The treatment of patients with coronary heart disease changed dramatically with the development of surgical coronary artery revascularization techniques in the 1970s and with percutaneous coronary intervention (PCI) in the next decade, performed initially with balloon angioplasty and then, beginning in 1986, with metallic stents and then, in 2003 in the United States, with drug-eluting stents (DESs). This chapter addresses the development and contemporary use of catheter-based coronary artery intervention, including selection of patients and devices, procedural issues, adjunctive therapy, results, complications, and future directions.
Percutaneous transluminal coronary angioplasty (PTCA) was conceived and shepherded into worldwide acceptance by Andreas R. Gruentzig, but the stage was set by the pioneering work of Dotter and Judkins,1 who in 1964, mechanically dilated femoral arteries with a coaxial double-catheter system, and of Zeitler et al,2 who applied this technique successfully in West Germany and introduced it to Gruentzig. After Gruentzig's development of a polyvinyl chloride balloon catheter with fixed maximal inflated diameters in 1974, balloon angioplasty evolved rapidly.3-5 In September 1977, the first PTCA was performed in Zurich in a 37-year-old insurance salesman with severe angina pectoris and high-grade stenosis of the proximal left anterior descending (LAD) coronary artery.6-8 Balloon angioplasty was successful in relieving the stenosis, and on the 10th and 23rd anniversaries of this landmark procedure, coronary arteriography revealed wide patency of the LAD, and stress testing remained normal (Fig. 62–1).9
Right anterior oblique coronary arteriogram of the first patient who underwent transluminal coronary angioplasty on September 16, 1977 (left) and on September 16, 1987 (right). During this 10-year period, the patient remained completely asymptomatic, and the arteriogram at 10 years showed no narrowing in the coronary arteries. Subsequent angiographic follow-up at 23 years revealed continued patency of this first percutaneous transluminal coronary angioplasty site.9
Following the report of Gruentzig's first five patients in 197810 and 50 patients in 1979,11 worldwide interest in the technique was assured. Under the auspices of the National Heart, Lung, and Blood Institute (NHLBI), multicenter registries were formed to report experiences with the evolving technique of coronary angioplasty.12,13 Development of an over-the-wire balloon catheter by Simpson et al,14 combined with advances in guidewire and balloon catheter technology, resulted in steerable balloon catheter systems capable of crossing and dilating heretofore unreachable coronary stenoses. The use of percutaneous revascularization (PCI) exceeded 130,000 procedures in the United States in 1986, 400,000 in 1995, 1,000,000 in 1999, and 1,313,000 in 2006, approximately a three-fold dominance over the use of surgical revascularization.
PTCA versus Medical Therapy
The favorable results of observational studies reporting outcomes in single-vessel and multivessel diseased patients15,16 led to a series of randomized trials comparing balloon angioplasty with medical therapy and with coronary artery bypass graft (CABG). ...