THERAPY AND PREVENTION
CORONARY ARTERY DISEASE
Coronary angioplasty of multiple vessels: short-term
outcome and long-term results
MICHAEL J. COWLEY, M.D., GEORGE W. VETROVEC, M.D., GERMANO DISCIASCIO, M.D.,
STEPHEN A. LEWIS, M.D., PAUL D. HIRSH, M.D., AND TIMOTHY C. WOLFGANG, M.D.
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ABSTRACT Experience with percutaneous transluminal coronary angioplasty (PTCA) of multiple
vessels was reviewed to assess short-term outcome and long-term results. PTCA of multiple vessels
was performed in 100 of the initial 500 patients (20%) who underwent PTCA at the Medical College of
Virginia between July 1979 and August 1984. Eighty-nine percent had class 3 or 4 angina, and 66% had
unstable angina. Two-thirds had severe stenosis of two vessels or major branches and one-third had
three-vessel disease. One or more significant lesions were dilated in two vessels in 84 patients, in three
vessels in 14 patients, and in four vessels in two patients. PTCA of 273 lesions (2.7/patient) was
attempted (range two to eight per patient) with angiographic success in 250 lesions (91.6%). Primary
success (angiographic and clinical improvement) was achieved in 95 of 100 patients (95%); 84% had
success in multiple vessels, and 79% had success in all attempted lesions. Complications occurred in 11
patients (11%); four patients (4%) underwent urgent bypass surgery and four additional patients (4%)
had myocardial infarction. Long-term results were assessed in 44 patients with primary success who
had follow-up of more than 1 year (mean 26 months) after multiple-vessel PTCA. Twenty-eight
patients (64%) remain event-free and improved and 48% are event-free and asymptomatic. Clinical
recurrence developed in 15 patients (34%); four had sustained improvement with repeat PTCA, three
remain improved with medical therapy, and eight (18%) have undergone bypass surgery during followup. One patient (2.3%) developed late myocardial infarction, and no deaths have occurred in the
follow-up cohort. Including repeat PTCA, 75% have maintained clinical success during follow-up and
82% remain improved without bypass surgery. These short- and long-term follow-up results suggest
that PTCA of multiple vessels is a safe and effective therapy in selected patients with multivessel
coronary artery disease.
Circulation 72, No. 6, 1314-1320, 1985.
PERCUTANEOUS transluminal coronary angioplasty
(PTCA) is a safe and effective method of myocardial
revascularization in selected patients with symptomatic coronary artery disease1-6 and has been used predominantly in patients with single-vessel disease or
selected patients with multivessel disease in whom a
single vessel is dilated. Application of PTCA in patients with more extensive coronary artery disease or in
multiple vessels has been limited,7-9 and the safety and
short- and long-term efficacy are less clear. This report reviews our experience with PTCA of multiple
vessels.
From the Division of Cardiology, Medical College of Virginia, Richmond.
Address for correspondence: Michael J. Cowley, M.D., Division of
Cardiology, Medical College of Virginia, Box 59, MCV Station, Richmond, VA 23298.
Presented in part at the American Heart Association 57th Annual
Meeting, Anaheim, CA, November 1984.
Received March 12, 1985; revision accepted Aug. 22, 1985.
1314
Methods
PITCA of multiple vessels was performed in selected patients
at the Medical College of Virginia after October 1979 under a
protocol approved by the institutional Committee for Conduct
of Human Research. All patients were considered candidates for
coronary bypass surgery based on the presence and severity of
angina pectoris, evidence of myocardial ischemia by noninvasive studies (unless contraindicated), and the presence of significant coronary artery disease of more than one major vessel
or branch that appeared suitable for revascularization with angioplasty and/or bypass surgery. Multivessel disease was defined by the presence of 50% or greater stenosis in two or more
major vessels. However, angioplasty was generally not performed in vessels with less than 70% stenosis. Primary exclusion criteria for multiple-vessel PTCA were left main disease,
multiple total occlusions, and severe, diffuse disease with extensive involvement of all major vessels and branches. Patients
with distal lesions or total occlusions were not excluded if the
lesions appeared accessible for dilatation. In some patients,
additional disease was present in vessels not considered suitable
for PICA or for bypass grafting because of small size or diffuse
or distal involvement, so that PTCA was considered to offer a
reasonable probability of revascularizing the major ischemic
segments. In several patients, vessels were dilated that were not
CIRCULATION
THERAPY AND PREVENTION-cORONARY ARTERY DISEASE
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considered appropriate for bypass grafting. All procedures were
performed with a cardiac surgery team on stand-by. Patients
received aspirin (600 mg/day), dipyridamole (150 mg/day), and
a calcium antagonist for 1 to 2 days before PTCA and for 6
months after PTCA. All patients received heparin intravenously
(5000 to 10,000 IU), nitroglycerin ointment, and intracoronary
nitroglycerin during the procedure.
Angioplasty of the vessel considered to be the most important
(based on vessel size and lesion severity) was initially performed, and if successful, additional vessels were attempted.
When sequential lesions were present in one or more vessels, it
was frequently necessary to dilate the more proximal lesion
first, regardless of whether it was the more severe lesion. When
a vessel with high-grade disease supplied collaterals to another
vessel, the collateralized vessel was dilated first to protect its
source of collateral flow. A second or third vessel was generally
not attempted if dilatation of the preceding vessel was not successful. Angioplasty of additional vessels was also not performed at the same session when angiographic success was
equivocal or if major intimal split was evident that might progress to occlusive dissection. Angiographic success was defined
as 20% or greater improvement in luminal diameter. A procedure was considered successful when all vessels/lesions were
successfully dilated or the most important vessel was successfully dilated and clinical improvement occurred. Definitions of
complications have been previously reported.6 Lesion severity
was determined by visual assessment as the average diameter
reduction in multiple views before and after PTCA. Angioplasty
was performed by standard techniques, with fixed-tip catheters
in the early experience and moveable wire (steerable) catheter
systems when they became available.
Clinical recurrence was defined as recurrence of symptoms
after initial improvement associated with angiographic evidence
of restenosis of one or more lesions. Follow-up status was
determined at periodic follow-up visits or by telephone interview. Vital status, presence of angina, medication use, occurrence of myocardial infarction, and need for further revascularization with PTCA or bypass surgery were assessed. Long-term
follow-up status was analyzed for patients who had a minimum
of 12 months follow-up after multiple-vessel PTCA.
Statistical analysis was performed with the chi-square test for
discrete variables and t test for continuous variables.
The proportion of patients having PTCA of multiple
vessels increased with increasing experience: first 100
cases, nine; second 100 cases, 12; third 100 cases, 10;
fourth 100 cases, 26; fifth 100 cases, 43. The distribution of multiple-vessel PTCA also increased by calendar year: 1979, two patients; 1980, one patient; 1981,
five patients; 1982, 11 patients; 1983, 26 patients;
1984, 55 patients.
Angioplasty of two vessels was performed in 84
patients (84%), of three vessels in 14 patients (14%),
and of four vessels in two patients (2%). PTCA of
multiple vessels was performed in 91 patients at their
first PTCA procedure and in nine (who had undergone
prior single-vessel PTCA) at a second or third PTCA
procedure. In 98 patients, multiple vessels were dilated at the same session and two patients had "staged"
PTCA, with the second vessel dilated 1 day later. Two
lesions were attempted in 57 patients (57%), three in
25 patients (25%), four in 11 patients (11%), five in
four patients (4%), six in two patients (2%), and eight
in one patient (1%).
PTCA result by vessels/lesions. Overall, PTCA was
attempted in 273 lesions (2.7 lesions/patient) and angiographic success was achieved in 250 lesions
(91.6%). Success rate by individual vessel attempted
ranged from 96% for right coronary lesions to 79% for
circumflex lesions (table 2) and was significantly lower for the circumflex artery than for other vessels (p <
.05). The combinations of vessels attempted and paTABLE 1
Clinical profiles of 100 patients undergoing multiple-vessel PTCA
n
Results
PTCA of multiple vessels was performed in 100 of
the first 500 patients (20%) who underwent PTCA at
the Medical College of Virginia between July 1979 and
August 1984. The baseline clinical and angiographic
profiles of the patients are shown in table 1. There
were 71 men and 29 women with a mean age of 55 +
10 years (range 23 to 85). Eighty-six patients (86%)
had multivessel disease: 53 patients with two-vessel
disease and 33 with three-vessel disease. Fourteen patients (14%) had single-vessel disease by conventional
classification; each also had significant stenosis of one
or more major branches of the parent vessel. Fifteen
patients (15%) had prior coronary bypass surgery,
36% had prior myocardial infarction, and 66 had
(66%) unstable angina. Forty-six patients had class 4
angina (Canadian Heart Classification), 41 had class 3,
12 had class 2, and one had postcardiac transplant
ischemia.
Vol. 72, No. 6, December 1985
Age (mean)
Sex
Male
Female
Unstable angina
Prior MI
Prior CABG
Angina class (CHC)
Class 2
Class 3
Class 4
Other
Extent CAD
1 vessel
2 vessel
3 vessel
1st PTCA
2nd or 3rd PTCA
S
55 + 10 yr
(23-85 yr)
71
29
66
36
15
71
29
66
36
15
12
41
46
1
12
41
46
1
14
53
33
91
9
53
33
91
9
14
CABG = coronary artery bypass surgery; CAD = coronary artery
disease; CHC = Canadian Heart Class; MI = myocardial infarction.
1315
COWLEY et al.
TABLE 2
Success rate by individual vessels in patients undergoing multiplevessel PTCA
Vessel
n
Success
%
LAD
RCA
LCX
Diagonal
Graft
Left main
Septal
104
72
48
33
14
1
1
99
69
38
29
13
1
1
95
96
79A
88
93
100
100
Total
273
250
92
LAD left anterior descending; LCX
right coronary artery.
Ap < .05.
=
left circumflex; RCA
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tient and lesion success rates are shown in table 3.
The mean severity of the multiple lesions before and
after PTCA are shown in table 4. The initial severity of
first lesions was greater than that of subsequent lesions
(p < .01), although the relative severity of first
through sixth lesions dilated was similar (range 90% to
82%).
PTCA was not successful in 23 lesions (8%); in 19
the lesion could not be traversed with the balloon catheter (stenosis too tight in 14, tortuosity or unfavorable
angulation in five). In four unsuccessful attempts, the
lesion was dilated but occlusive dissection developed
at the dilated site (one patient) or distally (three
patients). Six unsuccessful attempts were of total
occlusions.
TABLE 3
Combinations of vessels dilated and patient and lesion success rates
with multiple-vessel PTCA
Vessels
LAD/RCA
LAD/Diag.
LAD/LCX
Graft/other
RCA/LCX
LAD/RCA/LCX
RCA/Diag.
LCX/Diag.
LAD/RCA/Diag.
LCX/marginal
LAD/septal
LAD/LCX/Diag.
Total
PatientsA
28/28
20/19
18/17
8/ 7
7/ 7
51 5
5/ 5
3/ 3
21 2
2/ 2
1/ 0
1/ 1
(100)
(95)
(94)
(88)
(100)
(100)
(100)
(100)
(100)
(100)
(0)
(100)
100/95 (95)
LesionsA
82/80
50/47
40/35
19/17
19/16
21/19
12/11
8/ 7
7! 7
7/ 7
3/ 2
4/ 2
(98)
(94)
(88)
(89)
(84)
(90)
(92)
(88)
(100)
(100)
(67)
(50)
273/250 (92)
Diag. = diagonal artery; LAD = left anterior descending; LCX
left circumflex; RCA = right coronary artery.
AExpressed as total number of patients or lesions/number successful,
with the percentage in parentheses.
1316
PTCA of total occlusions was attempted in 11 patients (11%) and was successful in five of 11 occlusions (45%). The occlusion was the primary vessel in
four patients, the second vessel in five, and the third
vessel in two; PTCA was successful in three of four
occlusions in the primary vessel, two of five in the
second vessel, and none of two in the third vessel.
Success rate for total occlusions was significantly lower than that for patent vessels (45% vs 94%; p < .001).
PTCA result by patients. PTCA was clinically successful in 95 of 100 patients (95%). Eighty-seven patients (87%) had successful PTCA of multiple lesions
and 84 patients (84%) had successful PTCA of more
than one vessel and associated clinical success. In 15
patients, PTCA of only one vessel was successful (11
with clinical success and four with clinical failure).
Seventy-nine patients (79%) had successful dilatation
of all attempted lesions (range two to eight lesions).
Thirty-six patients (36%) also had sequential (tandem)
lesions dilated in one or more vessels (31 in one vessel,
five in two or three vessels).
In eight additional patients, PTCA of multiple vessels was planned but was not performed because of
failure to dilate the primary vessel. Overall clinical
success rate of multiple vessel PTCA, including these
patients, was 95 of 108 patients (88%). In seven other
patients, multiple-vessel PTCA was considered but
was not performed despite success of the first vesssel
because of the length of the procedure or the small size
of the second vessel or because the second vessel lesion was not severe.
PTCA was not successful in five patients (5%) in
whom multiple vessels were attempted. In four the first
vessel was successfully dilated but PTCA of a second
major vessel was not successful or produced deterioration of flow and early bypass surgery was performed.
In the other patient with unsuccessful PTCA, although
the primary vessel (left anterior descending [LAD])
was unsuccessful, a secondary (large septal) vessel
TABLE 4
Coronary stenosis severity before and after PTCA for multiple
lesions
Lesion
n
1st
100
100
43
18
7
3
2nd
3rd
4th
5th
6th
% Stenosis
before
% Stenosis
after
90±+-7A
84± 11
43 ±+17
48+20
45±24
44 23
82±7
83 10
40± 10
85+11
84±9
32±15
Ap < .01 for first lesion severity vs other lesions before PTCA.
CIRCULATION
THERAPY AND PREVENTION-CORONARY ARTERY DISEASE
was dilated despite the need for bypass surgery
because the septal artery was considered to be of
clinical importance and would not otherwise be revas-
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cularized.
Complications. Complications during or after PTCA
of multiple vessels occurred in 1 1 patients (1 1%). Urgent bypass surgery was performed in four patients
(4%): one who had occlusive dissection beyond the
dilated site in the left circumflex artery (LCX) after
PTCA of an LAD graft, one who developed deterioration of flow in the primary vessel during PTCA of the
second vessel, one who developed subtotal occlusion
with delayed flow in the LAD whose septal branch was
then dilated before surgery, and one patient with unstable angina whose LAD could not be dilated after
PTCA of the LCX.
Evidence of myocardial infarction developed in five
patients (5%), with Q waves in two patients (2%) and
without Q waves in three patients. Both Q wave infarctions occurred after successful PTCA caused by acute
occlusion of one of the successfully dilated vessels 4
and 6 hr later. One had early reperfusion with repeat
PTCA and had evidence of residual function in the
infarct zone despite Q waves. Both had continued patency of major dilated vessels and were clinically improved despite myocardial infarction involving one of
the vessels. Both later developed return of angina after
TABLE 5
Follow-up outcome after successful multiple-vessel PTCA
>12 mo follow-up
No. of patients
Mean follow-up
Follow-up events
Clinical recurrence
Repeat PTCA
Success
2nd/3rd recurrence
Sustained improvement
CABG
For initial recurrence
After 2nd/3rd recurrence
For new disease
Medical therapy, improved
Myocardial infarction
Death
Event-free, improved
Asymptomatic
Continued successA
Improved, no CABGB
44
26 mo
16 (36%)
15 (34%)
9
6
1
4
8 (18%)
6
1
1
3 (7%)
1 (2%)
0
28
21
33
36
(64%)
(48%)
(75%)
(82%)
AIncludes patients with sustained improvement after repeat PTCA
and patient with myocardial infarction.
Blncludes patients with recurrence managed with medication and
improved.
Vol. 72, No. 6, December 1985
restenosis of a primary vessel, indicating that the initial
improvement was caused by revascularization with angioplasty. Of the three non-Q wave infarctions, one
occurred in a patient who had urgent bypass surgery
for occlusion of a major secondary vessel, and two
occurred in patients who had dissection of a second or
third dilated vessel that was managed without surgery.
Three other patients developed asymptomatic occlusion of secondary vessels that were collateralized. The
patients with non-Q wave infarction and with asymptomatic occlusion were each improved after PTCA.
Follow-up. Clinical status was assessed in the 45 patients who had completed at least 1 year of follow-up
after multiple-vessel PTCA through January 1985; 44
had successful PTCA and represent the follow-up cohort (table 5). Follow-up ranged from 12 to 62 months
(mean 26). The clinical profiles of the follow-up
cohort did not differ from those of the total study
population.
Twenty-eight of these 44 patients (64%) had sustained clinical improvement and were event-free (no
clinical recurrence, myocardial infarction, or death),
and 21 patients (48%) were asymptomatic and eventfree during follow-up. In the 16 patients who had
events, 15 had clinical recurrence, one had myocardial
infarction, and none died.
Clinical recurrence (return of angina and angiographic evidence of restenosis) occurred in 15 of 44
patients (34%). Mean time for clinical recurrence was
8.3 + 1 1 months (median 6), with a range of 1.5 to 47
months. Clinical recurrence developed during the first
year in 13 patients and occurred in two patients beyond
1 year (at 13 and 47 months). Repeat catheterization
was performed in 29 of the 44 follow-up patients
(66%), including all 15 with return of symptoms. In
the 15 patients with clinical recurrence, repeat PTCA
was attempted in nine and was successful in six; five of
these six have not had a second recurrence at a mean
follow-up of 12 months after the second PTCA. Bypass surgery was performed during follow-up in eight
patients (18%): for clinical recurrence in seven patients
(three without a second PTCA, three after unsuccessful repeat PTCA, one after a third recurrence) and in
one patient at 18 months for progression of disease
unsuitable for PTCA. In three patients clinical recurrence was partial associated with minimal return of
symptoms; these patients remain improved on a medical regimen without additional revascularization. One
patient (2.3%) developed myocardial infarction during
follow-up (at 6 months) because of new occlusion of a
vessel that had not had significant stenosis; both dilated vessels remained improved at restudy and clinical
1317
COWLEY et al.
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improvement has been maintained. Myocardial infarction rate during follow-up was 1.25%/year. No deaths
have occurred in the follow-up cohort.
Overall 33 of 44 patients (75%) have had continued
success of angioplasty: 28 who were event-free and
improved, four after repeat PTCA, and one with infarction involving an undilated vessel. Including the
three additional patients with partial recurrence managed with medical therapy, 36 of 44 patients (82%)
have remained improved or asymptomatic without requiring surgery during the mean follow-up period of 26
months.
Of the 15 patients with clinical recurrence, 12 (80%)
developed restenosis of only one dilated vessel or lesion and three patients (20%) had recurrence of multiple vessels or lesions. Overall, 18 of 34 lesions (53%)
and 18 of 29 vessels (62%) recurred in these patients.
The overall incidence of clinical recurrence at our
institution during this period was 83 of 294 patients
(28.2%) with follow-up of more than 12 months after
successful PTCA: 68 of 250 patients (27.2%) after
PTCA of a single vessel and 15 of 44 (34.1%) in
patients after PTCA of multiple vessels (p = NS).
Of the remaining 55 patients who have not reached 1
year after PTCA of multiple vessels, all have reached
at least 6 months after multiple vessel angioplasty. For
the total population (follow-up range of 6 to 62
months, mean 15), clinical recurrence has developed
in 31 of 95 patients (33%), infarction in two patients
(2.1%), and repeat PTCA in 25 patients with success
in 22 (88%). Bypass surgery was performed in 10
patients (10.4%). One death has occurred during follow-up in a 78-year-old patient who had clinical recurrence involving one of three vessels. Repeat PTCA
was successful but the patient died suddenly (presumably of an arrhythmia) 48 hr later. Overall mortality
rate during follow-up after multiple-vessel PTCA was
0. 8%/year.
Discussion
The initial guidelines for use of PTCA were restricted to patients with single-vessel coronary artery disease and selected patients with multivessel disease in
whom a single vessel was attempted and the safety and
efficacy of PTCA in these situations has been established.1-5 With improvements in technology and increased experience, application of PTCA in multiple
vessels and more complex anatomic situations has become feasible. However, experience with PTCA in
multiple vessels has been limited and the safety and
long-term efficacy in this setting are not as well characterized. These results with PTCA of multiple vessels
1318
in 100 patients over a 5 year period demonstrate that
satisfactory early and longer-term results can be
achieved with PTCA of multiple vessels in selected
patients. The majority of patients in this experience
had two-vessel disease, and only one-third had threevessel disease. Therefore the study population does not
represent a general population of patients with multivessel disease who may require revascularization.
However, the study population was severely symptomatic, with nearly 90% having functional class 3 or 4
angina and 66% having unstable angina.
In addition to angioplasty of multiple vessels, 36%
also had PTCA of sequential lesions in one or more
vessels, 43% had PTCA of three or more lesions, and
nearly 20% had dilatation of four or more lesions. An
average of 2.7 lesions/patient were dilated with an
angiographic success rate of 92%, and clinical improvement was achieved in 95% of patients. In a multicenter experience with complex angioplasty, Dorros et
al.7 have reported success rates in excess of 90% for
patients having multiple dilatations in a single vessel or
in more than one vessel. Hartzler et al. , in a preliminary report, have reported similar success rates in patients with complex anatomy and with multiple dilatations. Our results with PTCA of multiple vessels
confirm high initial angiographic and clinical success
rates in selected patients undergoing multiple-vessel
angioplasty. The clinical success rate in our multiplevessel dilatation group is higher than the overall success rate of 81% for our total PTCA population during
the same period. This in part reflects careful patient
selection for multiple-vessel PTCA and the higher proportion of patients undergoing multiple-vessel angioplasty in our more recent experience, when we had
more experience and better technology was available.
The proportion of patients undergoing multiple-vessel
PTCA progressively increased from 9% of the first 100
cases to 43% of the fifth 100 cases at our institution.
The high success rate is also to some extent artifactual,
since multiple vessels were not usually attempted if the
first was unsuccessful. However, inclusion of patients
in whom PTCA of multiple vessels was planned but
not performed would have resulted in an overall primary success rate of 88%. All patients with clinical success had improvement and most were asymptomatic.
The high frequency of symptomatic improvement likely reflects the high prevalence of successful revascularization of multiple zones, since most patients had
high-grade stenoses of multiple vessels and 88% of the
95 patients with primary success had successful PTCA
of multiple vessels.
Case selection guidelines were based on the estimatCIRCULATION
THERAPY AND PREVENTION-CORONARY ARTERY DISEASE
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ed technical feasibility of suitable revascularization of
the multiple vessels/lesions with PTCA and reflect
evolving experience with the technique. Patients were
generally selected as candidates for multiple-vessel angioplasty when they were judged as having a high
likelihood of successful revascularization of the major
ischemic segments, weighing the individual probabilities of successful dilatation of each lesion. The success rate for circumflex lesions was significantly lower
than that for other vessels; a similar relationship was
seen in the NHLBI PITCA Registry.3 Success rate was
also lower for total occlusions than for patent vessels
(p < .001), but nearly 50% of total occlusions were
successfully dilated. The mean severity of second or
subsequent vessels or lesions dilated was less than the
primary lesion but still represented high-grade stenoses (mean 82% to 85%) in the additional vessels.
The incidence of significant complications (myocardial infarction or urgent bypass surgery) of 8% in this
experience is comparable to results reported for patients in the NHLBI PTCA Registry,5'6 who had less
extensive coronary artery disease, and to other reports
of complex coronary angioplasty and multiple dilatations.7' 8 Urgent bypass surgery was performed in 4%
and evidence of infarction developed in four additional
patients. Each of the four patients with infarction managed nonoperatively was improved despite infarction,
probably because of effective revascularization of other major ischemic segments, and two of these four had
clinically small (non-Q wave) infarctions. No in-hospital deaths occurred with multiple-vessel angioplasty.
Although angioplasty of multiple vessels may carry
a higher potential risk than PICA of a single vessel,
the incidence of important complications in this experience was not appreciably different from published
reports predominantly involving patients with singlevessel disease. This may be due in part to improvements in technology and increased experience with
PITCA, which appear to have reduced the risk. as well
as to have increased success rates.6 10A2 The major
risks of multiple-vessel PTCA are acute occlusion of
multiple vessels or acute extensive ischemia caused by
occlusion of a major vessel that supplies collateral flow
to other vessels. Certain factors involving patient selection and technical considerations would appear important to minimize these risks. Most patients in our
study did not have three-vessel disease and patients
with left main stenosis, who are at increased risk with
PITCA,4 were generally not considered candidates for
PTCA in our study. Use of a staged or sequenced
approach to multiple vessels, with PTCA of the most
important or safest vessels initially and additional vesVol. 72, No. 6, December 1985
sels only if the preceding vessel has an excellent angiographic result, should minimize the risk of multiple
occlusions. When the angiographic result was equivocal in one of the vessels, additional vessels were
dilated later in a separate session when it was clear that
the primary vessel had maintained stable patency. In
addition, when severe stenosis was present in a vessel
supplying collaterals to other vessels, the collateralized vessel was dilated first to avoid jeopardizing the
source of collateral flow.
Long-term follow-up. The long-term results, analyzed
in the subset of patients who had a minimum follow-up
period of at least 1 year, indicate that sustained improvement was achieved in the majority of patients
after multiple-vessel PTCA; 64% are event-free and
remain improved and nearly 50% are asymptomatic
during the mean follow-up period of more than 2
years. Clinical recurrence, the most common event,
has developed in 34% during follow-up. Although
clinical recurrence was frequently evident during the
first 6 months, the mean time for clinical recurrence
was 8.3 months (median 6), suggesting that follow-up
of at least 1 year may better characterize the recurrence
rate with multiple-vessel PTCA than a shorter followup period. Although the recurrence rate after PICA of
multiple vessels was higher (34%) than that with single-vessel PICA at our institution (28%), the difference was not significant, and our clinical recurrence
rate with multiple-vessel PTCA is similar to other reports for recurrence after PTCA. 131 14 These results suggest that the recurrence rate after multiple-vessel
PTCA may not be substantially higher than that with
single-vessel PTCA and that recurrence may be patient-related rather than related to the number of vessels or lesions dilated. Of interest, 80% of patients who
developed recurrence after PTCA of multiple vessels
had restenosis of only one vessel. Repeat PTCA is
feasible in most patients with recurrence and often
achieves sustained improvement. 15
Bypass surgery after successful PTCA was performed in 18% of the follow-up cohort, usually for
recurrence in multiple vessels or recurrence plus progression of disease in other vessels, and in several
patients after unsuccessful repeat PTCA. The incidence of myocardial infarction during follow-up was
low (1 %/year) and no deaths occurred in the follow-up
cohort. Overall, including repeat PICA, 75% have
had continued success of angioplasty and 82% have
remained improved or asymptomatic without requiring
surgery during the mean follow-up of 26 months.
These long-term results with PTCA of multiple vessels
are comparable to the follow-up results reported from
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COWLEY et al.
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the NHLBI PTCA Registry in a population composed
predominantly of patients with single-vessel disease
who were followed for a mean of 18 months.4 Although the number of patients with follow-up of at
least 12 months in our study is relatively small and
represents only approximately 50% of the multiplevessel PTCA group, the incidence of continued improvement, clinical recurrence, and event-free outcome appears similar in the additional patients who
have not yet reached 1 year after PTCA of multiple
vessels. One death has occurred in the total study
group, representing an annual mortality rate of
0. 8%/year.
In summary, these short-term outcome and longterm follow-up results after PTCA of multiple vessels
indicate that multiple-vessel PTCA can be performed
with high success rates and acceptable complication
rates in selected patients, that continued success can be
achieved in approximately 75% of patients during
long-term follow-up, and that PTCA of multiple vessels is a safe and effective therapy in selected patients
with multivessel coronary artery disease. However,
comparative studies of PTCA with alternative therapies will be necessary to clarify the role of coronary
angioplasty in the various subsets of patients with multivessel coronary artery disease.
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CIRCULATION
Coronary angioplasty of multiple vessels: short-term outcome and long-term results.
M J Cowley, G W Vetrovec, G DiSciascio, S A Lewis, P D Hirsh and T C Wolfgang
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Circulation. 1985;72:1314-1320
doi: 10.1161/01.CIR.72.6.1314
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