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Disrupted coronary artery caused by angioplasty: supportive and surgical considerations
S J Phillips1, C Kongtahworn, R H Zeff
1Department of Cardiovascular Medicine and Surgery, Mercy Hospital Medical Center, Des Moines, Iowa.
Insights
Emergency coronary artery bypass grafting after percutaneous transluminal coronary angioplasty is a rare but serious complication. Careful management of coronary artery dissection and hemorrhage is crucial for patient outcomes.
Area of Science:
- Cardiology
- Cardiac Surgery
- Interventional Cardiology
Background:
- Percutaneous transluminal coronary angioplasty (PTCA) is a common procedure for coronary artery disease.
- Complications can necessitate emergency coronary artery bypass grafting (CABG).
Purpose of the Study:
- To review outcomes of patients requiring emergency CABG after PTCA.
- To identify factors influencing outcomes in these high-risk patients.
Main Methods:
- Retrospective review of 201 patients undergoing emergency CABG post-PTCA between 1979 and 1986.
- Patients were categorized into two groups: failed elective PTCA and PTCA during evolving myocardial infarction.
- Analysis of angiographic findings, procedural details, and patient outcomes.
Main Results:
- Overall emergency CABG rate post-PTCA was 7%.
- Group 1 (failed elective PTCA): 126 patients, 2.4% mortality, 20% experienced epicardial hemorrhage.
- Group 2 (PTCA during myocardial infarction): 75 patients, 4% mortality, all had myocardial injury.
- A steady decline in emergency CABG rates to <5% was observed by 1986.
Conclusions:
- Emergency CABG after PTCA is associated with significant mortality and morbidity.
- Management of coronary artery dissection and hemorrhage is critical.
- Improvements in PTCA techniques and support may have contributed to declining rates.
Abstract:
Of 2,859 patients having percutaneous transluminal coronary angioplasty, 201 (7%) underwent emergency coronary artery bypass grafting. Two categories of patients were reviewed. Group 1 consisted of 126 patients of 2,304 who had immediate coronary artery bypass grafting after failed elective percutaneous transluminal coronary angioplasty. Ninety-eight of these patients had angiographic evidence of occlusion of a coronary artery, and 28 had angiographic evidence of coronary artery dissection. Epicardial hemorrhage was observed at operation in 20% (25 patients). Three deaths (2.4%) occurred in group 1, and an average of 3.3 grafts was performed per patient. Group 2 comprised 75 of 555 patients who had unsuccessful attempted percutaneous transluminal coronary angioplasty during an evolving myocardial infarction and required immediate coronary artery bypass grafting. Angiography revealed coronary artery occlusion in 61 patients with dissection in 14. All group 2 patients had evidence of myocardial injury by electrocardiographic and enzymatic (myocardial-specific isoenzyme of creatine kinase) criteria. Three deaths (4%) occurred in this group, and there was an average of 3.4 grafts per patient. Percutaneous transluminal coronary angioplasty is routinely performed without surgical consultation, although an operating room and team are usually available. Supportive techniques include the intraaortic balloon pump and percutaneous cardiopulmonary bypass. In those patients with coronary artery dissection, care must be taken to reestablish the true lumen of the coronary artery. Hemopericardium should be surgically explored and broken guidewires or other foreign bodies or debris removed. From 1979 through 1986, the number of patients requiring emergency coronary artery bypass grafting after percutaneous transluminal coronary angioplasty steadily declined to less than 5%.