Catheterization and Cardiovascular Diagnosis 38:331 (1996)
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President's Page
Conflict or Collaboration:
The Legacy of Andreas Gruentzig
The scope of interventional cardiology continues to
change. This change is the result of several factors in-
cluding among others technical improvements such as
the introduction and widespread use of intracoronary
stents and the recognition that diseases in noncardiac
vascular beds can be addressed with devices similar to
those used to treat coronary artery stenoses. The initial
pioneers in the field of intravascular treatment were in-
terventional radiologists. The techniques were then re-
fined and adapted for the treatment of cardiac disease by
Andreas Gruentzig, leading to the first patient procedure
performed September 16, 1977. Early interchanges in-
volved interventional radiologists, cardiologists, and an-
giologists in a collaborative effort from which everyone
benefited greatly, physicians and patients alike.
Subsequently, the field of interventional cardiology
has experienced exponential growth in procedures as
well as the development of new devices, such as ather-
ectomy, lasers, and stents; the latter, stents, have been
particularly important adjuncts to balloon angioplasty .
Throughout this time, other developments have occurred
that have been less positive. One of the more notable
developments has been the growth of either absolute or
relative antipathy between interventional radiologists and
cardiologists and more recently between interventional
cardiologists and neuroradiologists. The growing antip-
athy between the latter two groups relates to the appli-
cation of percutaneous techniques to treat extracranial
carotid stenoses. Central to the perceived conflict are
several factors, including (1) control of patients, (2) ac-
cess to new technology, and (3) concern as to the co-
morbid conditions that often exist in this patient popula-
tion. On the one hand, invasive cardiologists have far
more experience with intravascular stents and angio-
plasty techniques; in addition, they are more experienced
in the care of the coexisting cardiac disease and, if need
be, can treat the cardiac disease during the same proce-
dure. On the other hand, neuroradiologists or some vas-
cular radiologists have a better knowledge of the anat-
omy of both extracranial and intracranial vessels and are
more experienced in cannulation of these vessels. Both
disciplines bring valuable information to the catheteriza-
0 1996 Wiley-Liss, Inc.
tion table. Similar issues are relevant in patients with
peripheral vascular disease involving the renal arteries,
the aortoiliac, or femoral systems. Again, similar factors
are central to potential conflict.
These conflicts were not part of the mind set of An-
dreas Gruentzig, who instead was a bridge builder be-
tween several disciplines. Current practitioners can learn
much from his initial approach. The Andreas Gruentzig
Society recently met for its semiannual meeting and ad-
dressed many of the issues of modern interventional
treatment as interventional radiologists, vascular sur-
geons, neurologists, neuroradiologists, and invasive car-
diologists were present and participated. A particular fo-
cus interface was the increasing interest in extracranial
carotid angioplasty and stenting. The goals of therapy
and assessment of therapeutic outcomes are best served
by keeping the patient foremost in consideration. The
approach with a new technique such as treatment of ex-
tracranial carotid disease should be multidisciplinary,
with involvement of neuroradiology, vascular radiology,
neurology, and invasive cardiology. In addition, input
from surgical colleagues is often very helpful. Identifi-
cation of the optimal treatment strategy involves consid-
eration of anatomy and comorbid conditions, as well as
technical considerations. For these processes, a multidis-
ciplinary approach that sets aside regional conflicts is
optimal and should indeed be requisite.
Advances in therapy are sometimes dramatic, such as
the introduction of percutaneous transluminal coronary
angioplasty (FTCA), and are sometimes characterized by
slow continued improvements, also illustrated by the
continued development of PTCA. The goal of identify-
ing optimal treatments for our patients is best served by
collaboration and free and open discourse about shared
problems, rather than strident posturing and conflict.
David R . Holmes, J r . , MD.
Division of Cardiovascular Diseases
Mayo Clinic
Rochester, Minnesota