The keynote speaker shares his perspective and experience on the evolution of coronary intervention. Starting from the philosophy of “blood is better than drugs” for ischaemic myocardium, Dr Holmes reflects on the ferocious pace of development seen after the first (inadvertent) percutaneous transluminal angioplasty of the iliac artery by Charles Dotter in 1963, to the first coronary angioplasty performed by Andreas Gruntzig in 1977, through to modern day intervention.
Describing the crucial role registries (e.g. NHLBI PTCA registry) played in the early days in defining the population who may benefit and providing early outcome data, Dr Holmes reflects on the stages of development of new technologies: ranging from initial unbridled enthusiasm to harsh realities and thoughtful adaptations before reaching ultimate applicability. A particular example in this regard is the adoption of drug-eluting stents following publication of the RAVEL trial in NEJM in 2002, before outcome data on late stent thrombosis began emerging some years later. Solutions to this particular problem included dual anti-platelet therapy, technical/peri-procedural improvements and improvements in stent design. Also described are innovations which ultimately proved unsuccessful, such as directional coronary atherectomy and vascular bracytherapy.
Dr Holmes looks to the future describing the next set of challenges and hurdles for coronary intervention. What about neoatherosclerosis, endothelial dysfunction and persistent metal skeletons? Are bioresorbable scaffolds a new paradigm? A 2016 meta-analysis of 6 trials in the Lancet 2016 reporting similar rates of repeat revascularisation and an increased risk of subacute stent thrombosis
in comparison to modern metal stents suggests there is still much work to do.
Reflections are also described on the best way to go forward and drive platforms for development,
with renewed focus on early feasibility/first in man studies to improve technologies before pivotal trials being seen in the United States.