Clinical characteristics affecting success or failure of PTCA in patients with multiple vessel disease and poor candidates for surgery

Abstract

A special form of complex coronary angioplasty is represented by the extension of indications for percutaneous transluminal coronary angioplasty (PTCA) to patients with multivessel disease (MVD) for whom surgery is not indicated, and thus for whom surgical standby is not available. Over a two‐year period, 254 consecutive coronary patients with multivessel disease underwent PTCA under such conditions. These patients could not benefit from surgery for various reasons. Of the 612 arteries involved, 155 were occluded, 47 had been previously bypassed. A distal nonbypassable lesion in one of the three major arteries was found in 244 patients, 61 had suffered from a previous infarct, 24 demonstrated an ejection fraction below 0.40, and in 19 a single patent vessel was found. Fifteen patients were in cardiogenic shock and 69 procedures were undertaken for unstable angina. Of this latter group, 25 emergency PTCA were attempted for refractory unstable angina, and 44 additional emergency procedures were directed to the treatment of acute infarct. A total of 40 intra‐aortic counterpulsations were needed. As far as possible the procedure aimed at full revascularization. Immediate outcome is strongly affected by the clinical context, and despite a rather constant initial success rate (88–95%), the procedural mortality (directly related or not) can change dramatically with clinical factors. Respective definitive success and mortality rates are: 93% and 0% when a complete revascularization is attempted, 89% and 0% in double‐vessel disease with stable angina, 80% and 2.8% with stable triple‐vessel disease, 85% and 3.2% in the overall elective procedures, 77% and 19% in emergency cases, 60% and 40% in cadiogenic shock, and 47% and 47% in cases of single patent vessel. In such nonsurgical MVD patients, some situations entail very high risks and clinical characteristics are powerful predictive factors. These clinical factors must be taken into account, isolated and associated, and included when weighing carefully the risks before any decision to treat. Copyright © 1990 Wiley Periodicals, Inc.