Is it a crime to do a plain balloon angioplasty in 2008 ?
Plain balloon angioplasty, the greatest innovation in cardiology when it was introduced in 1977 in a Zurich cath lab , has now become an ugly word for most of the cardiologist !
Why this turn around ? Has technology , really overtaken a great procedure and made it obsolete now ?
The answer is a definite ” No”
The restenosis which was the villian in the plain old angioplasty has never been overcome even today. Stents initally used as a bail out procedure during abrupt closure , later it was used conditionally, followed by provisional stenting and now in 2008 we are made to believe it is mandatory.
When we realised , bare metal stents are equally bad (If not slightly better ) in arresting the restenosis drug eluting stents came into vogue with a big bang in 2002. It was projected as the ultimate breakthrough in interventional cardiology and in 5 years the truth was exposed and it not only failed to prevent the restenois but also had a dreaded complication of acute stent thrombosis.
Now we know , metals inside a coronary artery carry a life long risk of sudden occulusion , and we talk about biodegradable stents (With poly lactic acid ).
Common sense ( Unscientific truths) would suggest
Plain balloon angioplasty still has a major role in our global cardiovascualr population.
Since restenosis is the only issue here, ( about 30% ) we can choose patients in whom even if restenosis is likely to happen no major harm is done . A vast majority of chronic stable angina patients fall in this category.
Aggressive lipid lowering with plain balloon angioplasty has never been tested properly . In future also it is unlikely, such trials will be done as it would be considered unethical . But that would be a premature conclusion.
The other major issue is the cost of stenting , the procedure of PCI/PTCA has become unaffordable for most of the population in developing countries .The primary reason being the PCI without stenting is considered ” A untouchable” . If only we remove this stigma from the cardiology community a signiificant population will be benefited.
A patient with chronic stable angina treated with POBA ,if develop further angina after few years , he is likely to get a recurrence of relatively safe stable angina. While in a post PCI patient any angina after the procedure becomes a unstable angina ( Braunwald classification) and requires emergency care . Angina in a stented patient is can not be taken lightly as the the course of angina is unpredictable .
POBA in primary PCI ?
Many may think it is a foolish idea . It has been found many times, when we rush the pateint to cath lab after a STEMI we are in for a surprise !. About 30% of times it is a very complex lesion profile like diffuse disese, tight bifurcation lesions , loaded with thrombus or a left main disese.
We fail to realise a basic fact , the initial aim of primary PCI is to salvage the myocardium ,and the next comes the prevention of restenosis . It may even , be argued salvaging myocardium is the only aim ! Myocardial salvage sould be done urgently . And even removing the thrombus and opening a IRA can be suffice in a patient who is crashing on table. Of course stenting can be done whenever possible. But for IRAs which has complex anatomy attempting a perfect stent PCI (Some may require more than few stents) as an emergency procedure invariably affects the outcome. One should spend shortest possible time inside the illfated coronary artery. Prolonged manipulations within the coronary artery in an unstable patient aiming at longterm patency of an IRA is to be avoided .The pending procedures can always planned in a next stage.
Final message
So it is not a crime to think about plain balloon angioplasty in some of our patients with acute or chronic coronary syndromes . Hope Gruentzig is listening from the heaven and hopefully agree with me !
Dr.S.Venkatesan, madras medical college, chennai, India .
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Dr.S.Venkatesan MD 