Percutaneous transluminal coronary angioplasty: state of the art and future directions.

Current developments in the practice of percutaneous transluminal coronary angioplasty concern increasing the safety of the procedure and reducing the incidence of lesion recurrence. Technical improvements and increased operator experience have greatly expanded the indications for the procedure. With experience, success in dilating proximal discrete lesions is now almost absolute. Old, calcified lesions and chronic total occlusions remain the barriers to total success. Careful case selection and expert anaesthesiology and surgical support are paramount in maintaining low complication rates. The largely unpredictable occurrence of acute vessel reclosure in approximately 2% of patients remains the major problem. This complication is usually the result of uncontrolled intimal dissection. These risks are considerably increased in patients with multivessel and diffuse disease and long lesions. Randomized trials are required to determine if such patients are best managed with bypass graft surgery. Early detection of less advanced coronary disease will ultimately lead to the most effective application of PTCA. Lesion recurrence may be reduced, in part, by careful attention to achieving an optimal, initial arteriographic and haemodynamic result. Otherwise, the solution to restenosis will depend on the development of pharmacological agents which prevent the rapid regrowth of atheromatous plaque.