PTCA Influence of intimal dissection on restenosis after successful coronary angioplasty

We studied 986 patients who underwent follow-up angiography after successful percutaneous transluminal coronary angioplasty (PTCA) to determine the influence of uncomplicated intimal dissection on restenosis rate. Angiographic evidence of intimal dissection after PTCA was present in 248 patients or 25%. After a mean follow-up time of 7 ± 5 months (SD) the restenosis rate in patients without intimal dissection was 30% compared with 24% in patients with intimal dissection (p = .08). Patients with available transstenotic pressure gradients were divided according to the hemodynamic result into two subgroups: those with final gradients at the conclusion of PTCA of 15 mm Hg or less (n = 638) and those with gradients greater than 15 mm Hg (n = 244).Patients with intimal dissection had a significantly lower restenosis rate than patients without intimal dissection if the final gradient was 15 mm Hg or less (19% vs 28%; p < .05). If the final gradient was greater than 15 mm Hg, the presence or absence of intimal dissection had no significant influence on restenosis rate, which was 35% and 39%, respectively (p = NS). We conclude that an uncomplicated intimal dissection after a successful coronary angioplasty has no adverse influence on angiographic restenosis. An excellent angiographic long-term outcome can be expected if the intimal dissection is associated with a favorable hemodynamic result. Circulation 72, No. 3, 530-535, 1985. PERCUTANEOUS transluminal coronary angioplasty (PTCA) is now an accepted revascularization procedure in the treatment of selected patients with coronary artery disease. The increase in vessel lumen is brought about partially by compression of soft atheromatous material.'1 2 However, stretching of the arterial wall and disruption of intima and media are thought to be the most important contributors in increasing the arterial lumen.3'6 This process is recognized arteriographically as an intimal tear or intimal dissection. During the healing process, arteriographic irregularities usually regress7 8 and either improvement (figure 1) or deterioration in luminal narrowing can occur. The precise relationship between intimal dissection and restenosis after coronary angioplasty, however, is unclear.4' 9 Some investigators have suggested that inFrom Emory University School of Medicine, Atlanta. Dr. Roubin is a National Heart Foundation of Australia Overseas Research Scholar. Address for correspondence: Andreas R. Greuntzig, M.D., Interventional Cardiovascular Medicine, Emory University Hospital, 1364 Clifton Rd., Atlanta, GA 30322. Received April 2, 1985; revision accepted June 13, 1985. Presented in part at the 57th Scientific Sessions of the American Heart Association, Miami Beach, 1984. *Present address: Deaconess Medical Bldg., Spokane, WA 99204. 530 timal dissection promotes restenosis ,4 0° while others have indicated that it is a benign arteriographic finding.7 Still others associate intimal dissection with an improved long-term outcome." The purpose of this study was to define the hemodynamic importance of an intimal dissection after uncomplicated, successful PTCA and its relationship to arteriographic restenosis.