Percutaneous Transluminal Coronary Angioplasty

Andreas R. Gruentzig

S INCE September 1977, 187 patients have undergone percutaneous transluminal cor-

onary angioplasty (PTCA) at University Hospi- tal, Zurich, Switzerland.‘,’ The age range was 26-68 yr. Of the 187 patients, 130 (70%) had single vessel disease (no other major artery having more than 50% obstruction); 18 (10%) had aortocoronary bypass graft (ACBG) with recurrent stenosis and symptoms; and the remaining 39 patients (21%) had double or triple vessel involvement.

All the patients were evaluated by clinical status, exercise tests, and coronary angiography before and after PTCA. The patients were followed every 3 mo for the first year with longer intervals thereafter. Reangiography was per- formed 6-9 mo after the angioplasty procedure.

We were able to pass the dilating catheter beyond the lesion in 157 of the 187 patients (84%). In 145 cases (78%) anatomic and hemo- dynamic success were obtained. A significant improvement in clinical parameters accompa- nied this. The coronary narrowing improved from a transluminal diameter reduction of 82% + 11% (mean + SD) to a mean reduction of 32% + 16% (p < 0.001). The percentage of stenosis was calculated as a mean of the measurements of the coronary diameter in at least three projections.

The mean pressure gradient across the steno- sis was measured through the main lumen of the double lumen dilatation catheter. The gradient across the lesion after dilatation was reduced from 56 mm Hg + 16 to 19 mm Hg * 12 (p < 0.001). The improvement in the anatomy and distal coronary pressure in patients with single vessel disease led to an increase of

From the University Hospital, Zurich. Switzerland and the Emory University Hospital, Atlanta, Ga.

Supported in part by the Swiss National Science Founda- tion.

Andreas R. Gruentzig, M.D.: ProfessorofMedicine (Car- diology) and Radiology, Emory University Hospital.

Reprint requests should be addressed to Andreas R. Gruentzig, M.D.. Emory University Hospital, 1364 Clifton Road, N.E.. Atlanta, Ga. 30322.

0 1981 by Grune & Stratton, Inc. 0037-I 98X/81/16024009$01.00/0

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submaximal working capacity consistent with a steady state from 77 * 46 W to 120 + 39 W, and normalization of thallium scintigrams.

Of the 145 anatomic successes (7X%), 3 patients had elevation of the MB fraction of creatine phosphokinase (CPK-MB) with ECG evidence of infarction during the hospitalization period, transmural in 1 patient and nontransmu- ral in 2. In spite of this, clinical improvement was noted following PTCA, and operation was not considered necessary.

Four patients showed no anatomic improve- ment, and 8 had sudden reclosure of the segment that had been dilated, with clinical symptoms of impending infarction. These 12 patients required ACBG, 8 within 24 hr and 4 thereafter. Five of these 12 patients had CPK-MB elevation, but only one had ECG evidence of myocardial infarction at the time of discharge.

We were unable to reach or pass the stenosis in 24 patients (13%). In these, the mean duration of angina pectoris was 20 mo as compared to a mean of 10 mo in the patients in whom it was possible to pass the lesion with the dilatation catheter. The failure in these 24 patients was mainly due to anatomic factors, such as tortuos- ity of the vessel, angled take-off of the left anterior descending artery, and tightness and eccentricity of the stenosis. All these patients had subsequent ACBG, 5 within 24 hr after the attempt at dilatation. Two of these patients had CPK-MB elevation with ECG evidence of myocardial infarction. There were no immediate deaths among the 187 patients. There was no evidence of embolization, and central nervous system deficits did not occur. Hematoma of the groin requiring evacuation occurred in 2 patients, and femoral occlusion at the puncture site, requiring endarterectomy, occurred in 1. Significant elevation of CPK-MB enzyme (> 10 U/L) was observed in 10 patients (mean peak value 32 U/L, with a range of 12-84 U/L). Six of these eventually showed ECG evidence of infarction, transmural in 4 and nontransmural in 2.

The mean follow-up time of the primary successes is now 9 mo (range l-36 mo). Two patients have died.2 One death was unrelated to

Seminars in Roentgenology. Vol. XVI, No. 2 (April), 1981

CORONARY ANGIOPLASTY 153

PTCA, the other was a sudden unexpected death in a 45-yr-old man with extensive hypertrophy of the medial smooth muscle cells of the left main stem. The extent of stenosis had been underesti- mated, and the vessel was therefore incompletely dilated. Autopsy showed no occlusion or dissec- tion and no infarction. The cause of death was not clear.

were treated medically, 18 had a second dilata- tion with at least early success, and 14 patients had ACBG. Of the I8 patients who had a repeat dilatation, only 3 had a second recurrence and required operation.

Up to July 1980, follow-up angiograms 6-9 mo after PTCA were available in 106 of the 145 patients (70%). These showed initial clinical improvement in vessel patency and wall smooth- ness in 60% of the cases. By July 1980, 25 recurrences were observed among the 145 patients with primary success (18%). Angiogra- phy was obtained in each case. Three patients

Optimal patients for PTCA are those with an accessible stenosis of I cm in length in a single vessel, as shown on the coronary arteriogram, and a short history of disabling chest pain (less than I yr). All the recurrences appeared within the first 7 mo after dilatation, and most in the first 3 mo.

As of July 1980, 133 of 145 patients (91%) had continuing clinical improvement during the follow-up period.

REFERENCES

I. Griint7ig AR: l‘ransluminal dilatation of coronary-

artery stenosis. Lancet 1978; 1:263.

2. Griintzig AR, Senning A, Siegenthaler WE: Nonoper-

ative dilatation of coronary-artery stenosis: Percutaneous

transluminal coronary angioplasty. N Engl J ‘Lied 1979;

301:61-8.