Thirty Years of Coronary Angioplasty

Thirty years of coronary angioplasty

On September 15th of last year, Adolph Black- meeting. As related by David Faxon in a recent inte- man, a 70-year-old retired insurance salesman, sto- rview [1] “one poster was completely crowded with od before a group of cardiologists in Zurich and in- people. A tall Swiss guy was presenting a crazy idea. troduced himself. But he needed no introduction. He had ligated the LAD of a dog and put a balloon Thirty years before, he and many of these same in it. That is crazy, but boy is that interesting.” At cardiologists had shared a historical moment, perhaps that time putting anything into the coronary arte- as important in our lifetime as when, over 150 years ries was absolutely forbidden. The reception was before, Dr. John Warren applied Morton’s discove- quite mixed; most physicians thought he was cra- ry and painlessly removed a tumour from the neck zy, but a few were intrigued. The next year in 1977 of a young girl before a group of surgeons in Bo- when the results of the procedure on Mr. Blackman ston. At both procedures, the observing physicians were reported, also at the AHA meeting, it was stan- realized they were witnessing something that wo- ding room only and after the presentation, the au- uld change medicine forever. Thirty years before, dience stood and applauded, almost unheard of at this healthy salesman had been disabled by angina scientific meetings. The procedure was named per- and in front of many of these same cardiologists had cutaneous transluminal coronary angioplasty (PTCA) undergone the first coronary angioplasty. He was modifying the terminology introduced by Dotter to now in Zurich to celebrate that event and to celebra- describe percutaneous peripheral lesion dilation. te the visionary physician, Andreas Gruentzig, who- Andreas Guentzig was born in Dresden, Ger- se dream and dedication as well as technical skill had many on June 25th 1939. His father died as a pilot in made it possible. Today, over one million percuta- the Luftwaffe during the war. After the war the East neous interventions are performed each year in co- German state planned for him to become a bricklay- ronary arteries and in almost every important arte- er, but his mother escaped with Andreas and his ry in the body as a direct result of this concept. sister (who became a professor of ophthalmology) To understand the importance of that event, to West Germany. He graduated from the Univer- one has to understand the limitations of the thera- sity of Heidelberg in 1969 and he trained as an in- py for coronary artery disease and its consequen- terventional radiologist. With Eberhard Zietler he ces, angina and myocardial infarction, in the late performed a large number of peripheral angiopla- 1970s. There were very few tools for the manage- sties using the Dotter coaxial tubular catheter me- ment of angina at that time. Although the role of chanism. Gruentzig became interested in perfor- lipid metabolism was appreciated, the pharmacolo- ming angioplasties on coronary arteries but he re- gy available to normalize the lipids was inadequate. alized that the Dotter technique was not suited to Beta blockers and nitroglycerine, and perhaps an- that site. As detailed in the excellent history by ticoagulation, were the major weapons available. Gary Roubin [2], the breakthrough occurred in 1974 The importance of thrombosis was not appreciated when, together with Professor Hoyt — a plastics and myocardial infarctions were thought to be the engineer from the Technical University of Zurich, result of coronary spasm. The value of aspirin as he was able to develop a balloon made of PVC which an antiplatelet agent had yet to be understood. Cal- could form a “sausage shape” of a predetermined cium channel blockers, long-acting nitroglycerine diameter at a given pressure. This protected the preparations and ACE inhibitors were not available. normal areas around the lesion from damage while The most effective approach was a drastic lifestyle concentrating the energy on the lesion (the previo- change with a nearly fat-free diet. Bypass surgery us balloon material, latex, tended to “dogbone” and was reserved for multivessel disease and even here damage the “normal” artery surrounding the le- it was controversial as no studies had yet been re- sion). He created a double lumen catheter by pla- ported showing any longevity advantage for surge- cing one catheter inside another and then folding ry over medical therapy. Surgery for lesser dise- the outside one by meticulously running a tool down ase was performed only reluctantly because of the it to create a “v” so it would not collapse under suc- likely need for additional surgery, so patients had tion. His workshop was the kitchen in his home [3]. to live with considerable angina before this could The development of equipment proceeded slowly be considered. at first. A small Swiss company, Schneider, known One year before, Gruentzig had presented for its needles, was chosen to manufacture it. The a poster at the American Heart Association (AHA) original catheter was manufactured in a garage with

www.cardiologyjournal.org 201 Cardiology Journal 2008, Vol. 15, No. 2 an output of 5 balloons per week, all handmade. flying from St. Simon Island to Atlanta in a rainstorm Guiding catheters had to be designed. Gruentzig for a Monday case. controlled every aspect of the manufacture and But his legacy did not end with his death, sin- quality control. As recalled by Heliane Canepa [4], ce plans were underway for an NIH grant to com- who later went on to become president of Schne- pare PTCA with coronary artery bypass grafting ider Worldwide, “Gruentzig was just a winner (CABG) in patients with multivessel disease. This — a winner personality. He was obsessed with his grant was pursued after his death and the study invention. He was a very serious character, very completed by King and colleagues at Emery. It sho- good-hearted but very demanding. He wanted the wed that the survival rate was similar in patients prototypes, he wanted it safe. He was a very tech- who were randomized to PTCA and CABG. nical person, so he could talk to the engineers on The present success of angioplasty owes much a technical basis.” to the man, Andreas Gruentzig, his charisma and He also totally controlled the use of the cathe- his careful stewardship of the development and pro- ter. In the beginning, in order to get a balloon ca- motion of the technique. According to Dr. King, his theter, a would-be angioplastier had to attend a co- watchword was “don’t exceed your capabilities — urse and then contribute data to a registry which stay within what you can do” [5]. After conceiving monitored every use — no data, no balloon. Gru- the procedure and carefully developing the early entzig protected and nurtured the procedure, so the tools, he courageously worked in the open to mini- procedure began slowly but with good results. mize scepticism, willing to discuss the cases. He An early challenge was training the cardiology emphasized scientific validation with randomized community in the new technique. Taking a clue trials. He pioneered the concept of a registry of all from the surgical demonstrations of the nineteenth procedures to monitor results and maintain quali- century, he pioneered the live demonstration co- ty. This concept was central to the organization of urse. The patients were presented and the proce- the Society for Cardiac Angiography [now the So- dures performed live; success or failure was not ciety for Cardiac Angiography and Interventions known before the procedure. Spencer King likened (SCAI)] and most recently to the American Colle- the atmosphere to that of a stock car race, in which ge of Cardiology in the National Cardiovascular Data the spectator watched not to see the cars race aro- Registry (NCDR), with several million procedures und the track but for the crash [4]. The real learning recorded. He pioneered the live demonstration co- occurred when Gruentzig dealt with the problem, the urse, a technique which has proven its value over crash, in “real time” (and usually solved it). He was time and which facilitated the rapid and widespre- a gifted teacher and impressed all who knew him. ad introduction of these new techniques. And first In 1980 Gruentzig left Zurich and moved to the and foremost, “he was a doctor. His first concern Emery School of Medicine in Atlanta, Georgia, was: was it appropriate to do it? Most of the time where he was appointed Professor of Medicine and (in discussion) was spent discussing the manage- was fully supported in his efforts to promote and ment of the patient, then the details of the proce- develop the procedure. The live demonstration co- dure” [1]. urse was refined into the form in which it remains So, in Zurich, while the celebration was for to this day. TV cables were drawn between the cath 30 years of a technique that revolutionised the ma- lab and a large auditorium. There would be a mini- nagement of coronary disease, even more, it was mum of three feeds, one of the operator talking to a celebration of the genius of one man who had the audience, one of his hands and one from the a dream and pursued and nurtured it so that it co- monitor in the room, so the audience could see what uld properly develop to benefit us all. Gruentzig saw. There was a moderator in the room, always a skilled interventionalist, asking questions so all the decisions were transparent and discus- References sed with the audience. In addition, the audience 1. http://clintrialresults.org/videos/Faxon_Popma.wmv. could query Andreas in real time. These courses 2. Roubin GS. History of cardiovascular intervention in interventional were extremely well attended by all cardiac angio- cardiovascular medicine. In: Roubin GS, Califf RM, O’Neill WW, graphers prior to starting their own programs and Phillips III HR, Stack RS eds. Churchill Livingstone Inc., New were widely copied by others in the years that fol- York 1994: 1–15. lowed. Even now, major meetings arrange for sa- 3. http://www.ptca.org/nv/interviews.html. tellite transmission of procedures from the US and 4. http://www.ptca.org/nv/interviews.html. international laboratories for live transmissions. 5. http://www.ptca.org/nv/interviews.html. On October 29th 1985, a year that saw the de- 6. http://clintrialresults.org/videos/King_Popma.wmv. aths of angiographic pioneers Melvin Judkins and Mason Sones, Andreas Gruentzig, as his father had Ronald J. Krone done before him, died at the controls of his plane, e-mail: [email protected]

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