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Coronary artery bypass for unsuccessful percutaneous transluminal coronary angioplasty
Insights
Coronary artery bypass after angioplasty failure led to significant complications and mortality, especially in unstable patients. Rapid extracorporeal circulation minimized adverse events, highlighting the importance of timely intervention.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Percutaneous transluminal coronary angioplasty (PTCA) is a common procedure for coronary artery disease.
- Angioplasty failure necessitates subsequent coronary artery bypass grafting (CABG).
Purpose of the Study:
- To evaluate the outcomes of patients requiring coronary artery bypass after PTCA failure.
- To compare outcomes between immediate, delayed, and urgent CABG following PTCA.
- To assess the impact of timing of extracorporeal circulation on outcomes in urgent CABG cases.
Main Methods:
- Retrospective analysis of 518 patients undergoing PTCA.
- Categorization of subsequent CABG into delayed, immediate, and urgent groups.
- Analysis of mortality, myocardial infarction, and other complications based on urgency and timing of intervention.
Main Results:
- 184 patients (35.5%) required CABG after PTCA failure.
- Urgent CABG was associated with higher mortality and myocardial complications, particularly in unstable patients.
- Rapid institution of extracorporeal circulation (within 25 minutes) in urgent cases completely avoided mortality and myocardial complications.
Conclusions:
- Coronary artery bypass following angioplasty failure carries significant risks, especially in unstable patients.
- Timely intervention with extracorporeal circulation is crucial for improving outcomes in urgent CABG cases.
- Outcomes of CABG after PTCA failure differ significantly compared to primary CABG procedures.
Abstract:
Of 518 consecutive patients undergoing percutaneous transluminal coronary angioplasty for 571 coronary lesions, 184 eventually underwent coronary artery bypass because of angioplasty failure. Delayed coronary bypass (1 week to 19 months) was done in 27 patients with no deaths. Immediate bypass was done in 87 patients with two deaths, both of which were caused by further dissection of the artery after angioplasty. Urgent bypass was required in 63 patients who were in unstable condition because of ischemia on the electrocardiogram (52 patients), unrelieved angina (57 patients), or hypotension (13 patients). There was one death in this group. In the remaining seven patients, urgent coronary bypass was done because of cardiac arrest (three deaths). Myocardial complications occurred in 23 of the 70 unstable patients, including the seven patients with cardiac arrest. There were only eight completed myocardial infarctions in the 70 unstable patients and a completed myocardial infarction rate of 11 of 184 (6.0%) overall. In the 10 patients in whom extracorporeal circulation was established within 25 minutes of myocardial insult, mortality and myocardial complications were completely avoided. The remaining patients in the urgent group were placed on cardiopulmonary bypass within 26 to 300 minutes (mean 82 minutes). Operative mortality (3.3%), completed myocardial infarction (6.0%), myocardial infarction in unstable patients (32.9%), postoperative hemorrhage (5.0%), and sternal problems (2.8%) were all significantly different from those in 3,500 consecutive coronary bypasses not following angioplasty, that were done in 1982.