Living history of medicine: vascular scaffolding, from dream to reality

Following the launch of balloon angioplasty in 1977, its deficiencies-abrupt occlusion requiring emergency bypass surgery in one in twenty attempts and recurrence in one in three cases-became soon apparent. The attempts to eliminate the element of chance from this otherwise highly attractive technique resulted in the concept of intra-vascular scaffolding. Following the inception of self-expanding mesh stents made from stainless steel and extensive bench testing and animal experiments, the first clinical data were obtained in Switzerland almost 30 years ago in 1986 with promising, albeit not undisputed results. Technical improvements including potent platelet inhibitors have made the technique a cornerstone of catheter-treatment of vascular disease. This paper gives an account of the sometimes difficult beginnings of coronary and non-coronary stenting at the University of Lausanne in Switzerland.

[Brief history of interventional radiology]

In 1923, angiography was first successively used for the human body. In 1953, a Swedish doctor Sven-Ivar Seldinger pioneered the Seldinger technique, which laid down the foundation of interventional radiology. In 1963, Charles Dotter first proposed the idea of interventional radiology. In 1964, Charles Dotter opened a new era of percutaneous angioplasty through accidental operation, marking the formation of interventional radiology. On this basis, the techniques of balloon catheter dilation and metal stent implantation was developed. Endovascular stent was proposed in 1969. In 1973, the percutaneous angioplasty has been a breakthrough with the emergence of soft double-lumen balloon catheter. Percutaneous coronary angioplasty is applied in 1977. Since the 1990s, balloon angioplasty relegated to secondary status with the emergence of metal stent. Currently, endovascular stent have entered a new stage with the emergence of temporary stent and stent grafts and biological stent. Transcatheter arterial embolization had been one of the most important basic techniques for interventional radiology since 1965, it had also been a corresponding development with the improvement of embolic agents and catheter technology for the treatment of diseases now. Transjugular intrahepatic portosystemic stent-shunt is a comprehensive interventional radiology technology since 1967, in which the biliary system can be reached through a jugular vein, and the improvement appeared with balloon expandable stent in 1986.Since 1972, non-vascular interventional techniques was another important branch of interventional radiology. Currently, it is applied in the diagnosis and treatment of many diseases of the internal organs like the pancreas, liver, kidney, spinal cord, Fallopian tubes, esophagus and other organs. In 1973, Chinese radiologist first conducted the angiography test. Interventional radiology was introduced into China in the 1980s, it was readily developed through the sponsoring of training class (1981) and academic conferences (1986). Along with the return of the overseas scholars, the gap in the interventional diagnosis and treatment technology between China and the world has been narrowing since the 1990s.

The Socratic attic, where much of the future of the stent was hatched

Although he makes no claim to be a pioneer, Prof. Patrick Serruys,who recently retired as Chief of Interventional Cardiology at the Thoraxcenter, Rotterdam, and his colleagues have taken the simple idea of the stent to new heights, and in the process produced an original paper once every few days, reports Barry Shurlock PhD.

Gentleman, rebel and believer: the radial way

The manuscript highlights some historic milestones of the universal trans-radial approach (TRA) and describes some characteristics that "radialists" share (at least in the author's opinion). The author argues against common misconceptions about the TRA, like the use of more iodine contrast, more X-ray exposition, a lower rate of successful angioplasty. Data illustrating the conversion from a trans-femoral approach catheterization laboratory to a complete TRA laboratory are presented, showing the speed of the switch and the rapid clinical benefit observed. The author concludes with possible future directions for TRA supporters, on how to optimize the material for the puncture step, how to reduce the radial occlusion rate and how to promote the TRA as the first access for acute coronary syndromes managed invasively.

[Brief history of percutaneous coronary intervention]

Percutaneous coronary intervention (PCI) is that delivering balloon catheter and/or equipment such as a stent to the target coronary artery bypass peripheral artery, at the same time, expanding and opening the stenosis of coronary artery. Through several decades of development, PCI has become a most effective way to rescue patients with coronary heart disease and become one of the biggest advances in the field of heart disease. Because of the development of PCI, more lives have been saved in patients with coronary heart disease. However, PCI does not meet the point of perfection, still has a lot of issues remain to be further resolved. Through a review the development of PCI, we may be able to get some insights to perfect the treatment technique for the patients of coronary heart disease.

Systems of care for ST-segment elevation myocardial infarction: impact of different models on clinical outcomes

ST-segment elevation myocardial infarction (STEMI) is one of the greatest medical emergencies, for which organization of care has a determinant impact on patient outcomes. The purpose of this paper is to review systems of care for STEMI patients. Although primary percutaneous coronary intervention (PCI) is the preferred option for patients with STEMI, offering easy and emergent access to this procedure often remains difficult because of geographic and diverse structural difficulties. intravenous fibrinolysis, especially when administered early after symptom onset and as part of a pharmacoinvasive strategy (i.e., followed by rapid coronary angiography with PCI when necessary), offers a reasonable therapeutic option in selected cases and has yielded satisfactory clinical results. Network organization is central for optimizing patient care at the acute stage of myocardial infarction. This review describes different clinical experiences with network implementation both in Europe and in North America. In all instances, early recognition of STEMI and, particularly in the pre-hospital setting, shortening time delays is central for the achievement of optimal clinical results. Overall, the encouraging results described in the models presented here, as diverse as they might be, should be an encouragement to promote and implement regional protocols according to the specific local constraints and to monitor their effectiveness by recording simple quality indicators in ongoing registries.

The comparative efficacy of percutaneous and surgical coronary revascularization in 2009: a review

Medical, percutaneous, and surgical therapies for coronary atherosclerotic disease are developing rapidly, with many recent breakthroughs in metabolic control, improvements in catheter and stent engineering, and advances in surgical technique. Treatment guidelines are still in their infancy and do not take into account several of these recent innovations. Consequently, determining the most appropriate treatment for many patients remains challenging. In this review, we examine the most recent revascularization guidelines, discuss important new data and trials comparing contemporary stent technology and coronary artery bypass surgery, and conclude with updated revascularization recommendations.

Contemporary percutaneous coronary intervention--30 years in the making

Angioplasty has come a long way in 30 years. It is now the dominant therapy for obstructive coronary disease and becoming so for acute myocardial infarction and for the majority of patients it is a simple, quick procedure with same- or next-day discharge with negligible morbidity. Many of the developments have been led by pioneers conducting independent large randomised trials, but there are issues still to resolve and there are new exciting developments such as bioabsorbable stents and stereotaxis in the wings. Many have a lot to be grateful for when we reflect on the insights and pioneering work of Andreas Gruntzig.

[History of Lithuanian heart surgery]

The aim of the article is to review Lithuanian cardiac surgery development, as well as authors and timing of the first operations performed. Historical review involves two periods: initial (1900-1964) and contemporal (1964-2002). Benevolent rivalry between Vilnius and Kaunas heart surgeons is given to show their contribution into Lithuanian surgery. Chronological development and amelioration of the main heart surgery fields are described: heart injuries, ischemic heart disease, congenital and acquired defects, heart rhythm disturbances, heart transplantation.

[Coronary angioplasty: view through 30 years]

Andreas Gruentzig executed the first successful percutaneous transluminal coronary angioplasty (PTCA) in 1977. Percutaneous coronary interventions (PCI) have considerably changed since this time. The changes have touched the technical equipment for PCI, the pharmacological and mechanical support of PTCA also. The serious revision was in recommendations for PCI too. New catheter technologies have allowed to perform successful PCI in patients with an acute myocardial infarction, with multivessel coronary disease and in many others. PCI became the most often method of a coronary revascularization for ischemic heart disease in the nineties. Percutaneous interventions pass ahead of coronary artery bypass graft operations in many countries of Europe and America. The coronary angioplasty is carried out more than in 2 million patients in the world annually, and 1 million patients is exposed to the PCI annually in the USA. Coronary stenting became most frequently used technology of PCI from the middle of the nineties. The implantation of drug-eluting stents has been the dominating catheter-based method in world clinical practice during last three years. Nevertheless, both these technologies are not deprived of restrictions and disadvantages. The coronary restenosis has become the main limitation for standard (bare-metal) stents, and late thrombosis has become the most terrible complication for the drug-eluting stents. The big success of a method and huge increase of quantity of coronary interventions would be impossible without sequence of openings, innovations and other important events which are surveyed in this review.

[Coronary stents. From a simple idea to a medical high-tech device]

BACKGROUND

Coronary stents were introduced in clinical cardiology in the middle of the 1980s, as balloon angioplasty was associated with a high incidence of acute vessel closure and restenosis.

EVOLUTION OF CORONARY STENTS

However, primarily designed to counteract elastic recoil after angioplasty, initial results were complicated by acute and subacute stent thrombosis. With the introduction of drugs effectively inhibiting platelet aggregation like ticlopidine and clopidogrel, stent could exhibit its superiority in comparison to angioplasty. Although the incidence of restenosis could be decreased significantly by coronary stents, restenosis remained a major drawback of this interventional technique. Several modifications of stent design and stent material had been tested, but without a real breakthrough. The introduction of active stent coating with anti-inflammatory and antiproliferative drugs marks a milestone in the development of this technology. With this approach the restenosis problem could be, even though not solved, but essentially mitigated. Current developments address bioabsorbable materials to make stents compatible with new upcoming noninvasive imaging techniques.

CONCLUSION

Introduced 20 years ago as a simple wire mesh, modified by new designs and materials, and coated by highly effective drugs, coronary stents have advanced to medical high-tech devices in interventional cardiology.

Switzerland is small in size but big on cardiology

Switzerland is a small country in the heart of Europe and well known worldwide for its Alps, foreign bank accounts, cheese, chocolate and watches. However, it also has made a significant contribution to cardiology, especially interventional cardiology. It was where balloon angioplasty and stenting of obstructed coronary arteries, two of the most stunning advances in cardiology in the last 30 years and the two most frequently performed interventional procedures in cardiology, originated. The author, who recently served as a visiting professor in the University of Geneva, University of Bern and University of Zurich, summarized his personal observations and impressions in this report.

[Thirty years of the balloon catheter--A. Grüntzig and percutaneous balloon angioplasty]

Percutaneous transluminal coronary angioplasty--PTCA--will forever be linked with A. Gruentzig's name. Building on the work of Charles Dotter and Malvin Judkins be developped novel technique of revascularisation and established a new speciality - interventional cardiology. The aim of this article is to sum up the most important data on Gruentzig's revolutionary work. Andreas Roland Gruentzig was born on June 25, 1939 in Dresden, Germany. In 1957 he received his B. A. in Leipzig (German Democratic Republic). In 1958, Andreas emigrated to the German Federal Republic, received another B. A. in Heidelberg, and entered the Medical School in Heidelberg where he qualified in 1964. In 1969 he moved to Zurich, Switzerland, in the Dept of Angiology of the University Hospital. He soon appreciated the potential of recanalising partially occluded lower limb arteries using the Dotter-Judkins catheter but also recognised its risks. In 1972-1973 he developped his balloon catheter and performed the first femoral angioplasty in February 12, 1974, and in January 23, 1975 the first one using his new double-lumen catheter. The first experimental coronaroplasty in a dog followed in September 24, 1975. He presented his results with balloon catheters in November 15, 1976 in Miami. After a further period of arduous experimental research--stil manufacturing the catheters with his small crew in the kitchen--he dilated a stenosed coronary artery in a 37-year-old man on September 16, 1977 in Zurich, with immediate relief of symptoms. The results of PTCA in five first patients were published in the February 14, 1978 issue of Lancet; the coronarography in the first patient, on April 10, 2000, revealed normal patency of the site that had been dilated (Prof. B. Meier, Bern). However, the news in Zurich 1978 was received with a certain incredulity and Gruentzig was unable--in spite of Professor A. Senning's support--to obtain facilities to expand his research program and clinical activities. In September 1980 he accepted the Chair of Medicine (Cardiology) and Radiology with the additional title of Director of the Dept of Interventional Cardiology at Emory University in Atlanta, Georgia. Prof. Hurst gave him half of his office suite at Emory and later even further facilities to expand his program. Here, at Emory, Gruentzig gave 10 angioplasty courses and performed with Dr. S. King and Dr. J. Douglas 5000 PTCAs till 1985. Before reaching the peak of his scientific carrier, he died in a flying accident, with his second wife Margareth Ann, near Forsythe, Monroe County, Georgia, on October 27, 1985. His work was appreciated in tributes from the U.S.A., U.K., Switzerland and Germany, by many international awards and honors; numerous interventional laboratories in the world carry A. R. Gruentzig's name.

Advances in the treatment of coronary artery disease

Initial pioneering efforts of direct coronary artery bypass were all performed on a beating heart. Although originally introduced into cardiac surgery for the repair of intracardiac defects, the ability of John Gibbon's heart-lung machine to create a motionless, bloodless operative field catalyzed coronary artery bypass surgery. During the ensuing decades tens of millions of patients benefited from coronary revascularization on cardiopulmonary bypass. As we celebrate the 50th anniversary of the invention of the heart-lung machine the landscape of interventional treatment of coronary artery disease has shifted dramatically. Although instrumental in the genesis of the field of coronary revascularization, the role of the heart-lung machine has now diminished. Two thirds of all coronary revascularization is now performed by percutaneous approaches and one fourth of all coronary artery bypass grafting procedures are performed without the heart-lung machine. However owing to the complexity of patients now requiring revascularization as well as recently introduced incremental improvements to cardiopulmonary bypass including coated, low prime circuits, closed integrated systems, and pharmacologic adjuncts Gibbon's heart-lung machine will continue to play an integral role in this field.

[Percutaneous coronary intervention in Denmark from 1989 to 1998. Results from the Danish PTCA registry]

INTRODUCTION

During the ten-year period 1989 to 1998, all percutaneous coronary interventions (PCI) in Denmark were recorded in the Danish PTCA Registry. The purpose was quality control based on treatment activity, severity of illness, technique employed, success rate, and complications.

MATERIAL AND METHODS

For each PCI procedure a number of 144 parameters were recorded in a national database. The present analysis of these data was carried out using parametric statistics and logistic regression analysis.

RESULTS

From 1989 to 1998 the annual number of PCI procedures increased from 240 to 3840. The database contains 13,868 procedures of which 10,804 are first time interventions. Men accounted for three fourths of the patients. The mean age was 60.7 years for women and 57.9 years for men. During the ten-year period a rise of two years on average was seen for both sexes with a doubling of patients being older than 70 years. More patients with acute coronary syndrome and multivessel disease had PCI. The use of coronary stents increased from 2.0% in 1992 to 90.7% in 1998 and the primary success rate rose from 81% to 90%. Serious complications decreased from 5.4% to 3.0%, mainly due to a significant fall in procedurally related acute bypass surgery. Mortality remained unchanged around 0.6%. Age was found to be the only independent predictor for major procedurally related complications.

DISCUSSION

From 1989 to 1998 a sixteenfold increase in the number of PCI was observed. In parallel to this was seen an increase in the use of coronary stents and in the procedural success rate, while the frequency of serious complications decreased. This progress is similar to that of several other European countries.

Charles Theodore Dotter. The father of intervention

The 1st percutaneous transluminal angioplasty marked a new era in the treatment of peripheral atherosclerotic lesions. The early techniques used in peripheral percutaneous transluminal angioplasty form the basis for subsequent percutaneous intervention both in the peripheral and coronary arteries and are largely the contribution of Charles Dotter. Dotter was the 1st to describe flow-directed balloon catheterization, the double-lumen balloon catheter, the safety guidewire, percutaneous arterial stenting, and more. This practical genius dedicated his considerable energy to the belief that there is always a better way to treat disease. His personal contributions to clinical medicine, research, and teaching have saved millions of limbs and lives all over the world.

Highlights from the past decade of interventional device research

The last decade of research and implementation in the interventional device arena has brought about an unprecedented improvement in the ability to safely and effectively treat coronary artery disease. This explosion of technology is not over; there remain questions to be answered and patient subsets whose care can be improved upon. Our understanding of the restenosis process has helped guide research in the appropriate directions, and by 2010 restenosis after a coronary intervention will most likely be of historic interest only. With the addition of thrombus removal catheters and protection devices, treatment of problematic high-risk lesions will also be improved upon. The effect of these devices on acute patient care and long-term outcomes, including quality of life, will be profound.