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Prolonged urokinase infusion for chronic total native coronary occlusions: clinical, angiographic, and treatment
1William Beaumont Hospital, Royal Oak, Michigan.
Insights
Prolonged urokinase infusion before angioplasty safely opens chronic coronary occlusions in about half of patients who previously failed intervention. This treatment improves coronary flow and is well-tolerated.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Chronic total coronary occlusions (CTO) pose a significant challenge in percutaneous coronary intervention.
- Standard angioplasty techniques often fail in CTO cases, necessitating alternative approaches.
Purpose of the Study:
- To evaluate the efficacy and safety of prolonged intracoronary urokinase infusion prior to angioplasty in patients with CTO.
- To assess urokinase's role as a prelude to intervention in complex coronary artery disease.
Main Methods:
- Twenty-five patients with CTO and ischemia underwent prolonged urokinase infusion (100,000-240,000 units/hr for 8-25 hrs).
- Infusion was delivered via SOS wire and guiding catheter, followed by attempted balloon angioplasty.
- Patients were screened for contraindications to lytic therapy.
Main Results:
- Mean urokinase infusion duration was 20.6 hours, with a slight drop in fibrinogen levels.
- Angiography showed improved coronary flow (TIMI-grade ≥1) in 28% of patients post-urokinase.
- Successful angioplasty was achieved in 52% of patients; complications included thrombus (20%) and dissection (32%).
- The procedure was well-tolerated with a low incidence of adverse events (chest pain, ECG changes, MI, bleeding).
Conclusions:
- Prolonged preangioplasty intracoronary urokinase infusion is a safe strategy for CTO.
- This approach can be successful in approximately half of patients with CTO who failed prior interventions.
- Urokinase infusion may improve outcomes in complex coronary interventions.
Abstract:
Prolonged intravascular infusion of urokinase has proven beneficial in reestablishing patency of chronically occluded peripheral arteries and saphenous vein grafts. This study was performed to assess the efficacy and safety of prolonged urokinase infusion as a prelude to angioplasty in chronically occluded native coronary arteries, that had failed standard angioplasty techniques. Twenty-five patients with objective evidence for ischemia in the distribution of a chronic coronary occlusion were referred for percutaneous intervention. Patients were assessed for any potential exclusions from lytic therapy. Urokinase infusion through both a SOS wire and a stable guiding catheter was continued at 100,000-240,000 units/hr for 8-25 hr; patients then underwent attempted balloon angioplasty. Mean duration of urokinase infusion was 20.6 +/- 7.7 hr (total dose 163,000 +/- 52,447 units/hr). Fibrinogen levels dropped slightly with this (300 +/- 129 to 203 +/- 81 mg/dl, P = 0.02). Angiography posturokinase showed improvement in 7 (28%) with regard to coronary flow (> or = 1 TIMI-grade). Angioplasty was successful in 13 (52%), with final angiographic result revealing thrombus in 5 (20%), or dissection 8 (32%). The infusions were well-tolerated with a low incidence of chest pain, 2 (8%) or ischemic ECG response, 2 (8%); myocardial infarction, 2 (8%); or significant bleeding 2 (8%). All patients survived the procedure, with a length-of-hospital stay = 5.1 +/- 4 days. Use of prolonged preangioplasty intracoronary urokinase infusion can be done safely with success in roughly one-half of patients with chronic total native coronary occlusions who have failed prior attempts at percutaneous intervention.(ABSTRACT TRUNCATED AT 250 WORDS)