Chapter 1 History, development and current activity in coronary intervention
HISTORICAL PERSPECTIVE
Cardiac catheterisation and coronary angiography
More than two decades have passed since Andreas Grüntzig (Fig. 1.1) first attempted the percutaneous relief of a coronary stenosis. This single event, representing the culmination of many years of experimentation, has now passed into legend. Percutaneous coronary revascularisation has emerged as a routine cardiac procedure, but the trials and tribulations of workers in the field of invasive cardiology, whose efforts led stepwise to that day in September 1977, are nevertheless worthy of review.
Other developments also allowed cardiac catheterisation to progress to a stage recognisable in the present day. In 1953, Seldinger introduced his technique of entering arteries percutaneously. Serious peri-procedural cardiac arrhythmias could be addressed with closed chest cardiac compression (1960) and the introduction of direct current (DC) defibrillation by Lown in 1962. X-ray documentation had been limited to single plate exposures until the image intensifier coupled to film exposure at rapid frame rates resulted in the emergence of true cineangiography. Cardiac events could thereby be visualised in ‘real time’ incorporating less contrast volume and less radiation exposure to both patient and operator.
Coronary angioplasty
Initial non-surgical attempts to address arterial obstruction focused on the peripheral circulation. Charles Dotter, together with Judkins in 1964, first reported a successful approach in leg arteries using co-axial sheaths to allow sequential dilatations. In an initial series of nine patients with severe perpheral ischaemia; six improved and four amputations were avoided. However, it was recognised that a better mechanical method of dilatation was required which exerted radial, rather than longitudinal force, on the vessel wall. A latex balloon was initially tried, but it was then appreciated that a non-elastic dilator was preferable. In 1974 Andreas Grüntzig developed a sausage-shaped polyvinyl chloride (PVC) balloon, mounted at the end of a catheter, which could be inflated to a predetermined diameter to exert a radial force of 3 to 5 atmospheres. This was initially used in the iliac and femoropopliteal system with satisfactory results, and was then extended to address disease in renal, basilar, coeliac and subclavian arteries.