Angioplasty in Malaysia Part 4

This is part 4 of the history of angioplasty in Malaysia from my front row seat. Part 3, 2 and 1 have been posted previously

Dr Clark and Dr Fischell left on the 18th of October 1988. We then began to do cases, keep a registry and to present our results at the Acdemy of Medicine Malaysia's quarterly scientific meeting. News began to spread among the medical specialist community that angioplasty was available in Malaysia and, more importantly, that it was effective and safe.

Every silver lining has a dark cloud and ours was restenosis. Besides restenosis, we also became aware that angioplasty was costly. The procedure required the use of guidewires, guiding catheters, balloon catheters and indeflators. Except for indeflators, we sometimes required the use of two or three of each consumable for one patient. As an indication, at the time, balloon catheter cost about RM 2,300 each, the guidewires RM 480 each and guiding catheters about RM 500 each. So if we needed two balloons, then the total cost of these consumables would be RM 7,000, making the angioplasty about RM 15,000 with a 30% chance of a repeat procedure. At the same time, bypass graft surgery was about RM 25,000. Angioplasty was not so attractive from the cost point of view even ignoring restenosis.

One of the strategies we adopted was to attempt the re-use of some of the consumables, starting with the indeflators. After each case, I had to personally open up the indeflator and clean the parts manually, then reassemble it together, package it and send it for EO (ethylene oxide) gas sterilisation. That saved us a little bit of cost.

Next, we tried to clean the guiding catheter and guidewire and repackage them for EO gasing. That was easy, it did save us some cost, but we were very unhappy reusing the guidewires, as they were very fine, and there was the risk of fracturing. We ceased re-use of the guidewire.

I remember spending much time every weekend, trying to clean the balloon catheters. This was very tough. If was very difficult to clean the balloon catheter. In those days, the balloon catheters were all over the wire system. The central lumen was virtually impossible to clean. What more with the balloon lumen, filled with diluted contrast inside? Then there was the sterilising process. We used to re-package for EO gas sterilisation again. We had no problem with sterility. No patients suffered from sterility. There were no pyogenic reactions but we had a lot of balloon failure, because we could not inflate or deflate smoothly. After struggling with this for a few months, I decided that this way of re-cycling was not wise. We needed another way of re-cycling the balloon catheters safely and easily, so that we could save RM 2,000 to 4,000 per case.

Asking around the international interventional circles, I found out that the French interventionalist were safely and happily re-cycling their balloon catheters. It was time to visit one the the centes in Paris to see how they did it and also update myself on the latest techniques in angioplasty. After the maturing of plain old balloon angioplasty, many devices were invented to reduce the incidence of restenosis. It was also time, in 1990, to go out and see how angioplasty was being done in the continent of Europe.

Again, USCI Bards, used their contacts to link us to an active interventional cardiac center in Paris and arranged for me to visit that center. This happened in mid-1990. I spend one week in a cardiac hospital in Les Cheney, in the west of Paris. The chief cardiologist there was Dr Thiery Corcos, a very nice French gentleman, who showed me how angioplasty was done in Paris, and how they re-use their balloon catheter with "Cidex" soaking. According to our host it was easy and safe.

One day, as we were working, he mentioned that he had a friend (interventional cardiologist) in Toulouse who was implanting coronary stents with wonderful results and low restenosis rates. I was interested, so he made a phonecall. The next night I was on the overnight train speeding at 200km/hr to Toulouse, to meet Dr Jean Marco and Dr Jean Fajadet (two of the foremost interventional cardiologist in France). That morning, Dr Fajadet was implanting a Palmaz-Schatz (PS 153) stent in a patient with a 80% stenosis in the proximal RCA. This went very smoothly. He first pre-dilated the lesion with Rx catheter (ACS), handcrimped the PS 153 stent over the same Rx balloon and then deliver it across the lesion. The post-procedure results were manificent. The artery wall at the lesion was so smooth that it looked exactly like the adjacent normal wall. The result was pristine and seductive. It was nothing like the post balloon angioplasty result that we were seeing. It was way better. Dr Fajadet told me that so far, their restenosis was very low. I was introduced to the world of coronary stents. I there and then decided that the stents were the way to go to reduce restenosis post angioplasty.

After Tuolouse, I also spent a day with Dr Claude Morice at Cardiologi du Nord at St Denis. She is also a very well known interventionist in Europe. She had a Laser machine to do hot balloon laser. She showed me a case that day. The patient suffered an acute dissection, once the hot laser balloon was turned on. That frightened me. The patient had to be sent to emergency bypass surgery. This was not a good introduction to laser angioplasty.

I resolved that when I returned, I'll try my best to learn stent angioplasty and bring this technology to Malaysia for the benefit of our patients.