CVVT 1201 Introduction to Cardiovascular Technology A HISTORICAL PRESPECTIVE

The concept of catheterization has been around for about 5,000 years The concept of catheterization has been around for about 5,000 years. Using metal pipes, the Egyptians first performed bladder catheterizations around 3,000 B.C.

In 1941 Dr. Andre Cournanad began to measure cardiac output by using catheters Right Heart techniques evolved Much of the drive came from Pediatric Cardiologist investigating congenital heat defects. Dr Zimmerman was the first to demonstrate the retrograde technique by passing a catheter into the left ventricle to measure pressures in 1949

In 1953 Dr. Seldinger developed the percutaneous femoral artery technique. Until the end of the 1950’s, only non-selective visualization of the proximal portion of the coronary vasculature could be documented. This was done by injecting a large bolus of contrast material in the root of the aorta

Werner Freeman usually credited with performing the first cardiac catheterization of a living person- himself He passed a catheter 64cm through one of his antecubital veins, guiding it with fluoroscopy until it entered the right atrium. He then went to the radiology department and documented it with a chest roentgenogram…….

Dr. Forssmann self cath. Note catheter

Dr Mason Sones Jr. performed the first selective coronary angiogram in 1959. He is known as the father of coronary angiography.

Dr. Sones preformed catheterizations via a one inch incision in the antecubital space to insolate the brachial artery, an approach now known as the Sones technique.

Dr. Sones’s Technique

Representation of a Sones catheter: note closed ends.

Alternative to Sones Technique

Other advances occurred regularly over the following years. Dr’s Ross and Brokenbrough developed Transeptal catheterization at the National Institute of Health Their techniques, and devices that they developed, are still in use today

Transeptal catheterization

In 1964, Drs Charles Dotter and Dr In 1964, Drs Charles Dotter and Dr. Melvin Judkins began working on patient’s that had peripheral artery disease. They found that by inserting a series of stiff dilators, gradually increasing the diameter, through the diseased sections of the vessels, blood flow was improved. Dotter called this technique transluminal angioplasty.

Dotter was ridiculed by his peers, and his technique was largely ignored in the United States for the flowing 15 years.

Seldinger’s technique

In 1967 , Dr. Judkins, a radiologist, began using Seldinger’s technique and catheters with pre-formed curves to visualize the coronary anatomy.

Dr Judkins took straight catheters and inserted stylets into then to form curves with them. Through trial an error, he found the most appropriate shapes for reaching the ostium of the coronary arteries. Because the pre-formed catheters made cannulation of the coronary arteries easier, the Judkins technique eventually surpassed the Sones technique as the preferred method of catherization.

Lt Coronary artery catheterization

These catheters are Judkins style, as they have an open end.

The era of modern coronary artery bypass surgery ( CABG ) began in 1967 when Dr. Rene Favaloro conducted the first modern saphenous vein bypass graft at the Cleveland Clinic.

Some of these catheters are used to engage the bypass vessels

Drs. Swan and Ganz introduced a flow-directed, balloon-tipped catheter for monitoring right heath pressures and thermodilution cardiac outputs in 1970.

This transformed the catheter into a tool that could be used at the bedside in an intensive care unit.

During the early 1980’s, cardiologists were limited by primitive equipment and inadequate materials

Balloons were originally fixed-wire and not available in the multitude of diameters and lengths they are today. They would easily break, and sometimes rupturing within the patient, resulting in severe vessel dissections. Guide catheters were about 10F and very stiff.

Cardiologist had to prove themselves to the world and to the especially to the skeptical surgeons that dilation was a safe, able alternative to standard medical therapy and surgery. Cardiologist would treat only single-vessel, proximal lesions. If a patient had more that one artery, most often they were referred for surgery. If the Cardiologist was aggressive , he would treat disease in one artery and then invite the patient back to dilate an additional artery.

Early Angioplasty Protocols Angioplasties were performed with surgical standby, with surgeons and staff waiting within the cath lab. Patient were often keep hospitalized for several days after an angioplasty for observation and anticoagulation therapy. Improved devices led to a greater procedural success, and Angioplasty became accepted as a valid alternative to surgical intervention. The differentiation between patients suitable for surgery and suitable for dilated was constantly being reviewed, a process that continues today.

Success of Angioplasty = new disease process : Restenosis

RESTEOSIS : Known as the Achilles heel of angioplasty. It occurred in roughly 40 % of the lesions treated Cardiologist began to speculate about other catheter based options Directional atherectomy Lasers the Rotablator the balloons themselves improved quickly, became available in a wider range of diameters and lengths with lower crossing profiles.

Atherectomy: This specialized procedure involves the insertion of a rotating catheter at up to 180,000 rpm. The obstructing fibrous plaque is pulverized into minute micro particles and washed away into the bloodstream.

Laser: produces a high intensity light beam which vaporizes the affected region without damaging the surrounding tissues

Angiojet: The saline jets create a near perfect vacuum in a 360 degree radius around the tip. This vacuum pulls the thrombus into the jet stream where it is broken into microscopic fragments and propelled out of the patient's body.

Lower profile balloons

Interventional Cardiology took its next step with the development of the intra coronary stent

In 1993 the FDA approved Gianturco-Roubin Coil Stent In 1993 the FDA approved Gianturco-Roubin Coil Stent . It resembled the spring in a ball point pen. The device was only approved for the acute and threatened closure by vessel dissection following balloon angioplasty

The Palmaz-Schatz Stent ( Johnson & Johnson) arrived shortly thereafter and became the first device to show any significant reduction in restenosis

It was found however, that stent placement also produced restenosis, although at rates lower than with PTCA Localized delivery of radiation ( vascular brachytherapy) Drugs Cryotherapy Microwaves Lasers Ultrasound Have been developed, some even clinically approved, to treat this phenomenon.

In 2002, the first drug – eluting stent received FDA approval. It combined a proven stent design with a pharmaceutical agent that inhibits smooth muscle profiliation

The Cypher Stent ( Johnson & Johnson) was the first technique/device ever to have 0% angiographic restenosis at six month follow-up in a clinical trial. Other Stent Companies , using other drugs, were not far behind in their development of coated stents. Only time will tell whether the Achilles’ heel of interventional cardiology has been overcome.

Other Vascular Stents

Valve Dilation using a balloon technique

Stenting for Aortic Anyesurim

Carotid Artery Stent Angioplasty

Q&A