Editorial Comment
-
Percutaneuus Transluminal
Coronary Angioplasty in Two and
Three Vessel Coronary Disease:
Information and Speculation*
PATRICK
L. WHITLOW,
MD,
FACC
ClrVPl”“d. o,,i*
Since its imroduclion by Gmentrig (I). coronary angioplasty
has evolved into an increasingly sophisticated technical
procedure. Although initially used for single discrete obstructions, tt is now being offered to patients with multilesion
and multivessel coronary artery disease, distal coronary
disease. poor left vent&dar
function, previous coronary
artery bypars grafts and acute myocardial infarction (Ml.
Despite these added risks, the emergency surgery rate
associated with an%ioplasty has declined and the nngioplasty
SUCEW rate has improved since 1982 (5). However, the
paucity of long-term follow-up data in complicated cases has
dampened cnlhuriasm for the widespread extension of
angioplasty 10 patients other than those with single vessel
coronary diserw rcsisIanf to medical managcmenl (6.7).
Optimal care of patients with coronary artery disexe
requires the cooperative efforts of interventional and oonintewentional cardiologists and cardiac surgeons. Further data
must be collected and analyzed to determine the proper
utilization of coronary angioplasty BE a therapeutic altemative. The article of Deligonul et al. (8) in this issue of the
Journal provides important information on the angiographic
SUCCESSrate, complication rate and intermediate Penn fo!low-up of patients with two and three vessel coronary
disease trealed with angioplasly.
Initial an@graphic results. The initial angiogmphic SUEcess rate for multilesion percutaneous transluminal coronary
angioplasty has exceeded 9&b in several recent reports
(2.3.~12). However. the number of patients with multivessel angiopia5ty versus multilesion angioplasty in a single
vessel eannol ix determined in many of these studies.
Delisonul et ai. (8) hdve provided important data by identi.
fying the exlenl of coronary artery disease in their patients.
The initial angiograpbic success rate of86% in Patients with
multivessel disease is lower than the success rate of 94%
reported by this same group (IO) in multitesion angioplasty.
To determine whether a lower initial angiogrdphic success
rate can be expected with multiveaset angioplasty than with
multilesion angioplasty in single vessel disease will require
funher study.
Complkatkms. For angioplasty to become established as
an alcernadve to coronary artery bypass surgery in patients
with multilesion. multivessel disease. mortality rates will
have to be substantially improved over the 2.3%.mported by
Deligonul Ed at. (8) and the 2.8% in patients with triple vessel
d&se reponed from the 1985-1986 angioplasty registry (5).
The explanation of tkligonul et al. thai four of the nine
patients who died were “nonoperative candidates” may
gccount in part for the mortality&e.
However, the cd&
for “nonoperative” candidacy were not defined and the
number of nonoperative patients was not tabulated. The
mortality rate was still
when nonoperative candidate
deaths were excluded (8). The mortality rate for primary
elective coronary artery bypass surgery in patients &th two
and three vessel disease was 1.6% at the Cleveland Clinic in
1986 (unpublished data). Unless multivessel angioplasty is
associated wilh a significantly lower mortality rate than that
of bypass soracy in operative candidates, its role wilt he
limited. However, otheigroups (2-l I) report a mortality rate
approaching 1% in patients undergting multilesion angioplasty. Two direct cornprisons of patients with muttivesBel
disease randomized to coronary angioplasty versus bypass
surgery are planned, and the results will be important in
assessing the relative morbidity and mortality rates.
Emergency bypass mrgrry WJ required in 6.4% of the
pntienrs rpponed on by Drligonal EI nl. IS). Data from the
coronary angioplasty registry (5) indicate that 3.7 and 4.3%.
respe-tivety. of patients with two and three vessel disease
treJtsd with angioplaaty required emergency surgery. Other
groups have reported a lower emergency surgery rate for
patients with multilesion dilation, but the extent of coronaw
artery disease in these patients is not clear. Emergency
bypass surgery usually requires use cf rdphenous veins
rather thsn mammary arteries as conduits. and myocardiat
infarction evolves in approximately 50% lt3). The overall
myocardial infarction rate of Deligonul et al. (8) was 2.1%
and that of the 1985-1986 registry (5) was 4.3%. The risks of
emergency surgery. myoc&diai infar&”
and death will
have to be carefully considered when recommending angioplasty 10 patients with multilesion. multivessel c&ondry
disease.
Angiographiifollow-up.
Sixty percent of eligible patients
reponcd on by Deligonul et al. (81 returned for angiOgraQhy
after angioplasly. and the restenosis rate per lesion in
t.%
I year
this group was 28%. This rate is similar to the 23% reported
l&tic
regression to adjost for baseline differences in left
by Mata, et al. (I I) 6 months efter angioplasty in patients
ventricular function. Comparing I27 patients with complete
with two lesion dilation and 96% complete angiogmphtc
~ersos I59 patients with incomplete revascularizalion. there
follow-up. Restenosis appean to be related more to the
“as no difference between the stews of the two cohorts at 2
lesion than to the patient becausean increased incidence of
year follow-up. Likewise. Thomas et al. (21) found no
restenosis per patient occurs when mul!iale lesions and
difference in clinical imorovement after mottivew3 an&.
multi& vessels are amroached. Fiftr oe&
of the .oaplasty between patients who received incomplete rather rban
tie& of Deligonul et ai.
(8)
with angioplasty in more than
complete revaw&rization. More information is needed to
one lesion or vessel and 34% of the patients with two vessel
clarify the role of complete revascularizarica in the longdilation reported on by M&a et al. (I I) had restenosis.
term outcome of multivessel, multilesion angioplasty.
However, Myler et al. (4) found that several patient-related
Conclusions. Coronary angioplasty can be utilized with a
variables are also predictive of restenosis in multilesron
high degree of angiographic and clinical successin selected
angioplasty. Patients with diabetes mellitus, hypercholestersymptomatic patient, with multivessel coronary anery disolemia, continued smoking and recent onset $g:,la had an
case. Angioplasty equipment and experience have evolved
increased risk of restenosis.
such that in 1988 more extensive and complex coronary
The high rote of resrrnosis is tt de/errcnt to extenlng
artery diseasecan be managed by coronary angioplasty with
angioplarry IO patients with mrdrilesion disease. Before
a risk of emergency surgery and myocardial infarction
undergoing multilesion multivessel angioplasty, patients
similar to that ofsingle vesselangioplasty in the early 1980s.
should aecept angioplasty a5 an initial treatment strategy
The mortality rate associated with multivesscl angioplasty
rather than as a definitive procedure because many of them
may approach that found with coronary artery bypass WIWill require multiple procedures. Patients accepting this
gay. Anpioplasty offers an alternative for selected patients
strategy will require close follow-up with frequent functional
who are at high surgical risk, have had previous bypass
testing or repeat angiography. The high rate of restenosts
surgery or have extensive distal diseaseand are not suitable
may defer widespread acceptace of multilesion angioplasty
candidates for bypass surgery. Multivessel angioplasty mey
for patients with multivessel disease until methods for rcalso be used in selected patients to permit delay of bypass
duciog restenosis are developed (14).
surgery oniil coronary artery diseasebecomes extensive 17).
Complete verses inecenpkte rew3eolarization. Deligonol
The majority of patients with multivessel coronary disease
et al. (8) report that 7% of patients are alive and have not
are candidates for bypass sorwy. A controlled clinical trial
had myocardial infarction or a need for bypass surgery at an
of multivessel. multilesion &ioplasty verses bypass soraverage follow-up interval of 2 years. Of the event-free
gery is needed to determine the merits of these alternatives
group. 8W were free of angina or had Canadian C!ISS f
for our patients. Unless the ratec of restenosis and procesymptoms. The functional I!Z!BE of :hese &rns
treated
dure-related mortality decline. coronary angioplasty will
with multivessel. multilesion angiaplasty appears excellem,
remain complementary to but not competitive with bypass
especially considering that 250% of the treatment group
sorgery for moat patients with two or three vessel coronary
received “incomplete revascularization:
artery disease.
Surgical repoRs(l5.16)docoment an improved event-free
survival rate with complete verw incomplete revasculimzztion. However. incomplete revascularizatian with angioplasly may be quite di&rent from that associated with
bypass surgery. If coronary artery disease progressesfrom
subcritical nerrowine to sienificant stenosis after initial
angioplasty. the pat&nt &undergo
a repad procedure.
Repeat anriovlasty will likely be associated with less morbidity, #no&&y and cost than will repeat bypass surgery.
Nonetheless, patients must udergo another angioplasty.
which is not free of risk or cost.
Angioplasty of /be“rrdprit ksion” o&rs an attractive
alternative to the treatment of patients with multivessel
coronary artery disease who have unsuccessful medical
therapy.(l7). however. severe1studies (8.18.19). including
that of Deligonul et al. (8). report a less fworable long_term
outlook for patients with angioplasty and incomplete revascularization. The 1985-1986registry patients i20) with wccessful dilation tar multivessel disease were analyzed with
,
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McGwn DC. ed.Ca~diovascuIw
Clinics. Cardisc Surgery. 2nd rd.
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wh IWO sod three w&
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