PATIENT SELECTION REDUCES THROMBOTIC COMPLICATIONS OF EMERGENT STENTING FOR FAILED PTCA

A comparison of consecutive initial and later patients receiving emergent coronary artery stents to salvage failed PICA procedures was made to determine whether experience with this procedure can improve patient outcome, Twenty-six consecutive patients underwent emergent, unplanned implantation of one or more Palmaz-Schatz coronary stents at our institution over a 3-1/2 year period. Indications for stent insertion included impending vessel closure (decrease in TIMI Row grade and clinical evidence of ischemia) or acute occlusion (TIMI flow grade 0 or 1 and greater than or equal to 99% stenosis) after PTCA. Immediate and final success (30 day) were determined, and the results in the first (Initial) 13 patients were compared to the remaining (Later) 13 patients. Baseline characteristics of the study population included a male predominance (69%) with a mean (+/-SD) age of 57+/-10 years. Conventional balloon PICA was performed in all three native coronary arteries with an increase in mean percentage stenosis from 76+/-13 to 85+/-14% (P<0.05). Twelve patients developed acute occlusion and 14 patients impending closure after PICA due to the appearance of thrombus (12%), dissection (46%), or both (35%). Palmaz-Schatz stents were successfully inserted in all patients restoring TIMI grade 3 antegrade flow; however, major complications developed in almost 50% of patients. Comparison of initial and later patients showed no differences in demographic or pre-PICA angiographic characteristics. Later patients had less severe stenoses post-PTCA (before stenting) and were less likely to have thrombus present at the angioplasty site (15% vs. 77%, P<0.05), These patients were also more likely to have stents inserted for impending closure rather than acute occlusion. Patients in the later experience had fewer complications (15% vs. 77%, P<0.05) including subacute thrombosis. Final success was 23% in the initial patients and increased to 85% (P<0.05) in the later experience. We conclude that emergency coronary artery stenting with the Palmaz-Schatz balloon-expandable stent is an effective technique to salvage failed angioplasty procedures. Improved results and lower rates of complications were achieved by using the device for impending closure due to intimal dissection, avoiding vessels containing thrombus, and careful attention to post-stent anti-coagulation. (C) 1995 Wiley-Liss, Inc.