CHALLENGES IN MANAGING PATENCY FOLLOWING PERCUTANEOUS TRANS LUMINAL CORONARY ANGIOPLASTY WITH BARE METAL STENTS

Abstract


Background:
Coronary artery disease may lead to sudden death and may cause symptoms that may limit an individual's ability to carry out normal daily activities. PTCA (percutaneous transluminal coronary angioplasty) is a procedure to relieve coronary obstructions in these patients. However, rates of re-narrowing of the treated vessel (re-stenosis) are high which may require a repeat intervention this may lead to significant impact on the heath system in a resource poor settings. To understand the burden of restenosis we undertook a comprehensive evaluation of patients who underwent this procedure over a period of six month in our Institute
Methods
Sixty consecutive patients underwent PTCA in the coronary care unit between September 2011 to February 2 012 w ho m et c linical a nd i nclusion c riteria , w ere t aken i n t he s tudy. A r ecent o nset o f s ignificant dyspnoea, orthopnea, and/or paroxysmal nocturnal dyspnoea and signs of congestive cardiac failure were considered . A detailed physical examination to rule out postural drop and ECG was done compared with the baseline .Ischemic work up was done after admitting the patient which involved treadmill , ECHO and angiogram. Patient data collected included risk factors for coronary artery disease, presenting condition at time of PCI ,angiographic data ,including number of stents placed, percent residual stenosis, residual dissection, post-procedural. Thrombolysis in Myocardial Infarction trial flow (TIMI) and maintenance antiplatelet therapy (none, aspirin, thienopyridine, or both), antiplatelet therapy before were recorded. Patients follow up visits and events records were coded
Results:
The Median age of our study population was 50(±10) years. The majority of participants were males (91.67%) .The burden of ISR in the study population was 33.3% patients. About 5% had ISR class II type 75 % had ISR class III type and 20% had ISR class IV type Among the study patients, 32.7% male patients and 40% female patients developed ISR In context of cardiac event 86.67% had presented with STEMI ,1.6% NSTEMI , 3.3% with unstable Angina and 8.3% patients had presented with Chronic stable Angina. In the STEMI group patient 69.3% had AWMI and 30.7% were IWMI . Among the STEMI Group of patients 32.69%, Non- ST elevation patients (100%) , Unstable Angina patients 50% , Chronic stable Angina, 20% developed ISR. About 21.62% with single vessel disease, 55.5% with two vessels disease, 40% patients with triple vessel diseases, developed ISR.. Patients with single vessel disease had minimal ISR. In the context lesion 31.81% had type A lesion and 68.1% had type B Lesion . Among the type A lesion, about 31.8% and 34.2% with type B lesions A bout 25% o f the patients had Thrombus p resent and 40%developed ISR . About 35.71% p atients w ho were smokers,62% who consumed alcohol developed ISR and majority had Grade IV ISR. About 25% of patients had type II Diabetes Mellitus and 40% had ISR .Hypertensive in the participants were 16.67% and 30% of them developed ISR. In regards to thrombolysis 57.69% had been Thrombolysed and 42.3% had been not Thrombolysed. Among patients with Lesion length less than 10mm, 14.2% patients developed ISR. In regards to stent length 32.1% patients with Stent length (<20mm) and 34.3% with Stent length (>20mm) developed ISR Among those with direct stenting 7.1% patient and 41.3 with non-direct stenting developed ISR. About 51.6% patients under went Post dilatation of the stent \Post and 38.7% patients developed ISR Among patients in whom Post dilatation was not done, 27.5 %patients developed ISR A bout 8 .3% p atients h ad T IMI 2 fl ow a fter P TCA a nd 9 1.67% p atients h ad T IMI 3 fl ow . Among p atients w ith TIMI 2 (100%) and TIMI 3 flow, (27.27%) patients developed ISR With respect to medication 41.6% patients were given Tirofiban a nd p atients 5 8.3% w ere n ot g iven T irofiban . A mong p atients g iven T irofiban, 3 6% p atients a nd 31.42% not given Tirofiban developed ISR. Among the patient who presented with stable Angina, 52.3% , Unstable Angina about 80%,3.4% of asymptomatic developed ISR. . Among TMT positive patient, all patients developed ISR (100%). Among TMT Negative patients, 30% developed ISR. Among patients with sustained improvement in RWMA, 21.6% among those with no change in RWMA, 55.5% and patients with worsening of RWMA, 50% patients developed ISR
Conclusion:
Restenosis (re-narrowing) of vessels treated with stents may lead to major adverse cardiac events I t t he f orms a m ajor c omplication t o t ackle i n l ow r esource c linical s etting. I n o rder t o r educe r est enosis, stents that elute drugs are effective. Use of DES will result in decrease in the number of times patients had to be re-treated and also decreases immediate complications.

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