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Coronary thrombi increase PTCA risk. Angioscopy as a clinical tool
C J White1, S R Ramee, T J Collins
1Department of Internal Medicine, Ochsner Clinic, New Orleans, La, USA.
Insights
Coronary angioscopy detects more intracoronary thrombi than angiography, and these thrombi are linked to worse outcomes after angioplasty. Angiography misses many thrombi, underestimating the risk of complications during coronary interventions.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Intracoronary thrombus presence is variably linked to post-coronary angioplasty complications.
- Angiography is less sensitive than angioscopy for detecting intracoronary thrombi.
- The clinical significance of thrombi detected by angioscopy but missed by angiography remains unclear.
Purpose of the Study:
- To compare the detection rates of intracoronary thrombi using angioscopy versus angiography.
- To investigate the association between angioscopically detected thrombi and adverse outcomes following percutaneous coronary angioplasty (PTCA).
Main Methods:
- 122 patients undergoing PTCA were studied using percutaneous coronary angioscopy.
- Angioscopic findings were compared with angiographic results for thrombus detection.
- In-hospital complications and recurrent ischemic events were recorded and analyzed in relation to thrombus presence.
Main Results:
- Coronary thrombi were identified in 61% of lesions by angioscopy versus only 20% by angiography.
- Patients with angioscopic thrombi experienced significantly higher rates of major in-hospital complications (14% vs 2%) and recurrent ischemia (26% vs 10%).
- Angioscopic thrombus presence strongly predicted adverse outcomes (RR 3.11), while angiographic thrombi did not (RR 0.85).
Conclusions:
- Angiography significantly underestimates the prevalence of intracoronary thrombus.
- Thrombi visualized by angioscopy, often missed by angiography, are associated with increased adverse outcomes after coronary angioplasty.
Background:
The presence of angiographically identified intracoronary thrombus has been variably associated with complications after coronary angioplasty. Angiography has been shown to be less sensitive than angioscopy for detecting subtle details of intracoronary morphology, such as intracoronary thrombi. The clinical importance of thrombi detectable by angioscopy but not by angiography is not known.
Methods And Results:
Percutaneous coronary angioscopy was performed in 122 patients undergoing conventional coronary balloon angioplasty (PTCA) at six medical centers. Unstable angina was present in 95 patients (78%) and stable angina in 27 (22%). Therapy was not guided by angioscopic findings, and no patient received thrombolytic therapy as an adjunct to angioplasty. Coronary thrombi were identified in 74 target lesions (61%) by angioscopy versus only 24 (20%) by angiography. A major in-hospital complication (death, myocardial infarction, or emergency bypass surgery) occurred in 10 of 74 patients (14%) with angioscopic intracoronary thrombus, compared with only 1 of 48 patients (2%) without thrombi (P = .03). In-hospital recurrent ischemia (recurrent angina, repeat PTCA, or abrupt occlusion) occurred in 19 of 74 patients (26%) with angioscopic intracoronary thrombi versus only 5 of 48 (10%) without thrombi (P = .03). Relative risk analysis demonstrated that angioscopic thrombus was strongly associated with adverse outcomes (either a major complication or a recurrent ischemic event) after PTCA (relative risk, 3.11; 95% CI, 1.28 to 7.60; P = .01) and that angiographic thrombi were not associated with these complications (relative risk, 0.85; 95% CI, 0.36 to 2.00; P = .91).
Conclusions:
The presence of intracoronary thrombus associated with coronary stenoses is significantly underestimated by angiography. Angioscopic intracoronary thrombi, the majority of which were not detected by angiography, are associated with an increased incidence of adverse outcomes after coronary angioplasty.