Percutaneous transluminal coronary angioplasty in chronic coronary artery occlusion

Department of Invasive Cardiology, Royal Brompton National Heart and Lung Hospital, London, England, United Kingdom.

OBJECTIVES. This study was conducted to determine the procedural success rate, complication rate and long-term outcome of percutaneous transluminal coronary angioplasty in chronically occluded coronary arteries. BACKGROUND. Coronary angioplasty of chronically occluded vessels has a lower success rate than has angioplasty of nonoccluded vessels, but it is frequently considered safe because the target vessel is already occluded. The purpose of this study was to determine the reliability of these assumptions at our institution, with the objectives stated above. METHODS. We identified from the angioplasty data base at our institution 100 consecutive coronary angioplasty procedures performed between 1987 and 1991 for chronic total occlusion, defined as complete occlusion (Thrombolysis in Myocardial Infarction [TIMI] grades 0 and 1 flow) for > or = 3 months. The records of the 95 patients who underwent these procedures were reviewed to determine procedural outcome and medium-term results. RESULTS. Procedural success was obtained in 47 occluded vessels (47%). Significantly fewer successes were obtained in the right coronary artery (26.8%) than in either the left anterior descending (57.1%) or the left circumflex (45%) coronary artery (p < 0.05). A procedural failure without serious adverse consequences occurred in 45 procedures (45%), but in eight patients (right coronary artery in five, left anterior descending artery in three) attempted recanalization was complicated by extensive coronary dissection with acute myocardial ischemia, and one of these patients died. There were no emergency operations, but elective coronary artery bypass surgery was undertaken in 26 patients (in 3 after extensive dissection, in 7 after an apparently good result and in 16 in whom the procedure failed). At 12 months after the procedure, 64.1% of those with a procedural success were event free compared with 32.6% of those whose procedure was both unsuccessful and uncomplicated (p < 0.025) and 25% of those in whom it was unsuccessful and complicated by coronary dissection (p < 0.025). CONCLUSIONS. In this series of recanalization of chronically occluded coronary arteries, there was a low procedural success rate, particularly for the right coronary artery. However, when procedural success was obtained, the long-term outlook was good. The overall risk of coronary dissection was comparable to the risk in nonoccluded vessels but was particularly high in the right coronary artery (13%).

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