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At its height, the popularity of surgical coronary revascularization spurred improvement in catheter-based technology—first for imaging quality and later for attempted therapy. In 1974, Andreas Gruentzig completed development of the double-lumen balloon catheter that was miniaturized for use in coronary arteries. Soon afterward, techniques for percutaneous transluminal coronary angioplasty (PTCA) expanded as technical breakthroughs were applied to subselective catheters, devices, guidewires, balloon materials, and lastly, coronary stents. Presently trial evidence attests that percutaneous therapy is useful as a treatment in patients with unacceptably controlled angina whose anatomy does not imply a survival benefit from revascularization or for patients with uncontrollable, unstable symptoms. However, surgical and percutaneous revascularization cannot be considered equivalent.1
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In the early balloon angioplasty era, several technical limitations restricted percutaneous techniques to low-risk patients with proximal, discrete coronary artery stenoses, and procedural outcomes lacked predictability. As advances in tools and techniques were developed, higher-risk patients became candidates for percutaneous therapy. Over time, several principles for safety and success were recognized (Table 20-1).
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Guiding catheters differ from diagnostic catheters in that a wire-braid supports a thin catheter wall, allowing for a larger central lumen and providing enough rigidity to support the advance of subselective catheters to the distal regions of the coronary bed. The anatomy of the ascending aorta and the origin of the treated coronary artery determine the shape of the guiding catheter that will provide the most secure positioning (Fig. 20-1). The choice of guiding catheter often is the deciding factor ...