Blowup in the Arteries

Tiny balloon unclogs heart blood vessels

Stricken with the suffocating, spasmodic chest pains of severe angina, Robert, a 47-year-old chauffeur, recently entered Manhattan's Lenox Hill Hospital. Tests showed that his left main coronary artery was clogged with cholesterol-laden plaque. That made him a likely candidate for a coronary bypass, an operation in which segments of leg vein are sewn onto the arteries to shunt blood around blocked areas. But with Robert's approval, Lenox Hill doctors decided to forgo surgery and try a new and highly experimental alternative: a procedure with the tongue-twisting name of "percutaneous transluminal coronary angioplasty."

After Robert had been mildly sedated and his leg anesthetized, Cardiologist Simon Stertzer inserted a narrow, hollow Teflon tube called a guiding catheter into an artery in the leg (although an arm artery can be used instead). Working the catheter up through the blood vessels, he reached the opening of the obstructed heart artery. Then Stertzer inserted a narrower and more flexible hollow catheter, with a tiny deflated balloon near its tip, through the Teflon tube and into the heart artery itself. Guided by X rays that determined precisely where the artery was blocked, he positioned the balloon exactly in the middle of the arterial narrowing and inflated it for several seconds. That compressed the obstructing plaque against the arterial wall, widening the diameter to near normal size. Then, deflating the balloon, the doctor withdrew both catheters. The entire procedure took less than an hour and was apparently successful; a new set of X rays showed that the artery, free of obstruction, once more carried blood freely. Two days later, his angina gone, Robert left the hospital and returned to work.

Robert is one of only three dozen carefully selected cardiac patients in the world to have been treated with the new technique since it was introduced in Switzerland by Dr. Andreas Gruentzig less than a year ago. The procedure grew out of a similar technique that has been used with some success to clear clogged leg arteries. Of the ten so-called balloon dilatations attempted on heart patients at Lenox Hill since March, seven have been successful in clearing soft, non-calcified plaque obstructions and relieving angina. (In three cases, doctors were unable to work the catheters through the arteries to the point of blockage.) The promising findings lead Chief of Medicine Michael Bruno to estimate that the procedure could be used in place of bypass operations in perhaps 10% to 15% of patients--and at about one-tenth the $15,000 average cost of a bypass.

For other patients, a variation of the new technique may make bypass surgery feasible. Explains Cardiac Surgeon Eugene Wallsh: "When you have too many obstructions in an artery, you can't bypass each one. But with the balloon catheter, you can open up some blocks and then bypass others." Wallsh has done just that in six patients. Adds Stertzer: "It might also be possible to reopen bypass grafts that have closed down."

Despite their enthusiasm, Lenox Hill physicians caution that the technique is experimental. With Griintzig and a team of San Francisco researchers led by Dr. Richard Myler, they are working to refine the equipment and determine which patients could benefit from the procedure. Equally important, the doctors are trying to assess the long-range effects. For example, do the arteries close down again, and when? Where does the plaque eventually go? Stertzer speculates about a possible "self-healing" mechanism. Indeed, when the arteries of a few patients were re-examined a month or so after balloon dilatation, doctors could not see where the original narrowings had been. The same phenomenon has been noticed in some of the hundreds of patients who have undergone plaque compression in leg arteries. In 70% of 300 cases studied, the arteries are still open two to three years later.

Before they know if a similar percentage holds true for heart arteries, doctors will have to use the balloon dilatation technique on hundreds of cardiac patients. Then, says Stertzer, "if 80% of the arteries are open after a year, we're into a revolution in cardiology.''

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