European Heart Journal (1992) 13, 1649-1657
Therapy for acute vascular complications in percutaneous transluminal coronary angioplasty with the autoperfusion balloon catheter * Department of Cardiology, ^Department of Thoracic and Cardiovascular Surgery, Heart Center North Rhine-Westphalia, University Hospital of the Ruhr University ofBochum, BadOeynhausen, Germany KEY WORDS: Acute vascular complications, PTCA, autoperfusion balloon catheter. Prolonged dilatation with an autoperfusion balloon catheter (APBC) (High-Flow-CPC-Mainz® (Schneider) in 23 cases and Stack Perfusion® (A CS) in 50 cases) was carried out in 73 patients (60 men, 13 women, mean age 59-3 ± 8-8 years) with acute vascular complications occurring during PTCA (25 occlusive dissections (34%), five thrombotic occlusions (7%) ,42 non-occlusive dissections (58%) and one non-occlusive thrombus with reduction offlow(1%)) in order to avoid stem implantation or emergency bypass surgery. On average l-5±0-8 inflations were carried out per patient with a mean maximum inflation time of 141 +8-4 min and a mean total inflation time of 16-8 ±12-3 min. In 61 patients (83-5%), the vascular complication could be controlled successfully with APBC, but in 12 APBC was not successful. Eight patients (11%) had emergency surgerv. A stent was implanted in three patients (4-1%), and one suffered an acute myocardial infarction. Out of the 61 patients with positive result after prolonged dilatation, the hospital phase was uncomplicated in 53 (86-9%), five (8-2%) suffered an infarct with a maximum rise in CKof350 U. l~', two with multivessel disease had elective operations and one was dilated a second time because of a subacute reocclusion. Our experience indicates that when an acute vascular complication occurs, prolonged dilatation with an A PBC is good interventional therapy avoiding stent implantation or emergency bypass surgery. However, new techniques cannot always replace surgery so an emergency bypass operation may still be necessary. Introduction
More than a decade after the introduction of percutaneous transluminal coronary angioplasty (PTCA) into coronary heart disease therapy1'-2', acute vascular occlusion due to dissection or a thrombus is still the most important complication. The incidence reported in the literature is 1-5% to 10% of dilatations'3"18'. In the early phase of PTCA, where an acute vascular occlusion occurred during angioplasty, emergency bypass was standard therapy to avoid acute myocardial infarction[3.4.7-i5.i8.i9]
A s
e a r ] y
a s
1 9 8 3 ) success
fu]
treatment
of an acute vascular occlusion by reintervention was reported'20'. The development of the long wire technique12'-22' enabled the exchange of balloon catheters with the guide wire left in the vessel, and was a prerequisite for using an autoperfusion catheter to maintain myocardial perfusion between failed PTCA and emergency bypass operation123-24'. Using the autoperfusion balloon catheter (APBC), prolonged balloon inflation is rendered possible and myocardial perfusion is maintained'25"29'. The object of prolonged dilatation is to attach the dissection membrane in an acute vascular occlusion during PTCA'30'. Acute vascular complications can also be treated successfully by implantation of an intravascular stent'3IJ2J3'. Here, the follow-up treatment required is Submitted for publication on 24 February 1992, and in revised form 8 July 1992. Correspondence. Hubert Seggewiss, MD, Department of Cardiology, Heart Center North Rhine-Westphalia, University Hospital of the Ruhr University ofBochum, Georgstr. 11, D-4970 Bad Oeynhausen, Germany. 0195-668X/92/121649 + 09 $08.00/0
more complicated and the incidence of late complications is high. Here we report on the experience and results of treating acute vascular complications during PTCA with APBC, particularly as regards avoiding emergency stent implantation and bypass operation. Patients and methods PATIENTS
Between September 1989 and May 1991, 2410 dilatations were carried out at the Department of Cardiology in the Heart Center North Rhine-Westphalia. The dilatations were carried out with surgical standby at the Department of Thoracic and Cardiovascular Surgery in the Heart Center North Rhine-Westphalia Heart Center. In 73 patients (30%), an APBC was inserted to repair an acute vascular complication. A review of the patients' basic data is given in Table 1. The mean age of the 73 patients (60 men (82%) and 13 women (18%)) was 59-3 ± 8-8 (range 33-79) years. Forty-three patients (59%) survived an acute infarct and in 10 (14%), a restenosis was dilated. Forty-three patients (59%) had single-vessel disease, 26 (36%) double-vessel disease and the remaining four patients (5%) triple-vessel disease. The left ventricular ejection fraction was, on average, 68 ± 12%. In 45 patients (62%), a stenosis of the left anterior descending (LAD) coronary and in six patients (8%) a stenosis of the left circumflex (CX) artery was dilated. A stenosis of the right © 1992 The European Society of Cardiology
Downloaded from https://academic.oup.com/eurheartj/article-abstract/13/12/1649/651318 by Western Sydney University Library user on 12 January 2019
H. SEGGEWISS*, U. GLEICHMANN*, D. FASSBENDER*, J. VOGT*, H. MANNEBACH* AND K. MrNAMif
1650 H. Seggewiss et al.
Table I Basic data of the 73 patients in whom a prolonged dilatation with APBC was carried out because of an acute vascular complication
Age (years) 59-3±8- 8
Women Previous infarction Re-PTCA Coronary artery disease Single-vessel disease Two-vessel disease Three-vessel disease Dilated vessels LAD CX RCA
Clinical indication for PTCA Stable angina Unstable angina Acute infarction Silent ischaemia Angiographic indication for APBC Non-occlusive dissection Occlusive dissection Non-occlusive thrombus Occlusive thrombus Prior dilatation procedure PTCA Recanalization CTO < 3 months Rotablator Acute occlusion ELCA LVEF(%)
%
60 13 43 10
82 18 59 14
43 26 4
59 36 5
45 6 22
62 8 72
52 12 6 3
72 16 8 4
42 25 1 5
58 34 1 7
62
85
3 1 5 2
4 I 7 3
68±12
PRIOR DILATATION TECHNIQUE
In 62 patients (85%), acute vascular complications occurred after dilatation of a single lesion. APBC was used in four patients (5%) after successful recanalization of a chronically occluded (less than 3 months) coronary artery. Three patients were first dilated with a standard balloon after successful passage of the occlusion with the guide wire. In the fourth patient, it was not possible to achieve passage of a balloon catheter after successful passage of the occlusion with the guide wire. The 0014 in High-Torque-Floppy Wire® (ACS) was exchanged for a 0009 in thick steel wire via an intervention catheter (SOS Intervention Catheter®, Cook). Afterwards, rotablation[33] was carried out with 1-5 mm and 2-15 mm burrs. Long-term dilatation was carried out with the APBC because of a pronounced dissection. In five patients, the APBC was carried out after successful recanalization of an acute vascular occlusion with subsequent reocclusion. Finally, an acute vascular occlusion, as a result of excimer laser angioplasty (ELCA), constituted the indication for prolonged dilatation with APBC in two patients (3%). DILATATION TECHNIQUE WITH THE APBC
The usual practice in our hospital is for PTCA to be carried out after premedication'351. On the evening before PTCA and on the morning of dilatation, the patients received 500 mg acetylsalicylic acid p.o. as well as 20 mg isosorbide mononitrate and 10 mg nifedipine p.o. coronary artery (RCA) was present in 22 patients (30%), Immediately before PTCA, the patients received 10 mg stable angina pectoris was a clinical indication for PTCA nifedipine p.o. and 0-8 mg glycerol nitrate s.l. as well as in 52 patients (72%), 12 patients (16%) had unstable 500 mg acetylsalicylic acid i.v. and 15 000IU heparin i.v. angina pectoris, six (8%) were dilated because of an acute Twenty-four hour follow-up observation was carried myocardial infarction, and a silent ischaemia led to out on the intensive care unit, during which time the i.v. angioplasty in three patients (4%). heparin was administered, so that the prothrombin time was prolonged two to three-fold. The introducing sheaths were removed after completion of heparin infusion. ANGIOGRAPHIC INDICATION FOR APBC The double-lumen APBC can be used with the usual Forty-two patients (58%) had pronounced dissection with reduction of flow but no complete occlusion of long wire technique. The High Flow CPC Mainz Ballon® the coronary vessel. An acute vascular occlusion due to (Schneider) has six side holes proximal and three side dissection was the reason for use of APBC in 25 patients holes distal to the balloon. The Stack Perfusion® catheter (34%), in four of whom the occlusion occurred in the first (ACS) has 10 side holes proximal and four side holes 6 h after PTCA during the surveillance phase on the inten- located distal to the balloon. The advantage of the High sive care unit. Five dissections were longer than 2 cm. An Flow CPC Mainz Ballon® is compatibility with the extensive thrombus with reduction of flow, but without standard 7 French guide catheter. vascular occlusion was present in one patient (1%). An Following the decision tocarry out prolonged dilatation acute thrombotic vascular occlusion was found in five with APBC after an acute complication, the stenosis or the patients (7%). In the patients with vascular complications occlusion must be crossed with a guide wire. If the wire was due to dissection, immediate emergency stenting would withdrawn after angioplasty with the standard balloon the also have been a possible alternative. lesion must be passed once again. When shorter guide CTO = chronic total occlusion, ELCA = excimer laser coronary angioplasty. For other abbreviations, see text.
Downloaded from https://academic.oup.com/eurheartj/article-abstract/13/12/1649/651318 by Western Sydney University Library user on 12 January 2019
Sex Men
n
APBC was unsuccessful in six patients, but without vascular complications in terms of pronounced dissection or thrombus formation after dilatation with a conventional balloon system. In four further patients, APBC was used primarily for dilatation of proximal recurrent stenosis of the LAD, since pronounced ischaemic reactions had occurred with the short dilatation times used in the first dilatation. These last 10 patients are not included in the study population, since APBC was not employed to treat acute vascular complication.
Therapy for acute vascular complications 1651
wires are used, these can be lengthened with a Doc-Wire® (ACS) in order to avoid withdrawal from the vessel. Afterwards, exact positioning of the APBC is carried out under fluoroscopic control. After maximum inflation of the balloon, the guide catheter is retracted first, followed by the guide wire up to the proximal side holes (Fig. 1). In this way, myocardial perfusion is made possible if the arterial pressure of the patient is adequate. The nominal diameter of the APBC is reached with an inflation pressure of 6 bar. A balloon pressure of 4 to 6 bar should not be exceeded in order to maintain an adequate perfusion. Manual flushing with heparin solution is carried out at intervals of 2 min to avoid formation of thrombi in the APBC. After completion of dilatation, the guide wire is initially advanced into the distal part of the dilated vessel. Afterwards, intubation of the coronary artery is carried out with the guide catheter. After deflation and removal of the APBC from the coronary artery, the result of dilatation is checked angiographically. If the result is inadequate, additional dilatation with APBC is possible.
mean PCW pressure > 5 mmHg compared to the time before PTCA and/or occurrence of angina pectoris symptoms during angioplasty was rated as ischaemia. A >20% stenosis reduction with subsequent residual stenosis of 0 0 5 mV, a rise in
Continuous variables are expressed as mean value ± standard deviations. The chi-square test was used to compare discrete variables and the t-test to compare continuous variables. A significant difference was assumed at />50% n=l
1654 H. Seggewiss et al.
Therapy for acute vascular complications in percutaneous transluminal coronary angioplasty with the autoperfusion balloon catheter * Department of Cardiology, ^Department of Thoracic and Cardiovascular Surgery, Heart Center North Rhine-Westphalia, University Hospital of the Ruhr University ofBochum, BadOeynhausen, Germany KEY WORDS: Acute vascular complications, PTCA, autoperfusion balloon catheter. Prolonged dilatation with an autoperfusion balloon catheter (APBC) (High-Flow-CPC-Mainz® (Schneider) in 23 cases and Stack Perfusion® (A CS) in 50 cases) was carried out in 73 patients (60 men, 13 women, mean age 59-3 ± 8-8 years) with acute vascular complications occurring during PTCA (25 occlusive dissections (34%), five thrombotic occlusions (7%) ,42 non-occlusive dissections (58%) and one non-occlusive thrombus with reduction offlow(1%)) in order to avoid stem implantation or emergency bypass surgery. On average l-5±0-8 inflations were carried out per patient with a mean maximum inflation time of 141 +8-4 min and a mean total inflation time of 16-8 ±12-3 min. In 61 patients (83-5%), the vascular complication could be controlled successfully with APBC, but in 12 APBC was not successful. Eight patients (11%) had emergency surgerv. A stent was implanted in three patients (4-1%), and one suffered an acute myocardial infarction. Out of the 61 patients with positive result after prolonged dilatation, the hospital phase was uncomplicated in 53 (86-9%), five (8-2%) suffered an infarct with a maximum rise in CKof350 U. l~', two with multivessel disease had elective operations and one was dilated a second time because of a subacute reocclusion. Our experience indicates that when an acute vascular complication occurs, prolonged dilatation with an A PBC is good interventional therapy avoiding stent implantation or emergency bypass surgery. However, new techniques cannot always replace surgery so an emergency bypass operation may still be necessary. Introduction
More than a decade after the introduction of percutaneous transluminal coronary angioplasty (PTCA) into coronary heart disease therapy1'-2', acute vascular occlusion due to dissection or a thrombus is still the most important complication. The incidence reported in the literature is 1-5% to 10% of dilatations'3"18'. In the early phase of PTCA, where an acute vascular occlusion occurred during angioplasty, emergency bypass was standard therapy to avoid acute myocardial infarction[3.4.7-i5.i8.i9]
A s
e a r ] y
a s
1 9 8 3 ) success
fu]
treatment
of an acute vascular occlusion by reintervention was reported'20'. The development of the long wire technique12'-22' enabled the exchange of balloon catheters with the guide wire left in the vessel, and was a prerequisite for using an autoperfusion catheter to maintain myocardial perfusion between failed PTCA and emergency bypass operation123-24'. Using the autoperfusion balloon catheter (APBC), prolonged balloon inflation is rendered possible and myocardial perfusion is maintained'25"29'. The object of prolonged dilatation is to attach the dissection membrane in an acute vascular occlusion during PTCA'30'. Acute vascular complications can also be treated successfully by implantation of an intravascular stent'3IJ2J3'. Here, the follow-up treatment required is Submitted for publication on 24 February 1992, and in revised form 8 July 1992. Correspondence. Hubert Seggewiss, MD, Department of Cardiology, Heart Center North Rhine-Westphalia, University Hospital of the Ruhr University ofBochum, Georgstr. 11, D-4970 Bad Oeynhausen, Germany. 0195-668X/92/121649 + 09 $08.00/0
more complicated and the incidence of late complications is high. Here we report on the experience and results of treating acute vascular complications during PTCA with APBC, particularly as regards avoiding emergency stent implantation and bypass operation. Patients and methods PATIENTS
Between September 1989 and May 1991, 2410 dilatations were carried out at the Department of Cardiology in the Heart Center North Rhine-Westphalia. The dilatations were carried out with surgical standby at the Department of Thoracic and Cardiovascular Surgery in the Heart Center North Rhine-Westphalia Heart Center. In 73 patients (30%), an APBC was inserted to repair an acute vascular complication. A review of the patients' basic data is given in Table 1. The mean age of the 73 patients (60 men (82%) and 13 women (18%)) was 59-3 ± 8-8 (range 33-79) years. Forty-three patients (59%) survived an acute infarct and in 10 (14%), a restenosis was dilated. Forty-three patients (59%) had single-vessel disease, 26 (36%) double-vessel disease and the remaining four patients (5%) triple-vessel disease. The left ventricular ejection fraction was, on average, 68 ± 12%. In 45 patients (62%), a stenosis of the left anterior descending (LAD) coronary and in six patients (8%) a stenosis of the left circumflex (CX) artery was dilated. A stenosis of the right © 1992 The European Society of Cardiology
Downloaded from https://academic.oup.com/eurheartj/article-abstract/13/12/1649/651318 by Western Sydney University Library user on 12 January 2019
H. SEGGEWISS*, U. GLEICHMANN*, D. FASSBENDER*, J. VOGT*, H. MANNEBACH* AND K. MrNAMif
1650 H. Seggewiss et al.
Table I Basic data of the 73 patients in whom a prolonged dilatation with APBC was carried out because of an acute vascular complication
Age (years) 59-3±8- 8
Women Previous infarction Re-PTCA Coronary artery disease Single-vessel disease Two-vessel disease Three-vessel disease Dilated vessels LAD CX RCA
Clinical indication for PTCA Stable angina Unstable angina Acute infarction Silent ischaemia Angiographic indication for APBC Non-occlusive dissection Occlusive dissection Non-occlusive thrombus Occlusive thrombus Prior dilatation procedure PTCA Recanalization CTO < 3 months Rotablator Acute occlusion ELCA LVEF(%)
%
60 13 43 10
82 18 59 14
43 26 4
59 36 5
45 6 22
62 8 72
52 12 6 3
72 16 8 4
42 25 1 5
58 34 1 7
62
85
3 1 5 2
4 I 7 3
68±12
PRIOR DILATATION TECHNIQUE
In 62 patients (85%), acute vascular complications occurred after dilatation of a single lesion. APBC was used in four patients (5%) after successful recanalization of a chronically occluded (less than 3 months) coronary artery. Three patients were first dilated with a standard balloon after successful passage of the occlusion with the guide wire. In the fourth patient, it was not possible to achieve passage of a balloon catheter after successful passage of the occlusion with the guide wire. The 0014 in High-Torque-Floppy Wire® (ACS) was exchanged for a 0009 in thick steel wire via an intervention catheter (SOS Intervention Catheter®, Cook). Afterwards, rotablation[33] was carried out with 1-5 mm and 2-15 mm burrs. Long-term dilatation was carried out with the APBC because of a pronounced dissection. In five patients, the APBC was carried out after successful recanalization of an acute vascular occlusion with subsequent reocclusion. Finally, an acute vascular occlusion, as a result of excimer laser angioplasty (ELCA), constituted the indication for prolonged dilatation with APBC in two patients (3%). DILATATION TECHNIQUE WITH THE APBC
The usual practice in our hospital is for PTCA to be carried out after premedication'351. On the evening before PTCA and on the morning of dilatation, the patients received 500 mg acetylsalicylic acid p.o. as well as 20 mg isosorbide mononitrate and 10 mg nifedipine p.o. coronary artery (RCA) was present in 22 patients (30%), Immediately before PTCA, the patients received 10 mg stable angina pectoris was a clinical indication for PTCA nifedipine p.o. and 0-8 mg glycerol nitrate s.l. as well as in 52 patients (72%), 12 patients (16%) had unstable 500 mg acetylsalicylic acid i.v. and 15 000IU heparin i.v. angina pectoris, six (8%) were dilated because of an acute Twenty-four hour follow-up observation was carried myocardial infarction, and a silent ischaemia led to out on the intensive care unit, during which time the i.v. angioplasty in three patients (4%). heparin was administered, so that the prothrombin time was prolonged two to three-fold. The introducing sheaths were removed after completion of heparin infusion. ANGIOGRAPHIC INDICATION FOR APBC The double-lumen APBC can be used with the usual Forty-two patients (58%) had pronounced dissection with reduction of flow but no complete occlusion of long wire technique. The High Flow CPC Mainz Ballon® the coronary vessel. An acute vascular occlusion due to (Schneider) has six side holes proximal and three side dissection was the reason for use of APBC in 25 patients holes distal to the balloon. The Stack Perfusion® catheter (34%), in four of whom the occlusion occurred in the first (ACS) has 10 side holes proximal and four side holes 6 h after PTCA during the surveillance phase on the inten- located distal to the balloon. The advantage of the High sive care unit. Five dissections were longer than 2 cm. An Flow CPC Mainz Ballon® is compatibility with the extensive thrombus with reduction of flow, but without standard 7 French guide catheter. vascular occlusion was present in one patient (1%). An Following the decision tocarry out prolonged dilatation acute thrombotic vascular occlusion was found in five with APBC after an acute complication, the stenosis or the patients (7%). In the patients with vascular complications occlusion must be crossed with a guide wire. If the wire was due to dissection, immediate emergency stenting would withdrawn after angioplasty with the standard balloon the also have been a possible alternative. lesion must be passed once again. When shorter guide CTO = chronic total occlusion, ELCA = excimer laser coronary angioplasty. For other abbreviations, see text.
Downloaded from https://academic.oup.com/eurheartj/article-abstract/13/12/1649/651318 by Western Sydney University Library user on 12 January 2019
Sex Men
n
APBC was unsuccessful in six patients, but without vascular complications in terms of pronounced dissection or thrombus formation after dilatation with a conventional balloon system. In four further patients, APBC was used primarily for dilatation of proximal recurrent stenosis of the LAD, since pronounced ischaemic reactions had occurred with the short dilatation times used in the first dilatation. These last 10 patients are not included in the study population, since APBC was not employed to treat acute vascular complication.
Therapy for acute vascular complications 1651
wires are used, these can be lengthened with a Doc-Wire® (ACS) in order to avoid withdrawal from the vessel. Afterwards, exact positioning of the APBC is carried out under fluoroscopic control. After maximum inflation of the balloon, the guide catheter is retracted first, followed by the guide wire up to the proximal side holes (Fig. 1). In this way, myocardial perfusion is made possible if the arterial pressure of the patient is adequate. The nominal diameter of the APBC is reached with an inflation pressure of 6 bar. A balloon pressure of 4 to 6 bar should not be exceeded in order to maintain an adequate perfusion. Manual flushing with heparin solution is carried out at intervals of 2 min to avoid formation of thrombi in the APBC. After completion of dilatation, the guide wire is initially advanced into the distal part of the dilated vessel. Afterwards, intubation of the coronary artery is carried out with the guide catheter. After deflation and removal of the APBC from the coronary artery, the result of dilatation is checked angiographically. If the result is inadequate, additional dilatation with APBC is possible.
mean PCW pressure > 5 mmHg compared to the time before PTCA and/or occurrence of angina pectoris symptoms during angioplasty was rated as ischaemia. A >20% stenosis reduction with subsequent residual stenosis of 0 0 5 mV, a rise in
Continuous variables are expressed as mean value ± standard deviations. The chi-square test was used to compare discrete variables and the t-test to compare continuous variables. A significant difference was assumed at />50% n=l
1654 H. Seggewiss et al.
