter stenosis in one or more stenoses and no major ischemic complications) was achieved in 290 patients (82.8%), and an additional nine patients (2.6%) had a reduction in diameter stenosis by 20% or more with a final diameter stenosis 51-60% and were without major complications. Major ischemic complications (death, myocardial infarction, or emergency bypass surgery) occurred in 30 patients (8.6%). In-hospital mortality was 1.1%. Stepwise regression analysis determined that a modified American College of Cardiology/American Heart Association Task Force (ACC/AHA) classification of the primary target stenosis (with type B prospectively divided into type B1 [one type B characteristic] and type B2 [greater than or equal to two type B characteristics]) and the presence of diabetes mellitus were the only variables independently predictive of procedural outcome (target stenosis modified ACC/AHA score; p less than 0.001 for both success and complications; diabetes mellitus: p = 0.003 for success and p = 0.016 for complications). Analysis of success and complications on a per stenosis dilated basis showed, for type A stenoses, a 92% success and a 2% complication rate; for type B1 stenoses, an 84% success and a 4% complication rate; for type B2 stenoses, a 76% success and a 10% complication rate; and for type C stenoses, a 61% success and a 21% complication rate. The subdivision into types B1 and B2 provided significantly more information in this clinically important intermediate risk group than did the standard ACC/AHA scheme. The stenosis characteristics of chronic total occlusion, high grade (80-99% diameter) stenosis, stenosis bend of more than 60 degrees, and excessive tortuosity were particularly predictive of adverse procedural outcome. This improved scheme may improve clinical decision making and provide a framework on which to base meaningful subgroup analysis in randomized trials assessing the efficacy of percutaneous coronary angioplasty.
Angiography↗
Coronary angioplasty of bifurcational stenoses: a new approach utilizing a single-guide, double-probe technique: case reports.
The authors describe a new approach to percutaneous transluminal coronary angioplasty (PTCA) of bifurcational lesions with a single-guide, "kissing balloon" technique, utilizing two probe dilatation systems, inserted simultaneously into the guiding catheter and across both diseased branches. The versatility of the probe dilatation system in complex angioplasty is portrayed, both for simultaneous or alternate balloon inflations, and the low-profile characteristics of the system are highlighted, which allow a double-probe introduction into a single guiding catheter, good visualization still being retained by guide injections.
Angioplasty, Balloon, Coronary↗