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Non-surgical Revascularization

Non-surgical Revascularization

1. History

A. Developed by Andreas Gruentzig in 1977
B. Original series
1)169 patients
a) 133 successfully ballooned
(1)95% ten year survival with one lesion
(2)81% ten year survival with more than one lesion
b) 23% went to surgery in the ten year period
C. 1981 series
1) 427 patients
a) 88% had single vessel disease
b) 94% successfully ballooned
(1) 91% ten year survival
(2) 30% redo PTCA in ten year follow-up
(3) 23% required surgery
(4) 55% freedom from MI, death, and surgery @ ten years

2. PTCA after CABG

A. 94% success with PTCA of SVG
1) depends on location
a) distal anastamosis: good results secondary to intimal hyperplasia
(1) 24% restenosis rate
b) restenosis rate increases in mid and proximal lesions, and in vein grafts over two years old

3. Primary Angioplasty in Myocardial Infarction

A. most beneficial in older patients and in AWMI
1) AWMI mortality 1.4% with PTCA
vs. 11.9% with lytic therapy
2) Age > 65 yrs mortality 5.7% with PTCA
vs. 15% with lytic therapy

4. New Interventional Devices

A. Rotablator
B. Transluminal Extractor Atherectomy Catheter (TEC)
C. Excimer Laser
D. Stents
1) indications widening, but the text states for use
a) after a dissection secondary to PTCA,
b) acute closure after PTCA
c) reduce restenosis
2) Benestent Trial and STRESS
a) each trial had >1000 randomized patients
b) end point was luminal diameter @ 6 months
c) restenosis ( defined as 50% ) was 42% in PTCA vs. 32% with PTCA and stenting
d reintervention was 15% in PTCA vs. 10% with PTCA and stenting
3) cost:
a) increased bleeding
b) increased hospitalization

5. PTCA vs. CABG

A. Emory Angioplasty Surgery Trial (EAST)
1) single center trial
2) 392 patients randomized and 458 non randomized patients
3) 60% had double vessel disease and 40% had triple vessel disease
4) excluded left main lesion, occluded vessels, and severe LV dysfunction
5) results:
Event mortality1%1%
3 year mortality6.3%7.1%
freedom from subsequent surgery79%99%
freedom from subsequent PTCA60%88%
Class I, II, III symptoms20%12%
6) Conclusion: PTCA can be safely done but will require repeat procedures
B. Bypass Angioplasty Revascularization Investigation (BARI)
1) largest trial ( 1829 patients ), followed for 5.4 years
2) multicenter
3) results:
Event mortality1.3%1.1%
5 yr survival89.3%86.3
Revascularization @ 5 yrs.8%54%
Diabetic's survival80.6%65.5%
C. RITA (United Kingdom)
1) single and multivessel disease, although 50% were single
2) required complete revascularization and were more compulsive regarding randomization
D. CABRI (Europe)
1) need for surgery in one year in the PTCA group was 20%
E. GABI (Germany)
1) need for surgery in one year in the PTCA group was 21%

6. Indications for PTCA

A. Nomenclature
1) Class I. : general agreement that PTCA is indicated, but not the treatment
2) Class II. : Divergence of opinion
3) Class III. : agreement that PTCA not indicated
B. Symptomatic patients
1) Class I and II :
a) amenable lesions
b) ischemic on maximal therapy
c) angina on maximal therapy
d) side affects of medical therapy
C. Asymptomatic patients
1) severe ischemia on testing
2) rescue from angina
3) in need of high risk surgery
D. Myocardial Infarction
1) Class I and II. :
a) AWMI with duration less than 6 hrs.
b) persistent pain within 12 hrs.
c) cardiogenic shock or continued ischemia following lytic therapy
2) Class III. : following lytic therapy