New Clogged Arteries Treatment Opens Controversy

January 06, 1991|By Robert Lee | Robert Lee,Staff writer

A tiny "Roto Rooter"-like device that can shave out clogged arteries has worked its way into the hearts of county coronary patients for the first time.

But while some cardiologists are heralding the device as the future in treatment of heart disease, others warn that it could easily be misused.

Two county cardiologists, Krishan K. Singal of North Arundel Hospital and Jonathan Altschuler of the Anne Arundel Medical Center, are among the first doctors in the state to add the new procedure to their repertoires.

So far the two have performed five of the operations in the last few weeks, and both say that they have been exceedingly cautious about the patients they select but that the technique will almost certainly have an important, though maybe limited, role in thefuture.

"I see this as the wave of the future. Eventually this will become the procedure of choice to remove blockages that have given us trouble before," Singal predicted.

Altschuler has a more guarded outlook.

"It's definitely going to find its niche, but one needs to be very careful not to equate new with better," he said. "These new devices lend themselves to abuses when they get into the wrong hands. Patients should be careful and know all their options before they go into it."

The drilling device, the Simpson Coronary AtheroCath, is the latest development in the relatively new field.

The Food and Drug Administration approved its use in the procedure known as directional coronary atherectomy last September.

The purpose of the operation, which must be performed with an open-heart surgery team on call in case of complications, is to clear out coronary arteries. Heart attacks can result when coronary arteries clog.

As with the 10-year-old "balloon treatment" called angioplasty, the Simpson tool fits on the end of a 50-inch catheter tube that a doctor inserts intoa major artery in the groin and then twists and turns into position wherever the plaque threatens circulation to the heart.

But unlike angioplasty, where the plaque is simply forced back by the inflationof the balloon, directional coronary atherectomy employs a 1-millimeter shaving device rotating 2,000 times per minute to cut the plaque away and push the shavings into the nose cone of the device.

"I think atherectomy will be better than angioplasty in some cases because it actually removes the plaque," Singal said. "But because of its limitations, it is best for larger arteries, for bypass grafts and for people who have had the balloon treatment but suffered restenosis (a re-collapse of the artery)."

Shortly after her Sept. 30 balloon treatment, Margaret Wilson of Glen Burnie joined the 20 percent of heart patients who suffer artery collapse. She said Singal told her about the atherectomy treatment and she opted for it in the hope that it might clear up the extremely sharp pain running down her arms.

"It felt much better than the balloon surgery. I feel a lot better now. The pains have reduced to aches, and I may not need a bypass," she said.

Wilson said she felt nothing during the two-hour procedure and was out of the Washington Adventist Hospital within three days.

Both doctors take their patients to Washington-area hospitals, where the open-heart surgical teams are available.

"Patient selection is really the most important aspect of its use," Singal said, noting that the tool is relatively bulky and can't be maneuvered into small or winding arteries that a balloon can reach.

He estimates that about15 percent of the patients who would have used the balloon treatment might do better with the drill. That share may increase to 40 percent within five years, he predicted.

Invasive cardiology, the specialty of cardiologists who stick tubes into patient's hearts, developed during the 1950s as the best way to discover clotted arteries. It wasn't until the late 1970s that tools which can actually solve the problem were added to the tips of the tubes.

Dr. James W. Ross, director of the cardiac care unit at Anne Arundel Medical Center and an invasive cardiologist, emphasized that the new procedure hasn't built a track record and warned of potential ethical problems developing asa result of the advent of such a procedure.

"The problem that many cardiologists don't discuss is that many of these folks should be going to bypass. It's terribly unfortunate, but cardiologists -- and Iinclude myself when I say this -- have a definite moral problem withself-referral where the person who diagnosis the problem is the sameperson who performs the angioplasty or atherectomy and therefore profits from the operation," Ross said. "I'm not saying it's done as a general practice, but there's a huge problem."

The number of angioplasties has grown tremendously in recent years, up to an estimated 300,000 last year, an Emory University study shows.

"Angioplasty is still relatively new and is finding its place. The relative value of atherectomy is very uncertain," Ross said.

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