Percutaneous transluminal coronary angioplasty: state of the art and future directions

  • Gary S. Roubin
  • Andreas R. Gruentzig


Current developments in the practice of percutaneous transluminal coronary angioplasty concern increasing the safety of the procedure and reducing the incidence of lesion recurrence. Technical improvements and increased operator experience have greatly expanded the indications for the procedure. With experience, success in dilating proximal discrete lesions is now almost absolute. Old, calcified lesions and chronic total occlusions remain the barriers to total success. Careful case selection and expert anaesthesiology and surgical support are paramount in maintaining low complication rates. The largely unpredictable occurrence of acute vessel reclosure in approximately 2% of patients remains the major problem. This complication is usually the result of uncontrolled intimai dissection. These risks are considerably increased in patients with multivessel and diffuse disease and long lesions. Randomized trials are required to determine if such patients are best managed with bypass graft surgery. Early detection of less advanced coronary disease will ultimately lead to the most effective application of PTCA. Lesion recurrence mav be reduced, in part, by careful attention to achieving an optimal, initial arteriographic and haemodynamic result. Otherwise, the solution to restenosis will depend on the development of pharmacological agents which prevent the rapid regrowth of atheromatous plaque.


percutaneous coronary angioplasty 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Gruentzig AR, Senning A, Siegenthaler WE: Non-operative dilatation of coronary artery stenosis: percutaneous transluminal coronary angioplasty. N Engl J Med 301: 61–68, 1979PubMedGoogle Scholar
  2. 2.
    CASS principal investigators and their associates: coronary artery study (CASS): a randomized trial of coronary artery bypass surgery. Circulation 68(5): 939–950, 1983Google Scholar
  3. 3.
    Bredlau C, Gruentzig A, Douglas J Jr, King S III: Acute complications of percutaneous transluminal coronary angioplasty (PTCA) — initial experience in 3000 consecutive patient attempts (Abstract). Circulation 70: 424, 1984Google Scholar
  4. 4.
    Cowley MJ, Dorros G, Kelsey SF, Van Raden M, Detre KM: Acute coronary events associated with percutaneous transluminal coronary angioplasty. Am J Cardiol 53: 12C-13C, 1984PubMedGoogle Scholar
  5. 5.
    National cooperative study group to compare surgical and medical therapy. II. In-hospital experience and initial follow-up results in patients with one, two and three vessel disease. Am J Cardiol 42: 839–848, 1978Google Scholar
  6. 6.
    National cooperative study group to compare surgical and medical therapy. Results in left anterior descending disease. Am J Cardiol 48: 517–524, 1981Google Scholar
  7. 7.
    Kramer JR, Matsuda Y, Mulligan JC, Aronow M, Proudfit WL: Progression of coronary atherosclerosis. Circulation 63(3): 519, 1981PubMedGoogle Scholar
  8. 8.
    Moise A, Bourassa MG, Theroux P, Taeymans Y, Pasternac A, Campeau L, Bois MA, Dyrda I, David PR: Prognostic significance of progression of cornary artery disease. Am J Cardiol 55: 941–946, 1985PubMedGoogle Scholar
  9. 9.
    Harris PJ, Harrell FE, Lee KL, Behar VS, Rosati RA: Survival in medically treated coronary artery disease. Circulation 60:1259–1269, 1979PubMedGoogle Scholar
  10. 10.
    Roubin GS, Harris PJ, Bernstein L, Kelly DT: Coronary anatomy and prognosis after myocardial infarction in patients 60 years and younger. Circulation 7: 743–748, 1983Google Scholar
  11. 11.
    Hammermeister KE, DeRouen TA, Dodge HT: Variables predictive of survival in patients with coronary disease. Selection by univariate and multivariate analyses from the clinical, electrocardiographic, exercise, arteriographic and quantitative angiographic evaluations. Circulation 59: 421–430, 1979PubMedGoogle Scholar
  12. 12.
    Participants of the veterans administration cooperative study of surgery for coronary arterial occlusive disease: Relation of severity of symptoms to prognosis in stable angina pectoris. Am J Cardiol 54: 988–993, 1984Google Scholar
  13. 13.
    Reeves TJ: Relation and independence of angina pectoris and sudden death in persons with coronary atherosclerotic heart disease. J Am Coll Cardiol 5: 1678–1748, 1985Google Scholar
  14. 14.
    Campeau L, Lesperance J, Hermann J, Corbara F, Grondin CM, Bourassa MG: Loss of improvement of angina between 1 and 7 years after aortocoronary arteries. Circulation 60(I): 1–5, 1979Google Scholar
  15. 15.
    Chesebro JH, Clements JP, Fuster V, Elveback LR, Smith HC, Bardsley WT, Frye RL, Holmes DR, Vlietstra RE, Pluth JR, Wallace RB, Puga FJ, Orszulak TA, Piehler JM, Schaff HV, Danielson GK: A platelet-inhibitor-drug trial in coronary artery bypass operation. N Engl J Med 307:73–78, 1982PubMedGoogle Scholar
  16. 16.
    Douglas JS, Gruentzig AR, King SB, Hollman JL, Bone DK, Guyton R: Percutaneous transluminal coronary angioplasty in patients with prior coronary bypass surgery. J Am Coll Cardiol 2: 745–754, 1983PubMedGoogle Scholar
  17. 17.
    Rentrop KP: Thrombolytic therapy in patients with acute myocardial infarction. Circulation 71: 627–631, 1985PubMedGoogle Scholar
  18. 18.
    Kennedy JW, Ritchie JL, Davis KB, Stadius ML, Maynard C, Fritz JK: The western Washington randomized trial of intracoronary streptokinase in acute myocardial infarction: a 12 month follow-up report. N Engl J Med 312: 1073–1078, 1985PubMedGoogle Scholar
  19. 19.
    Hartzler GO, Rutherford BD, McConahay Dr: Percutaneous transluminal coronary angioplasty: application for acute myocardial infarction. Am J Cardiol 53: 117C-121C, 1984PubMedGoogle Scholar
  20. 20.
    Gold HK, Cowley MJ, Palacios IF, Vetrovec GW, Akins CW, Block PC, Leinbach RC: Combined intracoronary streptokinase infusion and coronary angioplasty during acute myocardial infarction. Am J Cardiol 53: 122C-125C, 1984PubMedGoogle Scholar
  21. 21.
    Papapietro SE, MacLean WAH, Stanley AWH, Hess RG, Corley N, Arciniegas JG, Cooper TB: Percutaneous transluminal coronary angioplasty after intracoronary streptokinase in evolving acute myocardial infarction. Am J Cardiol 55: 48–53, 1985PubMedGoogle Scholar
  22. 22.
    Meyer J, Merx W, Dorr R, Erbel R, von Essen R, Lambertz H, Bethge C, Schmilz HJ, Bardos P, Minale C, Messmer BJ, Effert S: Sequential intervention procedures after intracoronary thrombolysis; balloon dilatation bypass surgery, and medical treatment. International J Cardiol 7: 281–293, 1985Google Scholar
  23. 23.
    Hall D, Gruentzig A: Influence of lesion length on initial success and recurrence rates in coronary angioplasty (Abstract). Circulation 70: 703, 1984Google Scholar
  24. 24.
    Meier B, Gruentzig A, Hollman J, Ischinger T, Bradford JM: Does length or eccentricity of coronary stenoses influence the outcome of transluminal dilatation? Circulation 67: 497–9, 1983PubMedGoogle Scholar
  25. 25.
    Anderson HV, Roubin GS, Leimgruber PP, Douglas JS, King SB, Gruentzig AR: Primary angiographic success rates of percutaneous transluminal coronary angioplasty. Am J Cardiol (In press)Google Scholar
  26. 26.
    Libow M, Leimgruber PL, Roubin G, Gruentzig AR: Restenosis after angioplasty (PTCA) in chronic total coronary artery occlusion (Abstract). J Am Coll Cardiol 5 (2): 445, 1985Google Scholar
  27. 27.
    Hall D, Gruentzig A: Recurrence rate after double-vessel dilatation (Abstract). Circulation 70: 425, 1984PubMedGoogle Scholar
  28. 28.
    Roubin GS, Leimgruber PP, Douglas JS, King SB, Gruentzig AR: Angioplasty in multivessel coronary artery disease: patient selection and dilatation strategy (abstract). J Am Coll Cardiol 5 (2): 445, 1985Google Scholar
  29. 29.
    Jones EL, Craver JM, Guyton RA, Bone DK, Hatcher CR, Riechwald N: Importance of complete revascularization in performance of the coronary bypass operation. Am J Cardiol 7–12, 1983Google Scholar
  30. 30.
    Robert EW, Guthaner DF, Wexler L, Alderman EL: Six year clinical and angiographic follow-up of patients with previously documented complete revascularization. Circulation 58: III-194, 1978Google Scholar
  31. 31.
    Knudtson ML, Hansen JL, Manyari DE, Roth DL, Flintoft VF: The role of incomplete revascularization by PTCA in patients with multivessel coronary artery disease. Circulation 70: II-108, 1984Google Scholar
  32. 32.
    de Peijter P, Wijne W, Simoons ML, Reiber JHC: Is single vessel angioplasty of the ischemia related vessel in unstable angina and multivessel disease an efficacious treatment. Circulation 70: II-108, 1984Google Scholar
  33. 33.
    Dorros G, Singh S, Janke LM: Coronary angioplasty in multivessel coronary disease. Circulation 70: II-107, 1984Google Scholar
  34. 34.
    Mabin TA, Holmes DR, Smith HC, Vlietstra RE, Reeder GS, Bresnahan JF, Bove AA, Hammes LN, Elveback LR, Orszulak TA: Follow-up clinical results in patients undergoing percutaneous transluminal coronary angioplasty. Circulation 71: 754–760, 1985PubMedGoogle Scholar
  35. 35.
    Ischinger T, Gruentzig A, Hollman J, King S, Douglas J, Meier B, Bradford J, Tankersley R: Should coronary arteries with less than 60% diameter stenosis be treated by angioplasty? Circulation 68: 148–154, 1983PubMedGoogle Scholar
  36. 36.
    Gould KL, Lipscomb K, Hamilton GW: Physiologic basis for assessing critical coronary stenosis. Am J Cardiol 33: 87–94, 1974PubMedGoogle Scholar
  37. 37.
    Leimgruber PP, Roubin GS, Anderson HV, Bredlau CE, Whitworth HB, Douglas JS, King SB, Gruentzig AR: Influence of intimai dissection on restenosis after successful coronary angioplasty. Circulation (In press)Google Scholar
  38. 38.
    Meier B, Gruentzig AR: Learning curve for percutaneous transluminal coronary angioplasty: skill, technology or patient selection. Am J Cardiol 53: 65C-66C, 1984PubMedGoogle Scholar
  39. 39.
    Kaltenbach M, Beyer J, Walter S, Klepzig H, Schmidts L: Prolonged application of pressure in transluminal coronary angioplasty. Cathet Cardiovasc Diagn 10: 213–219, 1984PubMedGoogle Scholar
  40. 40.
    Kaltenbach M, Kober G, Scherer D, Vallbracht C: Rezidivhäufigkeit nach erfolgreicher Ballondilatation von Kranzarterienstenosen. Kardiol 73: 161–166, 1984Google Scholar
  41. 41.
    Duprat G, David PR, Lesperance J, Val PG, Fines P, Robert P, Bourassa MG: An optimal size of balloon catheter is critical to angiographic success early after PCTA (Abstract). Circulation 70: 11–195, 1984Google Scholar
  42. 42.
    Schmitz HJ, Essen R, Meyer J, Effert S: The role of balloon size for acute and late angiographic results in coronary angioplasty. Circulation 70: II-295, 1984Google Scholar
  43. 43.
    Murphy DA, Craver JM, Jones EL, Gruentzig AR, King SB, Hatcher CR: Surgical revascularization following unsuccessful percutaneous transluminal coronary angioplasty. J Thoracic & Cardiovasc Surgery 84: 342–348, 1982Google Scholar
  44. 44.
    Murphy DA, Craver JM, Jones EL, Curling PE, Guyton RA, King SB, Gruentzig AR, Hatcher CR: Surgical management of acute myocardial ischemia following percutaneous transluminal coronary angioplasty. J Thoracic & Cardiovasc Surgery 87: 332–339, 1984Google Scholar
  45. 45.
    Dorros G, Cowley MJ, Janke L, Kelsey SF, Mullin SM, Van Raden M: In-hospital mortality rate in the National Heart, Lung and Blood Institute percutaneous transluminal coronary angioplasty registry. Am J Cardiol 53: 17C-21C, 1984PubMedGoogle Scholar
  46. 46.
    Vlietstra RE, Holmes DR, Reeder GS, Mock MB, Smith HC, Bove AA, Bresnahan JF: Balloon angioplasty in multivessel coronary artery disease. May Clin Proc 58: 563–567, 1983Google Scholar
  47. 47.
    Kennedy JW, Kaiser GC, Fisher LD, Fritz JK, Myers W, Mudd G, Ryan TJ: Clinical and angiographic predictors of operative mortality from the collaborative study in coronary artery surgery (CASS). Circulation 63: 793–801, 1981PubMedGoogle Scholar
  48. 48.
    Kennedy JW, Kaiser GC, Fisher LD, Maynard C, Fritz JK, Myers W, Mudd JG, Ryan TJ, Coggin J: Multivariate discriminant analysis of the clinical and angiographic predictors of operative mortality from the Collaborative Study in Coronary Artery Surgery (CASS). J Thorac Cardiovasc Surg 80: 876–887, 1980PubMedGoogle Scholar
  49. 49.
    Holmes DR, Vlietstra RE, Smith HC, Vetrovec GW, Kent KM, Cowley MJ, Faxon DP, Gruentzig AR, Kelsey SF, Detre KM, Van Raden MJ, Mock MB: Restenosis after percutaneous transluminal coronary angioplasty (PTCA): a report from the PTCA registry of the National Heart, Lung and Blood Institute. Am J Cardiol 53: 77C-81C, 1984PubMedGoogle Scholar
  50. 50.
    Thornton MA, Gruentzig AR, Hollman J, King SB, Douglas JS: Coumadin and aspirin in prevention of recurrence after transluminal coronary angioplasty: a randomized study. Circulation 69: 721–727, 1984PubMedGoogle Scholar
  51. 51.
    Levine S, Ewels CJ, Rosing DR, Kent KM: Coronary angioplasty: Clinical and angiographic follow-up. Am J Cardiol 55: 673–676, 1985PubMedGoogle Scholar
  52. 52.
    Meier B, Gruentzig A, King SB, Douglas JS, Hollman J, Ischinger T, Galan K: Higher balloon dilatation pressure in coronary angioplasty. Am Heart J 107 (4): 619–622, 1984PubMedGoogle Scholar
  53. 53.
    Whitworth H, Gruentzig AR, Hollman J, Galan K, Gershon L: Effect of nifedipine on recurrent stenosis after percutaneous transluminal coronary angioplasty (PTCA) (Abstract). J Am Coll Cardiol 5 (2): 524, 1985Google Scholar
  54. 54.
    Corlos T, David PR, Pere Guiteras V, Renkin J, Dangoisse V, Rapold HG, Bourassa MG: Failure of diltiazem to prevent restenosis after percutaneous transluminal coronary angioplasty. Am Heart J 109: 926–931, 1985PubMedGoogle Scholar
  55. 55.
    Hollman J, Gruentzig A, Meier B, Bradford J, Galan K: Factors affecting recurrence after successful coronary angioplasty (Abstract). J Am Coll Cardiol I: 644, 1983Google Scholar
  56. 56.
    Kent KM, Bentivoglio LG, Block PC, Bourassa MG, Cowley MJ, Dorros G, Detre KM, Gosselin AJ, Gruentzig AR, Kelsey SF, Mock MB, Mullin SM, Passamani ER, Myler RK, Simpson J, Stertzer SH, Van Raden MJ, Williams DO: long-term efficacy of percutaneous transluminal coronary angioplasty (PTCA): Report from the National Heart, Lung and Blood Institute PTCA Registry. Am J Cardiol 53: 27C-31C, 1984PubMedGoogle Scholar
  57. 57.
    Gruentzig A, Schlumpf M, Sigenthaler W: Long-term results after coronary angioplasty (Abstract). Circulation 70: 1290, 1984Google Scholar
  58. 58.
    Weinstein MC, Stason WB: Cost-effectiveness of coronary artery bypass surgery. Circulation 66: III-66, 1982Google Scholar
  59. 59.
    Jang GC, Block PC, Cowley MJ, Gruentzig AR, Dorros G, Holmes DR, Kent KM, Leatherman LL, Myler RK, Sjolander SME, Stertzer SH, Vetrovec GW, Willis WH, Williams DO: Relative cost of coronary angioplasty and bypass surgery in a one-vessel disease model. Am J Cardiol 53: 52C-55C, 1984PubMedGoogle Scholar
  60. 60.
    Kelly ME, Taylor GJ, Moses HW, Mikell FL, Dove JT, Batchelder JE, Wellons HA, Schneider JA: Comparative cost of myocardial revascularization: percutaneous transluminal angioplasty and coronary artery bypass surgery. J Am Coll Cardiol 5: 16–20, 1985PubMedGoogle Scholar
  61. 61.
    Reeder GS, Krishan I, Nobrega FT, Naessens J, Kelly M, Christianson JB, McAfee M: Is Percutaneous coronary angioplasty less expensive than bypass surgery? N Engl J Med 311: 1157–1162, 1984PubMedGoogle Scholar

Copyright information

© Martinus Nijhoff Publishers 1985

Authors and Affiliations

  • Gary S. Roubin
    • 1
  • Andreas R. Gruentzig
    • 1
  1. 1.Emory University School of MedicineAtlantaUSA

Personalised recommendations