Editorial Notes Coronary Percutaneous Transluminal Angioplasty LAST SUMMER the popular news media, ever eager for a "breakthrough," gave a good bit of space and time to a new approach to the treatment of coronary heart disease, coronary percutaneous transluminal angioplasty (1-3). In this technique a guiding catheter introduced via the femoral artery is positioned in the orifice of the right or left main coronary artery. A very small caliber balloontipped catheter is then passed through the guiding catheter and, if possible, advanced through a coronary stenosis so that the balloon is positioned within the lesion (which cannot be done when the stenosis is most critical, for example, greater than 90%). The balloon is then inflated at pressures of 4 to 6 atmospheres to dilate the stenosis. News promotion of coronary angioplasty has even extended to encouraging patients with angina to consult their physicians about a less risky, less costly alternative to saphenous vein bypass, free of the discomforts of coronary surgery (4). Unfortunately, in view of the extensive press publicity, full scientific reports of coronary angioplasty have not been published, as we prepare this editorial note. The only extensive formal reports to the medical community to date have been the papers read and posters displayed at the recent Scientific Session of the American Heart Association, Dallas, Texas, 13-16 November 1978. The only reports dealing with patients were presented by A. Griintzig and colleagues (5, 6). Griintzig invented coronary angioplasty and carefully evaluated the results of an international multicenter study; at Dallas he reported the experience with all 80 patients who have undergone coronary angioplasty. Patients were selected for proximal, discrete, concentric, noncalcified coronary obOfjft
February 1979
structions and disabling angina. The catheter was passed in 54 patients, with successful dilation in 49. Immediate surgery was required in five patients because of closure of the obstruction and in two others after unsuccessful passage of the catheter. But this study was done as an alternative to surgery only in patients suitable for saphenous vein bypass. There was a strong tendency to symptomatic improvement in patients followed for 3 to 12 months after successful dilation, and 10 of 12 patients had improved thallium-201 exercise scans; comparison was not made, however, with groups receiving surgery, or drugs only. Two well-dilated lesions later obstructed, necessitating surgery. Four reports in Dallas described experiences with the procedure in human cadavers (7-10). These studies confirmed angiographic increase in lumen diameter, usually substantial, but only in noncalcified lesions. The cadaver studies gave histologic evidence of intimal trauma, coronary rupture, and mural dissection. (In one study 10 of 12 atherosclerotic vessels were found to be dissected by the procedure.) It is difficult to translate complications seen in cadavers to what might be expected in the catheterization laboratory, but the histologic complications were commonly not evident on angiography of the cadavers. In one study, angiographic luminal diameter increased by an average of 1.2 mm in dissected vessels but only by 0.4 mm in undissected vessels, suggesting that intramural contrast material could in some cases contribute to the angiographic picture of a dilated obstruction. Many patients with coronary heart disease are not candidates for coronary angioplasty. In addition to the criteria cited above, the proximal obstructions must not be
• Annals of Internal Medicine • Volume 90 • Number 2
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located distal to acute bends in the vessel or beyond major branching points likely to divert the dilating catheter from its intended course. The patient must be a suitable candidate for surgery, with graftable distal vessels and adequate ventricular function, because surgery has been required in seven of 80 cases. We have looked at our data from 100 consecutive catherizations of patients with coronary disease and found only seven cases meeting the angiographic criteria (although 71 were acceptable for bypass surgery). Physicians considering the referral of patients for coronary angioplasty will need to know the incidence of restenosis; there have already been restenoses diagnosed within 6 months in two patients, and not all patients have as yet been recatheterized. We do not know what the rate of complications would be in the hands of anyone other than Dr. Griintzig and his colleagues. Further, patients should be made aware that comparing the relative merits, risks, and duration of benefit for coronary angioplasty, surgery, or drug therapy alone will require controlled studies, statistical analysis, objective assessment of coronary reperfusion, and long-term follow-up. Such studies are very difficult to do, and the news media should be made aware that it will be a long time before this still experimental procedure can be placed in a well-informed perspective. ( T O B Y R. E N G E L , M . D . ; A N D S T E V E N
MEISTER, M.D.; The Medical Philadelphia, Pennsylvania)
G.
References 1. Blow up in the arteries. Tiny balloon unclogs heart blood vessels. Time Magazine. 1978 July 3:85 2. CRAWFORD C: Columbia Broadcasting System Evening News, 1978 July 14 3. New procedure aids some heart patients. Opens clogged arteries by the use of balloon. The New York Times. 1978 June 17: 22. New York, June 15 4. W I N N E JW: Bypassing the bypass: a balloon shows the way. The Courier-Post [New Jersey]. 1978 November 7:8 5. GRUNTZIG A, MYLER R, STERTZER S, KALTENBACH M, T U R I N A M:
Coronary percutaneous transluminal angioplasty: preliminary results (abstract). Circulation 58(suppl II):II-56, 1978 6. HIRZEL HO, GROENTZIG A, NUESCH K, KRAYENBUEHL HP, HORST
W: Thallium-201 imaging for the evaluation of myocardial perfusion after percutaneous transluminal angioplasty of coronary artery stenosis (abstract). Circulation 58(suppl II):II-180, 1978 7. BAUGHMAN KL, PASTERNAK RC, FALLON JT, BLOCK PC: Coronary
transluminal angioplasty in autopsied human hearts (abstract). Circulation 58(suppl II):II-80, 1978 8. FREUDENBERG H, WEFING H, LICHTLEN PR: Risks of transluminal
coronary angioplasty. A postmortal study (abstract). 58(suppl II):II-80, 1978
Circulation
9. SIMPSON JB, ROBERT EW, BILLINGHAM ME, MYLER R, HARRISON
DC: Coronary transluminal angioplasty in human cadaver hearts (abstract). Circulation 58(supp. II):II-80, 1978 10. L E E G, IKEDA R, M A S O N DT, JOYE JA, K A K U R, BOGREN H, D E M A -
RIA AN: Effective dilation of human coronary artery obstruction due to atherosclerosis utilizing a balloon-tip catheter (abstract). Circulation 58(suppl II):II-80, 1978 © 1 9 7 9 American College of Physicians
College of Pennsylvania;
Editorial Notes
Downloaded from https://annals.org by Tulane University user on 01/12/2019
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February 1979
structions and disabling angina. The catheter was passed in 54 patients, with successful dilation in 49. Immediate surgery was required in five patients because of closure of the obstruction and in two others after unsuccessful passage of the catheter. But this study was done as an alternative to surgery only in patients suitable for saphenous vein bypass. There was a strong tendency to symptomatic improvement in patients followed for 3 to 12 months after successful dilation, and 10 of 12 patients had improved thallium-201 exercise scans; comparison was not made, however, with groups receiving surgery, or drugs only. Two well-dilated lesions later obstructed, necessitating surgery. Four reports in Dallas described experiences with the procedure in human cadavers (7-10). These studies confirmed angiographic increase in lumen diameter, usually substantial, but only in noncalcified lesions. The cadaver studies gave histologic evidence of intimal trauma, coronary rupture, and mural dissection. (In one study 10 of 12 atherosclerotic vessels were found to be dissected by the procedure.) It is difficult to translate complications seen in cadavers to what might be expected in the catheterization laboratory, but the histologic complications were commonly not evident on angiography of the cadavers. In one study, angiographic luminal diameter increased by an average of 1.2 mm in dissected vessels but only by 0.4 mm in undissected vessels, suggesting that intramural contrast material could in some cases contribute to the angiographic picture of a dilated obstruction. Many patients with coronary heart disease are not candidates for coronary angioplasty. In addition to the criteria cited above, the proximal obstructions must not be
• Annals of Internal Medicine • Volume 90 • Number 2
Downloaded from https://annals.org by Tulane University user on 01/12/2019
located distal to acute bends in the vessel or beyond major branching points likely to divert the dilating catheter from its intended course. The patient must be a suitable candidate for surgery, with graftable distal vessels and adequate ventricular function, because surgery has been required in seven of 80 cases. We have looked at our data from 100 consecutive catherizations of patients with coronary disease and found only seven cases meeting the angiographic criteria (although 71 were acceptable for bypass surgery). Physicians considering the referral of patients for coronary angioplasty will need to know the incidence of restenosis; there have already been restenoses diagnosed within 6 months in two patients, and not all patients have as yet been recatheterized. We do not know what the rate of complications would be in the hands of anyone other than Dr. Griintzig and his colleagues. Further, patients should be made aware that comparing the relative merits, risks, and duration of benefit for coronary angioplasty, surgery, or drug therapy alone will require controlled studies, statistical analysis, objective assessment of coronary reperfusion, and long-term follow-up. Such studies are very difficult to do, and the news media should be made aware that it will be a long time before this still experimental procedure can be placed in a well-informed perspective. ( T O B Y R. E N G E L , M . D . ; A N D S T E V E N
MEISTER, M.D.; The Medical Philadelphia, Pennsylvania)
G.
References 1. Blow up in the arteries. Tiny balloon unclogs heart blood vessels. Time Magazine. 1978 July 3:85 2. CRAWFORD C: Columbia Broadcasting System Evening News, 1978 July 14 3. New procedure aids some heart patients. Opens clogged arteries by the use of balloon. The New York Times. 1978 June 17: 22. New York, June 15 4. W I N N E JW: Bypassing the bypass: a balloon shows the way. The Courier-Post [New Jersey]. 1978 November 7:8 5. GRUNTZIG A, MYLER R, STERTZER S, KALTENBACH M, T U R I N A M:
Coronary percutaneous transluminal angioplasty: preliminary results (abstract). Circulation 58(suppl II):II-56, 1978 6. HIRZEL HO, GROENTZIG A, NUESCH K, KRAYENBUEHL HP, HORST
W: Thallium-201 imaging for the evaluation of myocardial perfusion after percutaneous transluminal angioplasty of coronary artery stenosis (abstract). Circulation 58(suppl II):II-180, 1978 7. BAUGHMAN KL, PASTERNAK RC, FALLON JT, BLOCK PC: Coronary
transluminal angioplasty in autopsied human hearts (abstract). Circulation 58(suppl II):II-80, 1978 8. FREUDENBERG H, WEFING H, LICHTLEN PR: Risks of transluminal
coronary angioplasty. A postmortal study (abstract). 58(suppl II):II-80, 1978
Circulation
9. SIMPSON JB, ROBERT EW, BILLINGHAM ME, MYLER R, HARRISON
DC: Coronary transluminal angioplasty in human cadaver hearts (abstract). Circulation 58(supp. II):II-80, 1978 10. L E E G, IKEDA R, M A S O N DT, JOYE JA, K A K U R, BOGREN H, D E M A -
RIA AN: Effective dilation of human coronary artery obstruction due to atherosclerosis utilizing a balloon-tip catheter (abstract). Circulation 58(suppl II):II-80, 1978 © 1 9 7 9 American College of Physicians
College of Pennsylvania;
Editorial Notes
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