When PTCA was introduced by Gruntzig in 1977 the whole world was awestruck. All he did was . . . to dilate a coronary stenosis with a balloon. No scaffolding was ever thought off at that time. It was a huge achievement . PCI version 1 was performed for over 20 years in nearly a million patients . Till his death stenting was an unknown concept.
When the stents first came in, it was first used with extreme caution . From the days of bail out stenting, it has evolved into provisional stenting, elective stenting ,and now what is called “mandatory stenting”
When Greuentzig was able to perfuse the obstructed coronary arteries successfully in thousands of patients in the 1980s, with a simple balloon
. . . what is the difficulty for us to replicate it in 2011 ?
Unfortunately advocates of POBA (Plain old balloon angioplasty) are considered to be un-scientiifc cardiologists or even carry a risk of labeled as quacks.
But please remember . . . POBA is alive and doing well too , in spite of the serious threat it faces from the current generation interventionists . It will continue to have an important role in many situations.
1.In patients with multivessel disease while the proximal lesion deserve a stent , POBA is preferred in distal lesions to reduce the overall metal load .
2.POBA has a major role to play in Primary PCI .We need to realise dying myocardium does not demand for stents. It simply requires quick and prompt restoration of blood flow. POBA can achieve this with flying colors in most situations.
3. Further , stenting may be difficult in complex lesions during primary PCI .Experience tells us , it is dangerous to prolong the primary PCI procedure time. Here POBA is the only choice , may be assisted by thrombus aspiration. Stenting may be delayed or even avoided in many STEMI patients. . We know there is huge STEMI population with pure thrombus with no atherosclerosis.
4.Patients with co morbid conditions , who are likely to have a non cardiac surgery in the near future and those who can not take antiplatelet drugs POBA will score over BMS/DES.
5.Finally a POBA costs nothing . .All it requires is a stiff balloon . In this recession prone world and ever increasing incidence of CAD , POBA could be the answer.
6. Acute recoil in POBA (Sudden deaths in POBA is a rare event !) are more of a perceived fear rather than a reality. It can be argued stents are primarily used to make cardiologists job easy and comfortable.
7.Cost effectiveness of plain balloon verses stenting was never properly tested .
Final message
When sudden deaths due to subacute thrombois in DES population is accepted with all those attendant pride . . . why not we accept a risk of less sinister event namely the late onset restenosis with POBA.
This is a funny world . The DES fiasco is driving us towards stent less world and a bio degradable stent is already being projected as new savior.
Meanwhile no one can kill POBA thats for sure ! It will ultimately be reinvented with another exotic study soon !
Dr.S.Venkatesan MD 