Test Your Knowledge: 10 Essential Questions on the Evolution of Interventional Cardiology

Interventional cardiology is one of the newest specialties within medicine, and I would venture to say it is the one that has undergone the most changes within the past decade. As fellows training for a career in this dynamic field, we can attest to the sacrifices we have made to achieve our goals of becoming interventional cardiologists. But now that we are well on our way, I think it is as important to look backward as it is to look forward. 

You might know the name Andreas Gruentzig, but do you know where the word “stent” originated from? Here are my top 10 questions every interventionalist should be able to answer about the history of our field:

1. When was the first coronary angiogram performed?

Mason Sones performed the first coronary angiogram at the Cleveland Clinic (Cleveland, OH) in 1958.

2. What were the events leading to this discovery?

Sones asked his associate Royston Lewis to withdraw the catheter tip from the left ventricle into the ascending aorta to perform aortography, and relied on the pressure tracing difference without imaging. He injected 40 cc of 90% diatrizoic acid (Hypaque) through the catheter into the dominant right coronary artery, and the patient developed asystole—not ventricular fibrillation as previously thought. Three to 4 explosive coughs were successful in restoring sinus rhythm.

3. Who proposed the concept of transluminal angioplasty?

Charles Theodore Dotter and Melvin Judkins proposed this concept in 1964. They used large rigid dilators, which proved helpful in the peripheral arteries but were restricting.

4. Who refined this work for a coronary application?

Andreas Gruentzig continued exploring the concept of angioplasty in coronary practice using animals, cadavers, and patients undergoing bypass surgery starting in 1974.

5. When was the first percutaneous transluminal coronary angioplasty performed in a conscious human?

On September 16, 1977, by Gruentzig.

6. How was this innovation received by the international interventional community?

The worldwide community responded with great skepticism. In 1979, a small group of cardiologists formed a registry of all coronary angioplasty cases sponsored by the National Heart, Lung, and Blood Institute. There were 3,000 cases registered by 1981.

7. Was the first guidewire steerable?

No, the first guidewire was fixed onto a balloon catheter. The first steerable guidewire was not introduced until 1983.

8. What is the famous quote from Dotter and Judkins?

“The guidewire is passed across the atheromatous block more by the application of judgment than of force.”

9. Where did the word “stent” originate from?

The English dentist Charles Stent built a career advancing the field of denture-making in the mid-nineteenth century. He refined the method of making dental impressions by improving the plasticity and stability of the material used in patients’ mouths, and built a company based on his technology. After his death in 1885, variations of the material came to be used in nondental capacities for skin graft surgeries, urology, and gynecology. The term was first used in cardiology in 1966—when researchers describing a prosthetic-stented aortic homograft used for mitral valve replacement assumed “stent” was a generic term for any kind of nonbiological support used for extending, stretching, or fixing in an expanded state.

10. How were coronary stents developed?

Ulrich Sigwart, Jacques Puel, and colleagues developed the first self-expanding stent in 1986. Cesare Gianturco and Gary Roubin then invented the first balloon-expandable stent, which was FDA approved in 1993. In 1987, Julio Palmaz placed the first balloon-expandable stent with diamond shaped windows in Brazil. Then 2 randomized trials (STRESS and BENESTENT) compared balloon angioplasty alone with the Palmaz-Schatz stent and found the stent was associated with a 20-30% reduction in clinical and angiographic restenosis, markedly improved initial angiographic results, and a larger post-procedure minimal luminal diameter. This led the FDA to approve the device in 1994. The first drug-eluting stent (Cypher; Cordis) was not approved for use by the FDA until 2003.