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If somebody is asked about the most important steps in the evolution of percutaneous coronary interventions (PCI), the answer might be: 1) coronary angiography by Mason Sones in 1957; 2) the noncompliant balloon and first angioplasty by Andreas Grüntzig in 1977; and 3) coronary stenting by Ulrich Sigwart in 1986. Guidewire technology will hardly be mentioned although this is used routinely today and without dramatic evolution. It was, however, not present from the beginning. Instead, the noncompliant balloon system introduced by Grüntzig was a balloon mounted onto a catheter that had short (10-mm) wire fixed to the catheter tip. To steer this catheter into an obstructed artery was a difficult maneuver. Therefore, the very first procedures of PCI were performed only in patients with proximal stenoses.
John Simpson used the Grüntzig catheter with a movable wire instead of the fixed stump. Despite this improvement, PCI remained difficult. Even years after the first procedures performed by Grüntzig, few centers had collected a broader experience (1). When presenting early PCI results during the World Congress of Cardiology in Moscow in 1982, there were only 4 groups, that of Grüntzig in Zürich and Atlanta, Richard Myler in San Francisco, Simon Stertzer in New York, and myself in Frankfurt, who had performed more than several hundred procedures (2). The main reason for this slow evolution was the primitive guidewire technology. After discussing the difficulties with Willy Rutishauser during a long walk in the Swiss Alps, an idea came to my mind to use a separate bare wire instead of the balloon catheter combined with the wire (Figure 1).
With this new wire technology, the most difficult part of the procedure, namely traversing the lesion, would become much easier. Steering of the bare wire would be more sensitive and more precise. The visualization of the distal artery was much clearer because contrast injection was not hindered by the obstructing balloon catheter.
The concept was realized with the “long-wire” technique (3,4). After passage of the lesion, the wire was held in place and the appropriate balloon catheter was introduced over the proximal long wire. Any type and size of catheter could be introduced. With the wire as a rail, stents, lasers, rotating instruments, ultrasound catheters, and so on could also be introduced.
When I presented the technique at the Davos meeting in 1984, Grüntzig was present. He was impressed and commented, “Every new method has advantages and disadvantages. What are the disadvantages?” I honestly answered I could see no disadvantage except perhaps the length of the wire. Back in Atlanta, Grüntzig did not introduce the new technique, and it was used essentially in Europe. Only after Bonzel had developed the monorail technique did the bare-wire principle became the standard.
Please note: Prof. Kaltenbach has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation