The Innovator of Angioplasty

There are few who are acknowledged as true pioneers in medicine, but Andreas Grüntzig was surely one ( Figure 1-1 ). He quite simply not only coined the term interventional cardiology, he was interventional cardiology. For many evenings, he, his wife Michaela, and Walter and Maria Schlumpf sat at the Grüntzig’s kitchen table fabricating balloon catheters. These catheters were the prototypes that enabled Grüntzig to eventually effectively treat peripheral and coronary artery disease without surgery. In September 1977, Grüntzig performed the first successful coronary angioplasty on Dolf Bachmann. This event initiated a cascade of innovations that have greatly changed the approaches and techniques for the treatment of patients with coronary disease as well as for others who have required traditional surgical procedures. This chapter will discuss the origin of angioplasty and the story of its inventor.

Andreas Grüntzig during a coronary angioplasty.

(Courtesy Dr. Gary S. Roubin.)

Andreas Roland Grüntzig was born in Dresden, Germany, June 25, 1939. He was the second child of Charlotta and Wilmar Grüntzig. Andreas was a child of World War II. He had one brother, Johannes, who was older. The boys quickly lost their father, a secondary-school science teacher, who was conscripted as a weatherman for the Luftwaffe.

Based on concerns for her family’s safety, Charlotta and her two boys moved from one home to another in Germany, then to South America and then back again. After World War II the fatherless family settled in Leipzig, then a part of East Germany. Day after day, Charlotta and her two boys would go to the local train station, eyeing the German troops returning from the Eastern front. They were waiting for Wilmar, who never arrived.

Although both boys performed well in school, East German rules of the day demanded they become laborers, based on the fact that their father had been educated. This concept did not sit well with either boy. West Germany was potentially accessible to Johannes and Andreas. As teenagers, they would occasionally sneak across the border at night for brief social excursions. Finally to pursue more desirable lives, Andreas, then age 17, and Johannes moved permanently to West Germany. They left their mother behind. How these boys were formally educated in this new country is unclear, but eventually they attended medical school at the University of Heidelberg.

Toward the end of this medical school curriculum, Andreas Grüntzig began a series of clinical rotations. These took him to several European venues. At age 28, he attended the London School of Economics. There he studied epidemiology and statistical methods. This experience was critical and provided the basis for his approach to evaluating the effectiveness and safety of coronary angioplasty.

At age 30, Grüntzig was accepted to the Internal Medicine training program at the University of Zurich ( Figure 1-2 ). His educational plans were disrupted when the program director died unexpectedly. Fortunately for Grüntzig, who had just moved to Zurich, Alfred Bollinger offered him a training position in “angiology.” Angiology was and remains an established medical discipline of European medicine. Grüntzig accepted. This opportunity exposed him to patients with peripheral artery disease, the substrate for his concept of balloon angioplasty.

Photograph Andreas Grüntzig submitted with his application for training in Internal Medicine, University Hospital, Zurich.

(Courtesy Ernst Schneider MD.)

While in training, Grüntzig heard a lecture by Eberhard Zeitler of the Aggertal Clinic about the “Dotter procedure” named after U.S. physician Charles Dotter. Dotter lived in Oregon and as a vascular radiologist had developed a technique for dilating atherosclerotic stenoses of peripheral arteries. He called the technique “transluminal dilatation,” a term Grüntzig would borrow when initially labeling coronary angioplasty.

The Dotter procedure involved crossing a stenotic arterial segment with a guidewire and then sequentially advancing progressively larger, tapered end-hole catheters across the narrowed segment. The actual relief in stenosis severity was quite modest, yet in many instances clinical improvement was substantial. Although this procedure was innovated in the United States, it was not well accepted by American physicians. Zeitler, however, had adopted the technique with enthusiasm. In 1971 he was performing Dotter procedures on a regular basis. Grüntzig met Zeitler, observed him, and eventually assisted him.

After returning to Zurich, Grüntzig began to perform Dotter’s procedure with mixed success. Resident vascular surgeons focused on complications of the procedure such as groin hematomas. Moreover improvement of Grüntzig’s skill was hampered by limited access to patients. In the back of his mind, however, was the thought of a different approach: namely, a balloon-tipped catheter that could dilate stenotic arteries.

Grüntzig’s laboratory for innovation was the kitchen of his and Michaela’s two-bedroom flat. The team included Andreas; Michaela; Maria, Andreas’ assistant; and her hus­band, Walter, an engineer by training. Identifying and obtaining materials that could serve appropriately for the catheter shafts and balloons were challenges. Grüntzig eventually selected polyvinyl chloride (PVC) as the balloon material for his catheters. This was a unique substance, particularly strong, and could be easily shaped. In fact, PVC was being used for making disposable bottles of Coca-Cola. Progress was slow but over a period of 2 years, and hours of cutting and gluing, a balloon catheter was fabricated that repeatedly yielded predictable performance.

The initial catheter was a single-lumen system. Once advanced over a guidewire and in proper position, the guidewire was removed and a tip occluding wire was placed in the catheter. Fluid injected into the catheter lumen then filled the balloon by means of side holes or skives in the catheter shaft.

The First Peripheral Arterial Angioplasty

It was on February 12, 1974, that Grüntzig used this catheter to dilate the iliac artery of a 67-year-old man in Zurich. The procedure was successful by all parameters: angiographic and hemodynamic assessments and the patient’s clinical response.

Although the risks were undoubtedly greater and the technical demands more difficult, coronary disease was always a goal for Grüntzig. Different but significant clinical challenges were unique to the coronary circulation. What would be the consequences of transient coronary occlusion? Would there be irreversible myocardial infarction? Would patients experience ventricular fibrillation? Thoughts such as these stimulated him to develop a two-lumen balloon catheter. One lumen would maintain coronary perfusion; the other lumen would be used for the balloon inflation. Navigation of the catheter would be difficult but aided with a short fixed wire at its tip to assist in entering the correct coronary artery and crossing the stenotic segment.

The logical testing site for the first double-lumen new catheter would be a peripheral artery. In January 1975, Grüntzig used his balloon catheter to dilate an iliac artery stenosis. The procedure was successful! Over the next 2 years, he would perform more than 200 peripheral arterial balloon angioplasties.

The Development of Coronary Angioplasty

Creating a “model” to test a coronary angioplasty balloon catheter was the next logical step prior to attempting coronary angioplasty in a patient. To accomplish this, Grüntzig created coronary stenoses in anesthetized open-chest dogs by placing sutures around the coronary arteries. Then with the aid of fluoroscopic guidance, he advanced his balloon-tipped catheters into the constricted coronary and dilated the ligated segment. Grüntzig presented this work at the Miami meeting of the American Heart Association in November 1976. Although his presentation was well attended, the prevailing response was skeptical.

Little is known about the very first attempted coronary angioplasty in man. The patient was a 66-year-old male with cardiogenic shock who had been rejected for cardiac surgery. In an effort to rescue the patient, Andreas attempted coronary angioplasty in Zurich, early 1977. Access was a problem. Following an unsuccessful femoral arterial approach, he eventually obtained access from the left brachial artery. An unwieldy, 9 Fr Teflon guide catheter was inserted. Grüntzig could not engage the catheter into the left coronary ostium and the procedure was aborted.

Grüntzig’s next steps were more cautious and modest. With the aid of Richard Myler of San Francisco, Grüntzig pursued a different approach. They evaluated his balloon catheters in the operating room, during coronary bypass operations. Once the coronary arteriotomy was made, catheters were advanced to the lesion and the balloon was inflated. Following a handful of cases, they concluded that Andreas’ catheters could dilate coronary lesions.

In September 1977, Andreas met Dolf Bachmann. Like Andreas, Bachmann was 38 years old. Unlike Andreas, he had severe angina, taking up to 15 sublingual nitroglycerine tablets a day. He was adamantly opposed to coronary bypass surgery. Following consultation with Grüntzig, he agreed to be the first patient to have coronary angioplasty. Importantly, he also agreed to coronary bypass surgery should angioplasty fail.

With a surgical operating room on standby, Bachmann’s procedure was performed on September 16. Andreas advanced a 3.0-mm short wire-tipped balloon catheter across a left anterior descending lesion and inflated the balloon. A second lumen in the balloon catheter, originally designed to deliver blood flow during balloon inflation, was used to measure coronary arterial pressure proximal and distal to the stenosis. When the balloon catheter crossed the stenosis, the balloon catheter tip pressure fell. Following the initial inflation, the distal pressure rose. According to protocol, the balloon catheter was withdrawn proximal to the lesion, which had improved substantially by angiography. The catheter was then re-advanced across the lesion and a second inflation performed. Angiography following withdrawal of the balloon catheter revealed no significant lesion. The case was a remarkable success. Grüntzig labeled this new procedure percutaneous transluminal coronary angioplasty (PTCA).

The following day Bachmann was completely asymptomatic and so overjoyed that he called a newspaper journalist. Grüntzig, ever a scholar and aware of the adverse potential consequences that might arise from a tabloid report, convinced Bachmann to hold off. The official accounting of this first successful case of PTCA was subsequently published in the February 4, 1978, issue of Lancet .