The outcome of coronary stenting has proved to be superior compared to balloon angioplasty for most indications. Improvements in device design and deployment technique were key components in reducing the restenosis rates of bare stents from 30%¹ initially, to 26.6%,² 24.4%,³ or 15.7%.⁴ Additional approaches included active and passive coatings.

Conventional balloon angioplasty aims to reduce or eliminate coronary arterial stenoses. This is achieved by a combination of plaque compression and fracture, creation of intimal flaps and localized medial dissection, as well as stretching and remodeling of the arterial wall. Depending upon the specific forces applied to the vessel wall and the physical and biological characteristics of the atherosclerotic lesion, differing degrees of each of these mechanisms will take place. The effect of the application of concentric pressure to the vessel wall will depend, therefore, on the physical characteristics of the lesion.

Rotational atherectomy (RA) has been utilized during percutaneous coronary interventions (PCI) for over a decade. It is particularly efficacious in ablating fibrocalcific plaque and facilitates PCI by enabling stent delivery. Although previously, RA was frequently utilized during PCI, enthusiasm for this device faded when a restenosis benefit over balloon angioplasty for both native lesions¹ and in-stent restenotic lesions^2,3 could not be demonstrated. RA is utilized in 3–5% of PCI procedures in contemporary practice,^4,5 primarily to facilitate PCI in calcified lesions, bifurcation lesions, ostial lesions, in-stent restenotic lesions and undilateable lesions. We queried a prospectively collected coronary and peripheral interventional database for all RA procedures performed at our institution between July 1, 2002 and June 30, 2004, to identify any novel uses of this device.

Intravascular administration of iodinated radio contrast agents is a common cause of hospital-acquired acute renal failure. Although the clinical presentation of contrast-induced nephropathy (CIN) has been well described, the incidence of CIN with new iso-osmolar radio contrast agents has not been thoroughly evaluated. Decreasing levels of renal function act as a major adverse prognostic factor after contrast exposure, with or without percutaneous coronary intervention.^1–4 Various strategies for the prevention of CIN have been investigated,⁵ some with detrimental results,⁶ and others were neutral to kidney function.^6,7 Potential beneficial interventions include intravenous hydration with normal saline,⁸ N-acetylcysteine,^9–11 the iso-osmolar contrast agent iodixanol,^12,13 hemofiltration¹⁴ and limiting the volume of contrast.¹⁵

Unlike patients with well-preserved renal function, in whom the choice of radio contrast agent appears to have minimal impact on the development of contrast-induced nephropathy (CIN), the patient with chronic kidney disease (CKD) historically has presented numerous challenges to the cardiologist performing cardiac catheterization. Studies have suggested that CKD not only increases cost and prolongs hospitalization, but also confers an increase in major adverse cardiovascular event (MACE) rates in patients undergoing cardiac catheterization for both the index hospitalization and long-term, especially in the subset of patients undergoing percutaneous coronary intervention (PCI).¹

Therapies Aimed at Mitigating CIN

In patients with proximal left anterior descending (LAD) disease, percutaneous coronary intervention (PCI) is a valid alternative to coronary artery bypass grafting (CABG), offering similar long-term survival and relief of angina as CABG, though there is a greater need for new procedures.^1,2 Coronary stenting provides clinical benefit in comparison with balloon angioplasty in patients with proximal LAD disease, and because of that, it is the most frequently employed PCI modality in these patients.³

Up to two million percutaneous coronary intervention (PCI) procedures are performed worldwide each year.¹ Coronary stents are typically implanted in over 90% of these procedures following two landmark studies demonstrating significant reduction in restenosis rates compared to balloon angioplasty alone.^2,3 Recent advances in stent technology have yielded further marked reductions in restenosis rates.^4–10 However, as the use of PCI, enabled by these advances, is increasingly stretched into more complex anatomical and clinical scenarios, so the potential risk of subacute thrombosis may be increased.

Case description. A 39-year-old male with recent onset angina was admitted to our department with an acute infero-lateral myocardial infarction. The patient had no prior cardiac medical history, except for episodes of chest pain in recent months. As a result of the chest pain, the patient performed a cardiac stress test, which was positive for ischemia. He did not have other cardiac risk factors and did not undergo further evaluation. Due to severe and prolonged chest pain on the day of admission, he presented to the emergency room where the electrocardiogram revealed Q-waves and S-T segment elevation in all three inferior leads with a first degree A-V block. The patient was treated with thrombolytic therapy (STK) with signs of successful reperfusion, after which the patient remained asymptomatic.

Case report 1. A 68-year-old caucasian male presented for a coronary angiography one month after an acute anterior myocardial infarction. It revealed total occlusion of the left anterior descending (LAD) artery. A decision was taken to attempt to open the totally occluded LAD, owing to the frequent occurrence of post-MI angina. The left main coronary artery take-off was normal, and was selectively cannulated with a 7 Fr Judkin’s Left-4 guiding catheter (Cordis J&J, Miami, Florida). The patient was given 10,000 units of heparin intravenously, and his activated clotting time 15 minutes later was 250 seconds. The LAD was negotiated with a ChoICE^®-PT wire (Boston Scientific-Scimed, Maple Grove, Minnesota). After securing the wire in a fairly distal position, multiple balloon inflations were performed in the LAD, from distal to proximal.

The International Andreas Gruentzig Society was inaugurated in the years after Andreas Gruentzig’s passing in 1985. A small group of his mentors, colleagues and trainees struggled to find a way to hold the memory of this remarkable man and push his innovative and ground-breaking work into the coming years. As I begin to write this reflection on the formation of the society, I cannot help but be reminded of the deep sadness and sense of loss that was universally felt by the cardiovascular community and especially by colleagues and co-workers close to this great man. It was a profound sadness not only driven by personal loss, but by a sense that progress in percutaneous catheter-based therapies would be dramatically inhibited by the loss of Andreas’s leadership.