Voyaging in the vein: medical experimentation with heart catheters in the twentieth century.

Historical research on physiology has to date largely been confined to the rise and peak of physiological investigations in the 18th and 19th century. This article examines how the instrument of the cardiac catheter was used in 20th century research on the heart. The development of the domain of interventional cardiology is shown in the efforts of standardising balloon angioplasty. A special focus is given in the three studies on Werner Forssmann, André Cournand and Dickinson Richards and Andreas Grüntzig to issues arising from the human being as an experimental object in medicine and to instruments as another material part in the experimental system.

Hybrid procedures for acute limb ischemia.

The most efficient treatment for acute arterial embolism is operative embolectomy using Fogarty's balloon catheter, especially if a single large artery is involved. Unfortunately, although the early surgical success of arterial thromboembolectomy often seems acceptable, the early clinical outcome still remains unsatisfactory. This may be related to the incomplete restoration of perfusion (i.e., residual thrombus in distal vessels not reached by the balloon catheter thromboembolectomy), propagation of residual thrombi or presence of underlying steno-occlusive lesions. In such a situation a meticulous intraoperative assessment of the adequacy of clot removal is decisive. Residual thrombus, chronic atherosclerotic disease and even vessel injuries secondary to balloon catheter passage can be corrected by endovascular techniques (hybrid procedures). The combination of surgical and endovascular options may overcome the limitations that characterize the traditional approach, and it is likely that in the future many treatments will be a mix of techniques that can be performed by vascular surgeons in the operating room or in a dedicated endovascular suite. This review article summarizes the hybrid treatment options for acute arterial occlusion caused by either embolism or local thrombosis.

Structural heart disease interventions: an emerging discipline in cardiovascular medicine.

Within the past decade, we have witnessed the exponential growth of novel percutaneous transcatheter therapies for the treatment of valvular and congenital heart disorders among others. Consequently, a new field has emerged in the world of adult cardiovascular medicine known as "structural heart disease interventions." We herein provide a contemporary review highlighting many of the important historical landmarks that have set the stage for the development of this new and exciting subspecialty, and introduce a comprehensive overview of the structured training and challenges that will be required to master this field. To our knowledge, our Structural Heart Disease fellowship constitutes one of the very first dedicated training programs in the United States. We believe our experience may be of value to other similar emerging programs across the country and the world.

Past, present and future of femoropopliteal stenting.

Endovascular stent implantation was introduced to femoropopliteal procedures almost 2 decades ago. Initial results with balloon-expandable stainless steel stents and self-expanding Elgiloy stents, however, were disappointing. In particular, recurrence rates after long-segment femoropopliteal stenting were catastrophically high, in the range of 60% to 80% at 1 year. Also, attempts to resolve the problem of in-stent restenosis (ISR) using first-generation covered stent-grafts led to unsatisfactory results, high procedural complication rates due to large introducers, and a high incidence of graft thrombosis, which did not make these devices convincing alternatives to bare metal stents. After years of stagnation, however, recent developments in femoropopliteal stent technology have been promising. Self-expanding nitinol stents have been evaluated in several prospective studies. Initial problems with stent fractures seem to be resolved using second-generation devices; for the first time, stenting has been shown to be beneficial compared to balloon angioplasty in longer femoropopliteal lesions. Nevertheless, although superior to balloon angioplasty, nitinol stenting is still associated with a considerable restenosis rate, and treatment of ISR remains problematic. Future concepts to further improve long-term patency after femoropopliteal stenting therefore are under investigation, including drug-eluting stents, biodegradable stents, and coated stent-grafts. From a current perspective, femoropopliteal stenting remains the Achilles' heel of the interventionist.

Clinical trials: past, present, and future.

Carotid stenting has been in evolution for the past 15 years. Initially limited by a lack of dedicated equipment, pivotal trials using both dedicated stent technology and embolic protection filters in patients at high risk for surgical endarterectomy have been largely completed, and results have compared favorably to both direct and historical surgical controls. While this has led to Food and Drug Administration approval of at least six carotid stent systems in the US, European randomized trials in standard surgical risk patients have had mixed results and confused the perception of the place of this technology in the care of patients with carotid stenosis. Current US trials are in progress, one nearing completion, and they will further contribute an understanding as to the place of stent therapy in the standard surgical risk patient, regardless of symptomatic status.

Carotid stenting: new devices on the horizon and beyond.

While popularization of carotid bifurcation intervention occurred only 10 years ago, the rapidity with which technology changed in performing the procedure was astounding. Restrictions upon the performance of the procedure has likely held off continued rapid advancement, nevertheless, there are devices currently in trial and more that have at least been conceived of which will decrease the risks associated with carotid bifurcation intervention. In the following article, device advances that the practicing carotid interventionalist can expect to see within the next few years are reviewed and a look to the future is presented as well.

Perspective: carotid stenting and the history of disruptive technology in vascular surgery.

This article defines disruptive technology and discusses such technologies in Vascular Surgery. It considers the question: Is carotid artery stenting (CAS) a disruptive technology? Although CAS will impact positively on the treatment of carotid bifurcation disease, it will probably never displace carotid endarterectomy in the majority of patients. The precise role of CAS remains to be determined.

How to introduce carotid angioplasty without compromising patient safety.

Carotid angioplasty with stenting (CAS) is increasingly being used in the treatment of extracranial carotid disease and numerous studies have demonstrated its feasibility. However, the exact role of CAS in the treatment of carotid stenosis and its long-term efficacy has not been defined. The assessment of the patient's medical condition, the exact identification of vessel anatomy as well as anomalies of the aortic arch and the cervicocerebral circulation is required for successful and safe performance of CAS. New CAS practitioners would be advised to start their experience in patients with predominantly easier anatomical situation as well as plaque configuration. The appropriate selection of interventional techniques as well as vascular access for CAS is dependent on the anatomy of the aortic arch and of the CCA proximal to the target lesion. Usually a retrograde femoral artery approach to access the CCA is preferred. In order to treat a patient safely with carotid artery stenting, it essential for interventionalists to appropriately chose a patient suited for endovascular therapy, to identify possible sources of complications prior to the interventional procedure as well as to know the key points for a successful carotid artery intervention. An interdisciplinary evidence-based approach will facilitate the choice of optimal intervention for each patient. Finally, trainee programs for physicians starting with CAS as well as facility certification are absolutely mandatory to ensure high success rates as well as low complication rates.

[Thirty years of the balloon catheter--A. Grüntzig and percutaneous balloon angioplasty]. / Tricet let balónkového katetru: A. Grüntzig a perkutánní balónková angioplastika.

Percutaneous transluminal coronary angioplasty--PTCA--will forever be linked with A. Gruentzig's name. Building on the work of Charles Dotter and Malvin Judkins be developped novel technique of revascularisation and established a new speciality - interventional cardiology. The aim of this article is to sum up the most important data on Gruentzig's revolutionary work. Andreas Roland Gruentzig was born on June 25, 1939 in Dresden, Germany. In 1957 he received his B. A. in Leipzig (German Democratic Republic). In 1958, Andreas emigrated to the German Federal Republic, received another B. A. in Heidelberg, and entered the Medical School in Heidelberg where he qualified in 1964. In 1969 he moved to Zurich, Switzerland, in the Dept of Angiology of the University Hospital. He soon appreciated the potential of recanalising partially occluded lower limb arteries using the Dotter-Judkins catheter but also recognised its risks. In 1972-1973 he developped his balloon catheter and performed the first femoral angioplasty in February 12, 1974, and in January 23, 1975 the first one using his new double-lumen catheter. The first experimental coronaroplasty in a dog followed in September 24, 1975. He presented his results with balloon catheters in November 15, 1976 in Miami. After a further period of arduous experimental research--stil manufacturing the catheters with his small crew in the kitchen--he dilated a stenosed coronary artery in a 37-year-old man on September 16, 1977 in Zurich, with immediate relief of symptoms. The results of PTCA in five first patients were published in the February 14, 1978 issue of Lancet; the coronarography in the first patient, on April 10, 2000, revealed normal patency of the site that had been dilated (Prof. B. Meier, Bern). However, the news in Zurich 1978 was received with a certain incredulity and Gruentzig was unable--in spite of Professor A. Senning's support--to obtain facilities to expand his research program and clinical activities. In September 1980 he accepted the Chair of Medicine (Cardiology) and Radiology with the additional title of Director of the Dept of Interventional Cardiology at Emory University in Atlanta, Georgia. Prof. Hurst gave him half of his office suite at Emory and later even further facilities to expand his program. Here, at Emory, Gruentzig gave 10 angioplasty courses and performed with Dr. S. King and Dr. J. Douglas 5000 PTCAs till 1985. Before reaching the peak of his scientific carrier, he died in a flying accident, with his second wife Margareth Ann, near Forsythe, Monroe County, Georgia, on October 27, 1985. His work was appreciated in tributes from the U.S.A., U.K., Switzerland and Germany, by many international awards and honors; numerous interventional laboratories in the world carry A. R. Gruentzig's name.

Stents com eluição de medicamentos / Eluting stents of medicamentous

Em 1977, Andreas Grüntzig introduziu a técnica de abordagem não-cirúrgica para o tratamento da doença arterial coronária, conhecia como angioplastia transluminal coronária percutânea. Posteriormente, com o acúmulo de experiência nesse campo, foram detectadas algumas limitações do método representadas principalmente, por quatro aspectos: morfologias de alta complexidade, estenoses residuais acime de 30%, oclusão aguda do vaso-alvo e reestenose coronária, que pela prevalência e consequências que acarreta, talvez represente o evento mais adverso na evolução da revascularização percutânea...

[One hundred years of the Association of Surgeons in the Netherlands. VII. Vascular surgery]. / Honderd jaar Nederlandse Vereniging voor Heelkunde. VII. Vaatchirurgie.

The Dutch Society for Vascular Surgery was founded in 1981, as the first daughter of the Association of Surgeons in the Netherlands. Twenty years of vascular surgery show a broad perspective. Aside from the traditional handywork--central vascular reconstruction, bypass surgery (especially in the legs), and carotid surgery--, there have been many developments. Operations are less invasive and vascular surgeons are cooperating more and more intensively with other medical disciplines, especially radiology. Examples are the endovascular treatment of abdominal aortic aneurysm, in which an endoprosthesis is inserted via minute incisions in the groin by the vascular surgeon and an (interventional) radiologist together. In addition, interventions such as percutaneous transluminal angioplasty and stenting as well as new diagnostic possibilities (e.g. MRA) strengthen the cooperation with the radiologists. The multidisciplinary approach is also extremely important in other areas. Vascular surgeons team up with internal-medicine specialists (diabetes, hypertension, lipid metabolism disorders, thrombotic syndromes, etc.), rehabilitation specialists and podotherapists (in cases of diabetic foot and amputation), vascular laboratory technicians (diagnostics and follow-up by means of doppler and duplex techniques), and neurologists (cerebrovascular diseases). In the vascular centres, patients are treated effectively by a multidisciplinary team that draws up a plan for diagnosis and treatment. The two-year postgraduate course in vascular surgery is one of the tools used to guarantee and improve the high standard of quality. To this end, cooperation within Europe in the European Society for Vascular Surgery and the development and organisation of European examinations in vascular surgery are also of the essence.