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Jaishankar Raman, MBBS MMed, FRACS, PhD

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Just a small hole in the groin!

August 12, 2018

If one was given the choice between a small hole in the groin, compared to a great big crack down the middle of the chest, there is no contest. I remember the early descriptions of successes in percutaneous coronary artery intervention - with stents in the early 1990s: I was training in cardiothoracic surgery and my learned superiors dismissed the notion out of hand. The common refrain - "Can you imagine showing a metal spring or coil into an artery?" We all had come to appreciate the endothelium or lining of blood vessels, especially small ones - they were so prone to spasm and injury. Coronary artery surgery was this delicate balance of skillful suturing of bypass grafts onto coronary arteries beyond major blockages, care being taken not to injure, interfere with or incapacitate the underlying artery. After all, the aim was to provide a durable and robust alternative blood flow to the blocked artery. 

As expected, early successes of stenting coronary artery were plagued by re-stenosis or repeat narrowing. This was due to the endothelial lining cells overgrowing the tube like stent and predisposing to recurrent obstruction. This was partially solved by medicating the stents with anti-cancer medication like sirolimus and tacrolimus; these agents retarded the growth of endothelial cells locally. However, the patients had to be placed on very potent blood thinners to prevent the clot forming platelets from sticking together.  together and causing obstruction.. Stent design and modifications have continued apace and for many years CABG (Coronary Artery Bypass Grafting) colloquially referred to Cabbage had declined in number. There was major concern about over supply of cardiac surgeons and not enough work. Please keep in mind that this was like deja vu - similar predictions in the 1970s had been made about valve related surgery, with greater preventive treatment of rheumatic valvular heart disease. Valve interventions are making a huge comeback - but that is the subject of another post.

Many studies in the era of PCI (percutaneous coronary intervention) and stenting, comparing these with CABG have shown a much better event free survival in patients undergoing open surgery. Amazingly, CABG is facing a resurgence in the West - not to the extent or numbers that were prevalent in the late 1990s, but enough to help a number of patients with a durable solution. Well, in terms of durability and longevity, much work has been done in the realm of multiple arterial grafts (bilateral Internal Mammary Arteries, Radial Arteries, etc). So, if you know of a patient being lined up for CABG, ask the cardiologist, surgeon or the treating team about the use of multiple arterial grafts.  I was very fortunate to be exposed to these techniques by my mentor, Prof Brian Buxton. He was and has been a pioneer in the expansion and use of all arterial grafts.  Dr Buxton trained initially as a vascular surgeon in Melbourne, then as a cardiac surgeon under the late Dr Denton Cooley at Texas Heart Institute and returned to Melbourne in the early 1980s. A gifted artist and an immensely talented surgeon, he studied outcomes of his patients from early in his practice - both in the private and public sectors.  He was able to track a lot of his patients and report on their long-term survival. Interestingly, the rate of multiple arterial grafting in CABG is very high in Melbourne because of the Buxton effect! The rate of multiple arterial grafting in the US is dismal - well below 15%. So, many of these patients come back with recurrent chest pain (due to blocked vein grafts or the arteries beyond) and in these circumstances, PCI is a preferable option.

The need for repeat intervention and recurrent PCI of blocked grafts and arteries is therefore higher in the US. This also accounts for a higher burden of heart failure in these patients.

I have digressed a lot. You can see that there are multiple reasons for patients to prefer holes in the groin for intervention into coronary arteries. Also, the holes in the groin have morphed into holes in the radial arteries in the forearm - since a lot of coronary artery intervention can be achieved through this approach.

The hole in the groin is now extending into valvular interventions. The big new developments are in Percutaneous or Trans-Catheter valve implants.

More of that later.

 

 

 

 

 

 

 

 

 

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