Failed PTCA: Myocardial Protection and Surgical Management in the Catheterization Laboratory

Abstract

Percutaneous transluminal coronary angioplasty (PTCA) has become, for many patients with symptomatic coronary artery obstructive disease, the first and only interventional treatment required to successfully manage their symptomatic state and functional limitations. Intra-arterial angioplasty techniques, first developed for the management of peripheral arterial disease, were introduced into general clinical use for coronary artery disease in the early 1980’s and, since that time, have surpassed coronary artery bypass grafting in terms of annual numbers of procedures performed.¹ The appropriate role of coronary angioplasty versus surgical bypass grafting for symptomatic patients with multi-vessel coronary artery disease is currently the subject of several randomized multi-institutional trials and initial information from these trials support the continued, if not expanded, application of PTCA for some patients with multi-vessel coronary artery disease. Because of the potential for the iatrogenic induction of cardiac ischemia and hemodynamic instability, so-called surgical back-up has been a feature of virtually all PTCA programs since the initiation of this therapy.² At least 5 percent of patients who undergo a PTCA procedure require early surgery, often urgently or emergently undertaken because of the occurrence of myocardial ischemia in the catheterization laboratory.³ The subject of this review is to present our view on how to best deal with these PTCA failures and whether there is a role for myocardial protective interventions while the patient is in the catheterization laboratory and prior to surgery.