Changing incidence and management of abrupt closure following coronary intervention in the new device era

Abrupt closure of the dilated segment occurs in approximately 4 to 7% of cases following conventional percutaneous coronary angioplasty. Additional balloon angioplasty reverses roughly 40% of these closures, to yield an overall 1.6 to 3.4% rate of emergent surgery. The impact of new devices on the incidence and reversal rate of abrupt closure has not been examined. Abrupt closure occurred in 80 (4.2%) of 1,919 consecutive coronary angioplasties performed in our single center, 389 (20%) of which were performed using newer interventions (208 Palmaz-Schatz stents, 170 directional coronary atherectomies, and 11 elective laser balloon angioplasties). Abrupt closure was less frequent following newer coronary interventions (1.8%) compared to standard balloon angioplasty (4.9%, P < 0.01), possibly reflecting case selection. When abrupt closure did occur, percutaneous rescue was successful in 53 (66%) patients, including 42 (53%) who were rescued using standard or perfusion balloon angioplasty, and 11 (13%) who were rescued using laser balloon balloon angioplasty after failure of additional angioplasty attempts. Medical therapy alone was used in 8 (10%), while emergent coronary bypass surgery was performed in 18 (23%), yielding an overall emergent surgery rate of 0.9%. Q-wave myocardial infarction was significantly less frequent (0.2%) following percutaneous rescue, compared to either medical therapy (25%) or emergent surgery (33%, P < 0.001). In our catheterization laboratory, use of these 3 new coronary interventional devices coincides with a trend towards a lower incidence of abrupt closure, a higher percutaneous rescue rate with reduced incidence of myocardial infarction, and a lower emergent bypass surgery rate.