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Will emergency coronary bypass grafting after failed elective percutaneous transluminal coronary angioplasty prevent
U Tebbe1, W Ruschewski, W Knake
1Department of Cardiology, University of Göttingen, FRG.
Insights
Emergency bypass surgery after percutaneous transluminal coronary angioplasty (PTCA) complications is crucial. Early surgery improves outcomes, while later surgery increases risks, highlighting the importance of timely intervention for acute myocardial ischemia.
Area of Science:
- Cardiology
- Vascular Surgery
Background:
- Acute myocardial ischemia can occur as a complication of percutaneous transluminal coronary angioplasty (PTCA).
- Prompt revascularization is critical for managing these complications and improving patient outcomes.
Purpose of the Study:
- To evaluate the outcomes of emergency aorto-coronary bypass grafting (ACBG) following acute myocardial ischemia after PTCA.
- To determine the optimal timing and strategy for managing PTCA-induced complications.
Main Methods:
- Retrospective analysis of 950 patients undergoing elective PTCA.
- Identification of 34 patients (3.6%) who required emergency ACBG within 12 hours of acute myocardial ischemia.
- Comparison of outcomes between early and late surgical interventions.
Main Results:
- Eight point eight percent (8.8%) of patients undergoing emergency ACBG died postoperatively from cardiogenic shock.
- Half of the surviving patients developed Q-wave (transmural) infarction, while the other half did not.
- Adequate residual perfusion was associated with non-Q-wave infarction in surviving patients.
Conclusions:
- Early ACBG is recommended for PTCA complications occurring in the catheterization lab, provided reperfusion cannot be reliably assured by other methods.
- Repeat PTCA may be preferable for complications arising later (hours post-procedure) in the intensive care unit, as surgery at this stage increases risks without preventing infarction.
Abstract:
An emergency aorto-coronary bypass grafting operation was performed within 12 hours after the development of acute myocardial ischemia due to partial or complete vascular occlusion in 34 of 950 (3.6%) patients who had received elective percutaneous transluminal coronary angioplasty (PTCA). Of the 34 patients, three (= 8.8%) died postoperatively in irreversible cardiogenic shock. Half of the surviving patients developed a Q-wave infarction after the operation, whereas the other half remained without transmural infarct. With comparable clinical data and times of operation up to placement of the aorto-coronary bypass vessel, an adequate residual perfusion must still have been present in the cases with non Q-wave infarction. Since in many cases a myocardial necrosis is unavoidable despite relatively early operative revascularization, the decisive role will be played by the remaining perfusion of the vessel concerned and any collaterals. It follows that treatment of an early PTCA complication, occurring in the catheter laboratory, ought to be the earliest possible aorto-coronary bypass operation unless available cardiological methods can reliably assure reperfusion. Treatment of a PTCA complication occurring later, however, e.g. after hours in the intensive-care unit, should be a repeat PTCA attempt: surgery at this stage will not prevent the transmural infarction but will increase risk of lethal complications.