World's first angioplasty patient is still going strong
Forty years ago, Andreas Grüntzig performed the world’s first coronary angioplasty (PCI)—fundamentally changing the management of coronary artery disease. Bernhard Meier, who worked with A. Grüntzig and actually identified the patient for the procedure, talks to The Daily Wire about this first procedure and about his role as an angioplasty pioneer.
How did A. Grüntzig make the leap from performing animal experiments to performing the first-in-man procedure?
He was already at the stage when he could perform coronary angioplasty in a human in 1975. However, finding the right patient was difficult because he wanted someone with single-vessel disease. At that time, people usually only underwent a coronary angiogram when they had advanced disease and, as a result, predominantly had multiple vessel disease. Therefore for more than two years, we were looking for a suitable patient for him until I happened to care for a patient—in September 1977—who had had started to experience severe symptoms of coronary artery disease two weeks prior to him presenting at clinic. Unusually for that time, because he was so young (38 years old), he underwent a coronary angiogram—the normal practice was to treat a patient medically for a few years before they underwent an angiogram. He was found to have single-vessel disease and I immediately showed his angiogram results to A. Grüntzig (who had actually just come back from an unsuccessful trip to the USA to look for a first patient there). He was very pleased to find finally have found a suitable candidate for his procedure!
How did the patient feel about undergoing the first-in-man coronary angioplasty?
He was immediately all for it when A. Grüntzig suggested it to him. He was scheduled to undergo coronary artery bypass grafting (CABG) and was in the same hospital room as another patient who had undergone CABG. This other patient was moaning and groaning about the pain from the procedure and about how hard the recovery was; therefore, I think this first patient was almost eager to undergo angioplasty because it was a chance to avoid CABG.
A. Grüntzig did explain that coronary angioplasty had only been performed in dogs at that stage and that it had never been done in humans before. He also told the patient that if something went wrong or the procedure did not work, he would still have to undergo CABG. But, given that he would have to have CABG if he did not undergo angioplasty, he was more than willing to try it. The procedure was scheduled the next day.
What was the procedure like?
It was a real success! The patient is still alive and is going to be celebrating the 40th anniversary of the procedure in September. He has never needed to undergo CABG!
However, he has undergone further angioplasty procedures—the second procedure about 23 years after the first procedure, when he rang me up (we have been in regular contact since that first procedure) and told me he was having similar symptoms to those that he had in 1977. On angiogram, we found that he did indeed have a narrowing of a coronary artery in the vicinity of the site treated back in 1977. He received a bare metal stent and soon thereafter needed another procedure for in-stent restenosis. Additionally, in 2015, he underwent percutaneous coronary intervention (PCI) with drug-eluting stents for two new narrowings, one close to the initial site and one in the right coronary artery. Since then, he has had no further problems.
In the 40 years since that first procedure, what do you think has been the biggest advance in angioplasty?
The stent, which was introduced in 1986, was the only innovation that dramatically improved the overall performance of the procedure. The subsequent introduction of the drug-eluting stent, which prevented the over-zealous coverage of the stent by tissue, was another significant advance—the restenosis rate was reduced from 15% to 3–4%. The stent is basically the only milestone. The significant improvements in guiding catheters and guidewires, that have made negotiating the coronary arteries much easier, and balloon catheter characteristics were welcome but not breakthrough advances like the stent.
That said, the changes in indications for coronary angiography, permitted by a multiplication of the respective facilities, have meant that we are now able to treat patients earlier on in the disease process. These days, patients tend to undergo coronary angiography as soon coronary artery disease is suspected and, therefore, are identified when they only have a single or a few rather than multiple lesions—meaning that they are suitable for angioplasty and do not need CABG. In the early days of the procedure, 85% of patients undergoing coronary angiography were not suitable because of the advanced stage of their disease. These days, angioplasty is the predominant approach for coronary revascularisation with only 15% of patients needing surgery.
What do you think has been your biggest contribution to angioplasty over the past 40 years?
Following the lead of A. Grüntzig, I have helped to simplify the angioplasty procedure. Initially, it was almost like CABG. You had to have the surgical unit on site and you put a pacemaker and a pulmonary catheter into the patient prior to the procedure with the patient being heavily sedated. Along with others, I stripped the procedure of the unnecessary stuff and enabled angioplasty to be something that could be easily accomplished within less than an hour with the patient watching what is happening on the monitor. Today, they can get up an hour after the procedure, leave the hospital after two hours, and play tennis (should they want to) later in the day. Of course, some cases are more complicated and have a longer procedure time. But a simple angioplasty is almost like fixing a tooth—not very costly and very tolerable for the patient.
Do you think the procedure becoming simplified has enabled more complex patients to be treated with the procedure?
The idea that we now treat more complex patients is, in part, a misconception. Even in the beginning, we treated complex patients with angioplasty—though it was more difficult to do because the equipment was not as good as it is today. Over the past 40 years, the indications for angioplasty have not really changed. Some people have tried to use it in very complex patients, but their results have not and will never rival those of CABG. Studies show that in patients with advanced multivessel disease surgery, long-term, is better than PCI.
Certainly, multivessel PCI to date is much safer than it was. Initially, the risk of a lesion abruptly occluding was about 7%—meaning that dilating four or more lesions in the one setting was too dangerous to attempt. The risk of abrupt occlusion is now less than 1% per lesion, so you can safely perform multivessel PCI. But time and time again, in the most complex situations, surgery has proven to be the superior therapy in the long term. However, one indication that has changed is that it is now possible to open up lesions that have been completely occluded for a long time. The ability to treat chronic total occlusions was limited in the beginning; now, with modern equipment, we can manage these lesions with PCI.
What do you think will be the biggest advance in the next 40 years?
Today, the procedural success rate is 98% and I am not sure we can expect any more breakthroughs. We are so close to perfection with the current stent technology that I cannot imagine anything replacing it that would allow you to have a 99% or a 100% success rate—although, of course, who would dare to exclude that something be invented to that end?
It was tried to improve outcomes with bioresorbable scaffolds for about 30 years but they have not really worked so far. They are simply no match for modern drug-eluting stents. At the moment, I would bank on permanent stents being used forever.
What will happen is that there will be more spin offs from angioplasty; other conditions will be increasingly fixed with catheters. Valvular disease and congenital heart disease are now being managed with these catheter-based techniques. Moreover, stents are now being put into digestive and urogenital tubes for various conditions. Coronary angioplasty has opened a whole wealth of possibilities in the field of minimally invasive treatment.