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Balloon dilatation of symptomatic subacute intimal dissection presenting as restenosis
H D Noveck1, L W Klein, B Kramer
1Northwestern Memorial Hospital, Chicago, Illinois 60611.
Insights
Repeat percutaneous transluminal coronary angioplasty (PTCA) is a viable option for subacute intimal dissections causing recurrent chest pain. Success is higher in patients without persistent contrast staining after initial PTCA.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Subacute intimal dissections after initial percutaneous transluminal coronary angioplasty (PTCA) can lead to recurrent symptoms.
- Fear of complications like extension and abrupt closure often limits repeat PTCA procedures.
Purpose of the Study:
- To evaluate the safety and efficacy of repeat PTCA in patients with subacute intimal dissections presenting with recurrent chest pain.
- To identify predictors of success for repeat PTCA in this patient cohort.
Main Methods:
- Retrospective review of patients with intimal dissections (staining or flap) after initial PTCA who presented with recurrent chest pain.
- Repeat angiography to confirm dissection as the cause of luminal compromise.
- Analysis of repeat PTCA outcomes based on dissection characteristics (contrast staining, intimal flap, extent).
Main Results:
- Twenty-two patients were identified with intimal dissections causing recurrent symptoms; 17 underwent repeat PTCA.
- Overall success rate for repeat PTCA was 76% (13 out of 17 patients).
- Patients with a frank intimal flap but no persistent contrast staining (Group 1) had a significantly higher success rate (10/10) compared to those with both staining and a flap (Group 2) (3/7, p=0.01).
Conclusions:
- Repeat PTCA is a feasible and potentially successful treatment for selected patients with subacute intimal dissections causing restenosis.
- Persistent contrast staining and significant luminal compromise by dissection are associated with poorer outcomes after repeat PTCA.
Abstract:
Repeat percutaneous transluminal coronary angioplasty (PTCA) for subacute intimal dissections that produce symptoms after a period of 1 month or more is reluctantly performed for fear of extension and abrupt closure. Patients were identified with demonstrated intimal dissections (intimal contrast staining or frank intimal flap) at the time of initial PTCA who returned a mean of 17.5 weeks (range 9 to 50) later with recurrent chest pain. Repeat angiography revealed luminal compromise due to dissection rather than restenosis in 22 patients. Of these, 17 underwent repeat PTCA. Elective bypass surgery without attempted PTCA was chosen in the other 5 patients because of extensive intimal dissections (greater than 2 balloon lengths) or involvement of critical branches. In the group of 17 patients who had repeat PTCA, 10 (group 1) had a frank intimal flap without persistent contrast staining after the initial PTCA, while 7 (group 2) had both persistent staining and a flap. Successful PTCA was performed in 13 of these 17 patients (76%). There were 2 abrupt closures and 2 unsatisfactory luminal openings. One of these patients required urgent coronary bypass surgery. All 10 group 1 patients had successful repeat procedures versus only 3 of 7 group 2 patients (p = 0.01). The 3 patients with the greatest degree of luminal compromise immediately after the initial PTCA had failed repeat PTCA attempts. These results suggest that repeat PTCA for subacute intimal dissections presenting as restenosis can be successfully performed in selected patients, and that the presence of contrast staining and the degree of luminal compromise by the dissection may be predictive of outcome.