The greatest advance in the next 40 years would be to remove the need for angioplasty

Spencer B. King

Spencer B. King performed some of the first coronary angioplasty procedures in the USA—having recently received a thank-you from the first patient that he treated. He tells The Daily Wire that the steerable guidewire, rather than the stent, was the greatest advance in angioplasty and that obviating the need for angioplasty, by successfully managing atherosclerosis with medicine, would be the greatest advance in the next 40 years.

It was Charles Dotter who first suggested using catheters to treat vascular disease. What was the evolution from his idea to Andreas Grüntzig to performing the world’s first coronary angioplasty?

C. Dotter’s procedure was for the legs rather than for the heart, which he achieved by passing large catheters into the leg and the pelvis. A. Grüntzig, after listening to a lecture about the procedure, adapted the technique for the heart. He envisioned using a balloon that was small enough to be used in the coronary arteries but could be expanded to open up a blocked artery and, therefore, his real breakthrough was to achieve this. He is the father of interventional cardiology.

You were one of the first operators to perform angioplasty in the USA. What were those initial procedures like?

The first coronary angioplasty procedure in the USA was performed by Richard Myler in San Francisco and Simon Stertzer in New York. I started doing the technique after that. I actually recruited A. Grüntzig to come work at Emory to perform angioplasty but my colleagues and I had started to do it before he arrived.
I found the procedure scary to begin with; the equipment was very primitive and we did not have any stents to use as a bailout procedure if you occluded the artery. If there was a problem, the patient had to be rushed to surgery. In those days, the equipment we had was not able to adequately cope with complications.
Another limitation with the equipment was that you were not able to reach areas of heart that we are able to do these days. We had rudimentary catheters that were only useful in certain kinds of obstruction—i.e. ones that were pretty straightforward.

How many patients would require conversion  to surgery in those early days?

Back then, you absolutely needed to have surgery on site. During the first year that we started to perform angioplasty at Emory, 6% of patients had to go to surgery because the angioplasty procedure had failed.

The first patient to undergo angioplasty is still alive. Do you know what happened to your initial patients?

I recently received a call from the first patient that I ever treated—he had apparently been meaning to call me to say thank-you for 37 years but “had not gotten around to it”. As angioplasty was not available in many places in the first years, we saw a lot of interesting people from the USA and abroad undergo angioplasty at our centre.

What was the initial reaction in the cardiology community to angioplasty?

There was an enormous interest in the procedure from the outset—we literally had 600–800 operators coming to our centre to be trained in angioplasty each year. By the middle of the 80s, there were thousands of hospitals around the world performing angioplasty. Therefore, there was a lot of enthusiasm about the procedure in the overall cardiology community. However, cardiothoracic surgeons were not as enthusiastic about the procedure because they saw it as a direct competitor to surgery. Also, they believed that they would do a more complete job with surgery—which was probably fair.

The first angioplasty patients had stable disease. When did the procedure start to be used to treat acute patients?

Initially, angioplasty was only used for patients with stable coronary artery disease whose symptoms were particularly bothersome. At that stage, a patient with ST-segment elevation myocardial infarction (STEMI) was treated with thrombolysis. However, three or four years after the first procedure—when angioplasty had become really popular—people then began to explore opening up an acutely occluded artery with a balloon as well.
Today, the vast majority of patients treated with angioplasty are acute patients. They either have had a myocardial infarction or are without infarction but are unstable and have symptoms suggestive of an ongoing process. Angioplasty is still used to treat stable patients, but the proportion is diminishing compared with the acute patients.

During the past 40 years, what do you think has been your biggest contribution to angioplasty?

We conducted the first trial to compare angioplasty to surgery in the context of multivessel disease. This study showed that among patients with suitable anatomy for angioplasty, the procedure had similar mortality to surgery. This trial led to the pivotal BARI (Bypass angioplasty revascularisation investigation) study, which was a much larger trial that was conducted in multiple centres across the USA. I would say that these trials were most important because they highlighted the value of angioplasty.
Also, there is my work in resolving the issue of restenosis. My centre was involved in using radiation therapy to block the restenosis, but this therapy was later replaced with drug-eluting stents—which, of course, is now the first-line treatment for managing occlusive coronary artery disease.

What do you think has been the greatest development in angioplasty?

The steerable guidewire, which was introduced long before drug-eluting stents. Initially, we could not easily move a balloon to where it needed to go. But once we had steerable guidewires, we were able to go where we needed to go. Therefore, I think that has been the biggest development.
Stents were the innovation that solved the acute problem, meaning we did not have to rush patients off to emergency surgery anymore if the balloon blocked the artery. The addition of drug-eluting stents further added to the development of angioplasty because they were not associated with as much restenosis as bare metal stents were.

Europcr is holding an exhibition of the 40th anniversary of angioplasty. Why do you think the exhibition is worth attending?

History is always important; we need to learn from the past to understand where technologies came from. I recently gave a lecture about the 40th anniversary for a Society of Coronary Angiography and Interventions (SCAI) training programme. They invited me because apparently they discovered many interventional cardiology fellows were not able to identify A. Grüntzig by picture or by name.  
I think understanding the blind alleys we went down with angioplasty is helpful; there were so many technologies that we tried in the late 80s and early 90s before we eventually abandonned them and started to use stents. If you are going to make progress in the future you have to understand the past.

What advances do you hope will happen in the next 40 years in angioplasty?

The most important advance would be for angioplasty to become unnecessary and I am not saying that in jest! If atherosclerosis can be controlled by medical means alone, then we would not need to open arteries with angioplasty. But the advances that we need now is to be able open up the artery and leave nothing behind in the long run. This need has led to the development of bioresorbable scaffold technology. At the moment, we have some concerns about this technology and it has not been proven to be better than second-generation drug-eluting stents. However, we will continue to look for ways to improve these devices.
Also, what we would really like to know—which is sort of the Holy Grail of coronary intervention—is which people with atherosclerosis (if they get old enough, most people develop atherosclerosis) are likely to have a heart attack and in what part of the artery the attack will occur. While we have a substantial amount of research in this area, we do not yet have a good way of identifying vulnerable plaque that will result in a heart attack.