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An angiogram is an invasive test (arteriogram) in which a radiopaque dye is injected through a catheter inserted into the right femoral artery located in the groin and carefully placed through the aorta into the opening of the coronary arteries in order to visualize the coronary arteries looking for abnormalities such as narrowing (stricture) due to atherosclerotic plaques and dilatations (aneurysm) etc.

Figure 52
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Figure 53
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Figure 53a
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Figure 55
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Figure 56a
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(see figures 52, 53, 53a, 54, 55 and 56a).

Complications of Coronary Percutaneous Angioplasty

Patients undergoing coronary intervention are subject to the same complications encountered with the performance of coronary arteriography. In addition, because instrumentation of the atherosclerotic lesion takes place, coronary artery dissection, thrombus formation, and coronary artery spasm may occur, leading to acute occlusion of the coronary artery or of side branches arising from it. Atheroembolism may occur and lead to MI in an otherwise successful procedure. Occlusion of the treated artery is the most common serious complication of coronary angioplasty and accounts for most of the morbidity and mortality related to the procedure.
Of Gruentzig’s first 50 patients, 5 experienced an acute deterioration necessitating emergency bypass surgery and 3 showed electrocardiographic evidence of MI. The results of 3500 patients undergoing elective balloon angioplasty at Emory were analyzed and reported in detail. Angioplasty was attempted in 3933 lesions, with a success rate of 91 percent. No complications occurred in 89 percent of patients, minor complications occurred in 6.9 percent, and major complications (emergency surgery, MI, death) occurred in 4.1 percent. Emergency CABG was performed in 2.7 percent of patients, who had an MI rate of 49 percent and a 0-wave MI rate of 23 percent. In patients sent for emergency surgery, the mortality rate was 2 percent. The overall MI rate was 2.6 percent. There were two nonsurgical deaths, giving a total mortality rate of 0.1 percent (4 of 3500). Five preprocedural predictors of a major complication were identified: multivessel coronary artery disease, lesion eccentricity, presence of calcium in the lesion, female gender, and lesion length.
The strongest predictor of a major complication was the appearance of an intimal dissection during the procedure. Intimal dissection was evident in 29 percent of patients, and its presence resulted in a sixfold increase in the risk of a major complication.
Minor complications tabulated in this study included the following: side branch occlusion (1.7 percent), ventricular arrhythmia requiring dc shock (1.5 percent), emergency recatheterization (0.8 percent), femoral artery repair (0.6 percent), transfusion requirement (0.3 percent), coronary embolus (0.1 percent), cardiac tamponade (0.1 percent), and stroke (0.03 percent). This early series of patients was treated with balloon angioplasty alone.
In 1995 at Emory University Hospital, over 1600 patients were treated (76 percent with balloon alone), with angiographic success in 94 percent, Q-wave MI in 1.1 percent, non-Q-wave MI in 2.9 percent, and death in 0.6 percent.
Stents have played an increasing role, being used in 66 percent of patients in 1998 with an improvement in acute outcome (see Table 1).
Although angiographic variables are important predictors of abrupt closure, of equal or greater importance is an estimate of the consequences of abrupt closure. This estimate is determined in large part by the amount of myocardium that is supplied by the artery in jeopardy. Occlusion of a small diagonal branch is of little consequence compared, for example, with the occlusion of a large LAD coronary artery that is also supplying collateral vessels to an occluded right coronary artery. In the first case, a small non-Q-wave MI is likely, whereas in the latter, occlusion would likely result in abrupt anterior and inferior ischemia and be associated with hypotension and possibly cardiogenic shock.MI will occur in up to one-half of patients, and there is a significant risk of mortality in this subgroup of patients.

An analysis of 294 acute occlusions occurring during 8207 consecutive coronary angioplasty procedures performed in two centers revealed 13 cardiac deaths (4.4 percent of acute occlusions) and an overall cardiac mortality of 0.16 percent. Of 13 patients who died, 12 were women. Multivariate analysis identified three independent predictors of death: collaterals originating from the dilated vessel, female gender, and multivessel disease. In an analysis of 32 deaths associated with 8052 PTCA procedures in three centers, left ventricular failure due to vessel occlusion, the most common cause of death, was independently correlated with female sex, “jeopardy score,” and PTCA of a proximal right coronary artery (RCA) site but not ejection fraction or presence of multivessel disease. Right ventricular failure due to occlusion of the proximal RCA and left main coronary dissections accounted for most of the remaining deaths.
The use of stents in the course of a failing angioplasty ( Fig. 56j ) and prospectively in patients with unfavorable anatomy has significantly reduced the risk of urgent bypass surgery and 0-wave MI. The increasing use of stents and adjunctive measures including new, powerful antithrombotic agents may herald a “new era” of coronary intervention. New complications specifically related to the use of nonballoon devices include coronary perforation, distal atheroembolization, arterial access complications, and “domino stenting” (additional stents to treat end-of-stent dissections). The risk of coronary perforation is a limiting factor in achieving optimal atherectomy and significantly restricts use of the TEC device in native vessels. Among 8932 patients treated at William Beaumont Hospital, perforation was reported in 0.4 percent (balloon, 0.14 percent; TEC, 1.3 percent; DCA, 0.25 percent; excimer laser 2 percent). This risk of perforation is highest in tortuous and smaller vessels and in laser angioplasty of right coronary lesions. In patients experiencing free perforations, Ellis reported that 75 percent required surgery, 29 percent had a 0-wave MI, and 14 percent died. Perforation was reported in 10 of 432 stent patients (2.3 percent), resulting in cardiac tamponade (50 percent), MI (40 percent), emergency surgery (50 percent), and death (30 percent). The manifestations of perforation were delayed (5—24 h) in 20 percent of patients. Angiographic features associated with stent-related perforation were complex lesion morphology, small vessel diameter (2.6 ± 0.2 mm), oversized stents (stent/ artery ratio 1.4 ± 0.1), tapering vessel (40 percent), and recrossing dissections (20 percent). These results should engender a cautious approach to stenting in small vessels and when there is uncertainty regarding wire position. One of the newest causes of perforation is the hydrophilic coronary guidewire, which easily penetrates the wall of small distal arteries causing bleeding and cardiac tamponade, especially when lib/Illa receptor inhibitors have been used. Prompt application of strategies for the management of vessel perforation can be lifesaving, and device angioplasty operators must be facile with them.
Fortunately, the risk of vascular access-site complications, a frequent accompaniment of stenting when heparin and warfarin anticoagulation is used adjunctively, has been reduced with less aggressive antithrombotic strategies. In our experience, complications at the femoral artery puncture site were more often related to advanced age, female sex, hypertension, and postprocedure heparin use than to the size of the catheter. Prolonged compression of pseudoaneurysms using ultrasound guidance and in some cases local thrombin injection obviates surgery in many patients with this complication. Closure devices are used actively in some centers but add significantly to the cost of the procedure and have their own complications, including infection.
Distal coronary atheroembolization is only occasionally recognized clinically with ballon angioplasty butprobaly occurs moderately frequently and is a clinically important of debulking srategies such as atherectomy and laser ablation, where ita, manifestations are slow coronary flow, ischemia, and infarction. Reports from CAVEAT indicate that creatine kinase elevations postprocedure were associated with worse long-term outcomes (death, MI, repeat intervention). Although procedural modifications with rotational atherectomy appear to have reduced the immediate impact of microparticulate embolization, the issue remains a source of concern and needs further study. Patients at increased risk include those with bulky or long native vessel lesions and nonfocal or thrombotic saphenous vein graft lesions, where embolization with TEC was noted in about 20 percent, and about one-third of patients with this complication died. Atheroembolization also complicates stenting, accounting for an increased rate of non-Q-wave MI compared with balloon angioplasty. Particulate embolism to the coronary microcirculalion may lead to otherwise silent infarction reflected by creatine kinase elevation, a topic of intense interest due to the finding of adverse late outcome, even with small elevations, and the recognition that lIb/Illa platelet receptor inhibitors, filters, and occlusion-aspiration” systems can protect against this complication. Not all studies, however, have found a correlation between enzyme elevations and adverse late outcome, and this issue of when to use lIb/Illa platelet receptors inhibitors is actively debated.
Acute contrast nephropathy requiring dialysis is a costly complication of coronary intervention, which occurred in 15 of 1828 (0.8 percent) patients and was associated with a high (33.8 percent) in-hospital mortality. Independent predictors of contrast nephropathy included decreased baseline creatinine clearance, diabetes, and contrast dose (no dialysis was required in patients receiving less than 100 mL of contrast material). Adequate periprocedural hydration and limitation of contrast volume are the most important measures in high-risk patients.

TABLE 1. Results of Percutaneous Coronary Intervention, Emory University Hospital













Arterial segments treated






Initial success. %a






Complication-free success, %b






Single-vessel disease. %b






Multivessel disease. %c






Multivessel PTCA, %''






Emergency CABG. %






Q-wave MI, %






In-hospital death, %






a - Less than 50% residual stenosis.
b - than 50% residual stenosis and freedom from complications.
c - At least 50% stenosis of LAD + RCA. LAD + CIRC, CIRC + RCA, or LAD + RCA + CIRC.
d - Dilatation of LAD + RCA, LAD + CIRC, CIRC + RCA, or LAD + CIRC + RCA.
ABBREVIATIONS: LAD = left anterior descending; RCA right coronary artery; CIRC = circumflex artery; PTCA = percutaneous transluminal coronary angiopllasty; CABG= coronary artery bypass graft; MI= myocardial infarction

Douglas,J.S. and others,PercutaneousCoronary Intervention,Hurst's The Heart,10th edition Chpt 45 pp.1437-1461.

Samir R. Kapadia, M.D.

Cleveland Clinic Foundation Cleveland, OH 44195
Maria Schlumpf, B.S.

University Hospital Zurich 8006, Switzerland

I told a patient who had a tightly narrowed left anterior descending coronary artery that he did not have enough experience to cite an accurate success rate for balloon angioplasty of this artery before he performed the procedure. He said that the patient was only his eighth, and his first from the United States, to undergo this procedure. Panel A shows the angiogram from 1978. The left-hand image shows a lesion in the proximal left anterior descending coronary artery (arrow), the middle image shows the balloon inflation, and the right-hand image shows the result after the balloon angioplasty, with minimal residual stenosis (arrow). For the next 24 years, the patient enjoyed excellent health and remained physically very active. In April 2002, he presented with an acute myocardial infarction of the inferior wall. Angiography showed total occlusion of the right coronary artery (Panel B, left-hand image, arrow); two severe lesions, including the total occlusion, were successfully stented (Panel B, middle and right-hand images, arrows). Amazingly, the left anterior descending coronary artery was patent, with no recurrence of disease (Panel C, arrows). The patient is now 76 years old.
Copyright © 2004 Massachusetts Medical Society

N ENGL J MED 351;13 SEPT23,2004