THE FIRST 20 YEARS OF CORONARY ANGIOPLAST Y - RETROSPECTIVE AND OUTLOOK

The first coronary angioplasty (PTCA) procedure performed by Gruntzig in Zurich in 1977 was not the beginning but the breakthrough in interv entional cardiology. PTCA is today the most frequent of the major inte rventions in medicine and constitutes an important economic factor. At first the development of PTCA was slow because many European countrie s postponed invasive assessment of coronary artery disease until the p atient was refractory to a combination of drugs. Thus, the early forms of coronary artery disease, optimal for PTCA, were rarely found among the coronary angiograms performed. In the US, facilities for coronary angiography were already expanding in the seventies. They provided th e ideal background for PTCA to thrive. Together with Andreas Gruntzig, PTCA moved to the New World in late 1980. Only very recently, the Old World and the Orient have caught up with the US and are now about to assume a leading role. In spite of untiring endeavors, the angioplasty balloon has not been replaced by more sophisticated systems. Only the coronary stent has proved invaluable as a complement to the balloon. After preliminary use in peripheral vessels, the first coronary stent was implanted by Fuel in Toulouse on March 28, 1986. In the meantime, the stent has grown to become an integral part of PTCA in about half t he cases. Indications for PTCA have not changed significantly since it s inception. Success and complication rates, however, have significant ly improved. The method is still best applied to single vessel disease . In double or triple vessel disease, it may be preferable to bypass s urgery or medical treatment in selected cases where not all main vesse ls are affected and the total number of lesions does not exceed 3-4. T he risk of an abrupt vessel closure during or immediately after PTCA h as decreased over time to about 2% currently compared with 7% before t he use of stents. Yet it continues to be a hazard to be taken seriousl y. The risk of recurrence has also diminished in the era of stents but still amounts to 20-40% depending on the situation. Switzerland occup ies an important position in Europe today concerning the use of PTCA p er head of population. It is in. a group with Belgium, France, and the Netherlands running up to the leader, Germany. Since 1993, there have been more PTCA procedures than coronary bypass operations in Switzerl and. PTCA is performed today at 5 university hospitals, 9 additional p ublic hospitals, and 9 private clinics. The majority of the procedures are done during the diagnostic study. The total number of coronary by pass operations has continued to increase slightly in spite of PTCA. T his documents the fact that true triple vessel disease is still a doma in for surgery and that the indication threshold has been shifted to t he elderly patient. Therefore, the total need for revascularization pr ocedures has drastically increased. Further growth of PTCA can be pred icted unless political measures, such as rationing, reduced credential ing, or drastic cuts in reimbursement are introduced. The recently dev eloped minimally invasive direct coronary artery bypass (MIDCAB) surge ry is likely to compete with conventional bypass surgery as much as wi th PTCA. Its final role remains to be defined. As a side benefit it re presents a means of quality control, uniting surgeons and intervention al cardiologists in case discussions again with increasing frequency.