History, development and current activity in coronary intervention

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Chapter 1 History, development and current activity in coronary intervention

MICHAEL S. NORELL

Following the first percutaneous coronary angioplasty in 1977, growth in the procedure has been exponential.

It is estimated that in 2000, approximately one million angioplasty procedures were undertaken worldwide.

In the USA the number of percutaneous transluminal coronary angioplasties (PTCAs) performed annually exceeds that of coronary artery bypass graft (CABG) procedures.

Despite major technological advances in equipment, and the increasing applicability of PTCA to a variety of patient subsets, the basic principles of the technique remain unchanged.

UK rates for PTCA remain below those in the USA and Western Europe as a result of restricted resources and limited access to cardiological investigation.

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.

Figure 1.1 Andreas Grüntzig.

The era of invasive cardiac investigation and intervention began with the pioneering efforts of Forssman in 1929. The latter half of the previous century had seen Claude Bernard and later, Chaveau and Marey, develop the concept of ‘cardiac catheterisation’ in animal subjects employing intra-arterial or intravenous intubation in horses or dogs, but it was Forssman who demonstrated its feasibility and safety in humans. Taking advantage of his friendship with a nurse, Gerda Ditzen, he was able to cut down on his own cephalic vein and advance a rubber urethral catheter to his right atrium, documenting its progress with X-ray fluoroscopy. Right heart catheterisation was further developed with the work of Cournand and Ranges (1941), while investigation of the left heart proceeded via parasternal, subxiphoid, apical, suprasternal, transbronchial, papravertebral and transseptal approaches; until Zimmerman reported the results of retrograde left heart catheterisation in 1949.

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.

By the mid-1950s, visualisation of the coronary circulation had been achieved only by flush injection into the aortic root. A number of modifications to this technique were in use, including power injection into the sinus of Valsalva. It was during one such procedure in 1958, that an National Institute of Health (NIH) catheter inadvertently migrated into the right coronary artery and the subsequent injection of contrast opacified the vessel without the patient experiencing ill effects; Mason Sones had thereby demonstrated that selective coronary arteriography was possible. During the next few years, the first 1000 coronary angiograms were performed with only 2 deaths and a 2% incidence of ventricular fibrillation. Pre-formed polyethylene catheters were introduced in 1962 and were further modified by Judkins heralding the modern era of comprehensive percutaneous cardiac investigation.

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.

Miniaturisation of this balloon system allowed it to be considered for coronary stenoses. Initial experiments in relieving mechanically produced strictures in canine coronaries, were reported in 1976. In May 1977, after careful planning, Grüntzig together with Richard Myler, decided to attempt balloon dilatation in a patient undergoing bypass surgery in San Francisco. During the operation, a balloon tipped catheter was passed retrogradely up the left anterior descending (LAD) artery from a distal arteriotomy. Following balloon expansion, no debris was produced downstream, and reinvestigation after surgery showed that vessel dilatation had been successful. A further 15 peri-operative cases were undertaken in San Francisco and Zurich before true percutaneous transluminal coronary angioplasty (PTCA) was attempted in the human subject.

Gruntzig’s description of the first PTCA, performed in Zurich on 16 September 1977, was later quoted in an article by Hurst:

After working seven years to develop peripheral arterial dilatation, using animal experiments, post-mortem examinations and intraoperative dilatations, we were ready to use the technique for coronary artery dilatation in man …. It happened in September 1977 that we did coronary angiography on a 37-year-old insurance salesman with severe and exercise induced angina pectoris. The coronary angiography revealed single vessel disease with a proximal stenosis in the left anterior descending artery located immediately before the take-off of a large diagonal branch …. The guiding catheter was placed in the left coronary orifice and the dilatation catheter was inserted … a roller pump (was in place to start coronary perfusion) through the main lumen of the dilatation catheter (if this became necessary). The stenosis was severe but the catheter slipped through it without resistance. (The balloon was inflated.) To the surprise of all of us, no ST elevation, ventricular fibrillation or even extrasystole occurred and the patient had no chest pain. At this moment, I decided not to start the coronary perfusion with the roller pump. After the first balloon deflation, the distal coronary pressure rose nicely. Encouraged by this positive response, I inflated the balloon a second time to relieve the residual gradient …. Everyone was surprised about the ease of the procedure and I started to realise that my dreams had come true.

This first case was reported in a letter to The Lancet in 1978. In it, Grüntzig prophetically stated:

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