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Frequency of Success and Complications of Coronary Angioplasty of a Stenosis at the Ostium of a Branch Vessel. AJC 1991

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Irvin Goldenberg Frequency of Success and Complications of Coronary Angioplasty of a Stenosis at the Ostium of a Branch Vessel
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  Frequency of Success and Complications of Coronary Angioplasty of a Stenosis at the Ostium of a Branch Vessel David W. Mathias, MD, Jodi Fishman Mooney, RN, MS, Helmut W. Lange, MD, Irvin F. Goldenberg, MD, Fredarick L. Gobel, MD, and Michael R. Mooney, MD The authors of this study hypothesixod that percu- taneous transhuninal coronary angioptasty of a ste- nosis at the ostlum of a branch vessel, whether iso- lated or associated with a bifurcation stenosis, was associated wlth reduced procedural success and in- creased in-hospital compliitions. One hundred six patients with 119 ostial branch stenoses were com- parod with 1,166 patients who underwent angio- plasty of nonostial branch stenoses. An ostial branch stenosis was deftned as a stenosis in the proximal 3 mm of a major branch vessel (diagonal [n = 661, posterior descending [n = 211, obtuse marginal [n = 341 and intermediate [n = 61). The ostial branch stenosis was isolated in 61% of the patients and associated with a bifurcation stenosis in 39%. Despfte a balloon to artery ratio of 1.06~1, angiographic success was 74% of ostial branch stenoses versus 91% of nonostial stenoses (p x0.01). Furthermore, angioplasty of ostial branch stenoses resulted in a compliition rate of 13 ver- sus 5% for angloplasty of nonostial branch steno- ses(p <0.01).me dore, angioplasty of ostial branch &noses results in decreased procedural success and dgnificant reshlual stenosis despite adequate balloon sizing, suggesting arterial elastic recoil and a significant increase in compliitions. (Am JCardiol lSS1;67:491495) From the Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota. Manuscript received August 8, 1990; revised manuscript received October 25, 1990, and accepted October 26. Address for reprints: Michael R. Mooney, MD, Minneapolis Heart Institute, 920 East 28th Street, Suite 300, Minneapolis, Minnesota 55407. P rcutaneous angioplasty for ostial lesions in the right coronary artery,’ the left anterior descend- ing2 and renal arteries3 have been associated with low technical success ates and increased complications. We have found that coronary angioplasty for a stenosis at the ostium of a branch coronary artery can also pre- sent technical difficulties. We therefore reviewed our experience in this subgroup of patients and sought to determine if angioplasty of a stenosis at the ostium of a branch coronary artery, regardless of whether it repre- sented an isolated ostial branch stenosis or a bifurcation stenosis, was associated with increased procedural risks, poorer overall results, and more frequent in-hospital complications. Furthermore, although double-wire and double-balloon techniques used for bifurcation stenoses have been shown to preserve side branch patency,4-9 there is little information as to their effect on successful dilation or prevention of angioplasty-related complica- tions attributable to dilation of the ostial branch vessel. METHOD6 Patients: Between November 1987 and January 1989, 1,274 patients underwent percutaneous translu- minal coronary angioplasty (PTCA) at the Minneapolis Heart Institute, Abbott Northwestern Hospital. Of these 1,274 patients, 106 patients with 119 stenoses n- volving the ostium of a branch coronary vessel were retrospectively identified. All patients demonstrated a X0% reduction in percent diameter within 3 mm of the bifurcation of a large epicardial coronary artery. Isolat- ed ostial branch stenoses n = 65 patients) and bifurca- tion stenoses n = 41 patients) were included for analy- sis. Procedure: Angioplasty was performed using stan- dard techniques in all patients. All patients were pre- medicated with aspirin and a calcium antagonist. Angi- oplasty was performed after 110,000 units of intrave- nous heparin were administered to obtain an activated clotting time of >300 seconds. The femoral approach was used in nearly all patients. Identical angiographic views, used for quantitative measurements, were ob- tained before and after PICA, after the routine admin- istration of 100 to 200 pg of intracoronary nitroglycerin. The following coronary angioplasty techniques were used depending on the coronary anatomy present: (1) single-balloon and wire technique (n = 65), and (2) double-balloon technique (n = 41), with successive or simultaneous nflations. THE AMERICAN JOURNAL OF CARDIOLOGY MARCH 1, 1991 491  AMI = acute myocardial Infarction; CABG = coronary artery bypass surgery; CAD = coronary artery disease. TABLE I Demographic and Clinical Data Age (mean) Men/women (%) Clinical presentation Stable angina (%) Unstable angina (%) Recent AMI (%) Class Ill or IV angina Risk factors for CAD Cigarette smoking (%) Systemic hypertension >150 mm Hg systolic (%) Diabetes mellitus (%) Serum total cholesterol >200 mg/dl Family history (%) Previous CABG (“IO) Prior AMI (%) Ostial Nonostial Branch Stenosis Branch Stenosis* (n = 106) (n = 1,168) 62 f 10.7 61 f 10.2 75 (71)/31(29) 864 (74)/304 (26) 36 (34) 467 W) 49 w 444 (38) 16(15) 327 (28) 82 (77) 1,016(87) 69 (65) 747 (64) 55 (52) 572 (49) 12 (11) 117 (10) 50 (47) 455 (39) e-0 (38) 514(44) ll(l0) 117 (10) 45 (42) 537 (46) Data acquisition and analysis: Demographic, clini- cal, angiographic and follow-up data were obtained in all patients undergoing coronary angioplasty and were included in a computerized coronary angioplasty data base. Angiographic data obtained included the location of all significant coronary artery stenoses, quantitative measurements using a Hewlett-Packard electronic cali- per in 12 identical orthogonal views (percent diameter stenosis and balloon to artery ratio), lesion morphology, and the presence or absence of localized or propagating intimal dissection. An angiographically successful coro- nary angioplasty was defined by residual diameter ste- nosis <Xl%. In this study, if multivessel or bifurcation angioplasty was performed, success was determined by assessing esidual stenosis n the ostial segment. The following in-hospital complications were ana- lyzed: abrupt closure, emergent coronary bypass, ecur- rent angina, delayed closure, periprocedural myocardial infarction, delayed coronary bypass, repeat in-hospital PTCA and death. Clinical success was defined as angio- TABLE II Percutaneous Transluminal Coronary Angioplasty: Procedure Data Ostial Branch Stenosis (n= 119) Nonostial Branch Stenosis (n = 1,553) Technical PTCA success % diameter stenosis Before PTCA After PTCA Number of dilations (mean) Atmospheres (mean) Duration (mean) Balloon:artery ratio Diagonal Posterior descending Obtuse marginal Intermediate 88 (74%)’ 1.413(91%)9 74% 35% 4 8 100 seconds 1.05:1 58 (49%) 21 (18%) 34 (29%) 6 (4%) 72% 28% 4 9 134 seconds 1.08: 1 * p <O.Ol. PTCA = percutaneous translumlnal coronary angioplasty graphic success lus none of the above-mentioned major complications occurring during the hospitalization, In patients with multivessel coronary angioplasty or bifur- cation lesions, complications were included in the analy- sis if they were clearly related to the angioplasty of the ostial branch stenosis. The data obtained from patients who underwent coronary angioplasty of a stenosis at the ostium of a branch vessel were compared with our gen- eral cohort of patients who underwent angioplasty of a lesion (or lesions) not localized at the ostium of a coro- nary side branch. Statisticcr: Continuous variables are expressed as mean f standard deviation. Chi-square analysis or Fisher exact tests were used to compare categorical variables. Differences were accepted as significant if the p value was <0.05. Analyses were performed on an IBM computer using SAS statistical packages. RESULTS The clinical, demographic and procedure data for the ostial and nonostial branch stenosis groups are listed in Tables I and II. Despite a mean of 4 fully inflated balloon dilations at 8 atm for 100 seconds ach (balloon to artery ratio of 1.05:1), angiographic angioplasty suc- cess was obtained in 74% of the ostial versus 91% of the nonostial branch stenosis groups (p <O.Ol). Further- more, the complication rate (abrupt closure, emergency coronary artery bypass surgery, myocardial infarction or death-Table III) was 13% with angioplasty of ostial branch stenoses versus 5% for PTCA of nonostial branch stenoses p <O.Ol). For patients with bifurcation ostial branch stenosis, a double-balloon technique was performed if the pri- mary vessel had an associated ignificant stenosis at the bifurcation. The outcome for the branch vessel was not affected by the specific angioplasty technique per- formed. Successful dilation of the ostial branch stenosis was obtained in 74% of the patients when a single-wire and balloon technique was used versus 78% when a dou- ble-balloon technique was used (difference not signifi- 492 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 67  cant). The residual ostial stenosis in the bifurcation loon technique was used (6.3 vs 6.6%). The success ate cases was persistent throughout the procedure and did for the primary vessel in these bifurcation cases was not appear to be the result of “snow plowing” from dila- 91%. Complications in the primary vessel were 3%. tion of the primary vessel. n addition, there was no dif- Representative cases of coronary angioplasty of both ference in in-hospital complications when a double-bal- isolated ostial branch stenoses nd ostial branch steno- TABLE III In-Hospital Complications Ostial Nonostial Branch Stenosis Branch Stenosis (n = 106) (n = 1.168) Abrupt closure (“ID) Emergent CABG (%) AMI (%) Death (%) Complications (abrupt closure, AMI. emergency CABG or death) (%) 10 (9) 47 (4) 4 (4) 25 2) Z(1.8) 15(l) 0 (0) 2 (0.2) 14(13)* 58 (5) * p <O.Ol. CABG = coronary artery bypass graft surgery; AMI = acute myocardial infarction: PTCA = percutaneous transluminal coronary angoplasty flGURE 1. A 64.year-old man with a pre- vleus ante&r wall myocaruliil infarction @0&tlWtOtdOCChl*OnOftlWldt- tl==Wi -ry artery) uwkment pereutaneoucr transbminal comeuwy wgi- oplasty (PTCA) of an ostial diagonal branch stenosis (A). Balloons, 2.6,3.0 and 3.5 mm were used (6). Agam, despite a balloon to artsiy ratio of 19:1, ths psr- centdlamterstenosiroftheostlaldllo- nalbranchwasreahcedfrsm76toonly zgaN&N transluminal cor- . THE AMERICAN JOURNAL OF CARDIOLOGY MARCH 1, 1991 493  FIGURE 2. A opla*ofa bih&ath stemds invoking the kft anterior desfinding comuwy a&y and ostial diagonal branch (A). A balkan in the kft anterior dcscen&ng artmy was simuftaneousiy Mated with a 2.5-mm fixed wire device in the diagonal branch (B). Although the percent diameter stenosis in the Left anterior descending arby was reduced from 86 to 1396, the pertxnt . . . . . -. ses associated with bifurcation lesions are shown in Fig- ures 1 and 2. Follow-up (mean 7.8 f 5.9 months) was available in all patients. Of the 88 stenoses hat were successfully dilated, repeat coronary arteriography was performed n 19 patients (22%). A patent ostial segment was present in 6 patients and restenosis was present in 13 patients. Repeat coronary angioplasty was performed in 12 pa- tients, with a technical success f 75%. Clinical follow- up in this cohort of patients is difficult to evaluate ow- ing to the presence of multivessel disease n 85% of the patients. Nonetheless, chest pain was eliminated or im- proved in 72% of the patients, 2 patients required coro- nary bypass surgery, and only 2 patients had a myocar- dial infarction during the follow-up period. DISCUSSION PTCA of stenoses at the ostium of a branch coro- nary artery results in decreased procedural success e- spite adequate balloon sizing and increased n-hospital complications when compared with our general popula- tion of patients undergoing PTCA. Our findings are similar to those reported with ostial disease nvolving the renal,‘O the right coronary,l and the left anterior descending coronary arteries2 These studies have sug- gested that angioplasty for ostial disease s associated with decreased technical success, more complications and increased restenosis. SOS t allo demonstrated hat, despite guidewire passage and adequate balloon sizing and inflations, angioplasty of ostial renal artery stenoses resulted in a 10 to 20% success ate versus 75% for non- ostial disease. Topol et al1 showed hat RICA of ostial right coronary artery stenoses roduced reduced success 494 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 67 rates and increased complications when compared with nonostial lesions. Several studies have also suggested n- creased restenosis n patients with coronary ostial dis- ease.2,3 t would appear that an ostial stenosis, egard- less of its location in the vascular system, has unique properties that make it resistant to or unfavorable for angioplasty. Previous reports have demonstrated that side branch occlusion during coronary angioplasty oc- curs in 14 to 17% of cases, articularly in branches with preexisting ostial disease.’ -l3 Because of this, various techniques have been proposed or coronary angioplasty of bifurcation stenoses uch as double-wire and double- balloon techniques with successive r simultaneous bal- loon inflations.4-9 Angioplasty success n these studies was determined by the outcome of the major epicardial vessel and not the branch vessel. In fact, the percent diameter stenosis before and after PTCA has not been reported for the branch vessel n any of these studies. Our data indicate that, although these techniques are useful in preserving side branch patency, they do not appear o improve the technical success f ostial branch coronary angioplasty, nor do they prevent subsequent ischemic complications of the branch vessel. The presence of significant residual stenosis n ostial branch lesions after angioplasty despite adequate bal- loon sizing suggests hat the primary mechanism re- sponsible for technical failure is elastic recoil. Clearly defined regions of high and low wall shear stress are created at the apex of bifurcations and in the proximal branches.14 his increased shear stress at branch points may lead to an increase n elastic tissue, and account for elastic recoil after balloon inflations. To overcome his elastic recoil, balloon oversizing has been used in the
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