History of Coronary Angiography

Diagnostic cardiac catheterization is recommended whenever it is clinically important to define the presence of cardiac disease that cannot be evaluated adequately by noninvasive techniques. Because the risk of a major complication from cardiac catheterization is less than 1% with mortality of less than 0.08%, many doctors can perform the catheterization safely now. We discuss the history of coronary angiography.

In teaching the anatomy of the blood vessels, the X-ray opens out a new and feasible method.The arteries and veins of dead bodies may be injected with a substance opaque to the X-ray and thus, their distribution may be more accurately followed than by any possible dissection.The feasibility of this method applies equally well to the study of the structures and organs of the dead body.To a certain extent, therefore, X-ray photography may replace both dissection and vivisection, and in the living body, the location and size of a hollow organ may be ascertained by causing the subject to drink a harmless fluid more or less opaque to the X-ray, or an effervescing mixture which will cause distention, and then taking the picture.In 1920, a radiographic atlas devoted only to the systemic arteries of the body was published in England, "The X-ray atlas of the systemic arteries of the body.London: Balliere, Tindall, and Cox, 1920," by Orrin.The reproductions showed blood vessels in cadavers with great clarity (Figure 3).In 1910, Franek and Alwens introduced a suspension of bismuth and oil into the hearts of dogs and rabbits directly through the large veins and observed the passage of droplets from the heart into the lungs.In 1922, the work of Sicard and Forestier represented the next major advance, when they used Lipiodol, an early oil-based contrast medium, to study the bronchial tree and then the spinal subarachnoid space.In 1923, they injected 5 ml of Lipiodol into the femoral vein of a dog and, with the aid of fluoroscopy, watched droplets move with increasing speed from the iliac vein into the heart.The Lipiodol was then pulverized by ventricular contraction, thrown with great speed into the pulmonary artery and finally spread as multiple emboli into the small vessels of the lungs, disappearing in 10-12 minutes.Nextly, they repeated the experiment with human subjects, in whom they carefully observed the course of the opaque oil from the antecubital vein to the pulmonary capillaries.They reported that the patients coughed as the oil reached the lungs but suffered no other ill effects.In 1923, Berberich and Hirsch reported the first arteriograms and venograms obtained in human subjects, using 20% strontium bromide (Figure 4).In 1924, Brooks described the intraarterial injection of sodium iodide as a means of showing vessels of the lower extremities in humans (Figure 5).In 1928, Moniz et al. described carotid angiography and its application to the study of cerebral lesions (Figure 6).

Cardiac catheterization
As Andre Cournand remarked in his Nobel lecture of Decenber, 11th, 1956 (http://nobelprize.org/nobel_prizes/medicine/laureates/).Cournand and his colleagues led us into a new era in the understanding of cardiac function in humans.According to Cournand, cardiac catheterization was performed and so named by Claude Bernard in 1844.The subject was a horse, and both the right and left ventricles were entered by retrograde approach from the jugular vein and carotid artery.His careful application of scientific method to the study of cardiac physiology using the cardiac catheter demonstrated the enormous value of this technical innovation.An era of investigation of cardiovascular physiology in animals then followed, resulting in the development of many important techniques and principles (pressure manometry, the Fick cardiac output method), which awaited direct application to the patient with heart disease.
In 1928, Werner Forssmann, having practiced on a cadaver, inserted a 65 cm catheter into his own antecubital vein until he felt that it had reached the right atrium [1] (Figure 7).With the catheter dangling from his arm, he walked through a hospital basement to the radiographic room.There he obtained a roentgenogram that confirmed his belief that the catheter tip had in fact reached the right atrium.During the next 2 years, Forssmann continued to perform catheterization studies including six additional attempts to catheterize himself.Bitter criticism, based on an unsubstantiated belief in the danger of his experiments, caused Forssmann to turn his attention to other concerns, and he eventually pursed another catheter-related career as a urologist.Nevertheless, for his contribution and foresight he shared the Nobel Prize in Medicine with Andre Cournand and Dickinson Richards in 1956.Forssmann's primary goal in his catheterization studies was to develop a therapeutic technique for the direct delivery of drugs into the heart.He wrote, "If cardiac action cases suddenly, as is seen in acute shock or in the heart disease, or during anesthesia or positioning, one is forced to deliver drugs locally.In such cases the intracardiac injection of drugs may be life saving.However, this may be a dangerous procedure because of many incidents of laceration of coronary arteries and their branches leading to cardiac tamponade, and death.Because of such incidents, one often waits until the very last moment and valuable time is wasted.Therefore I started to look for a new way to approach the heart, and I catheterized the right side of the heart through the venous system."Others, however, appreciated the potential of using Forssmann's technique as a diagnostic tool.In 1930, Klein reported 11 right heart catheterizations, including passage to the right ventricle and measurement of cardiac output using Fick's principle.In 1932, Padillo and coworkers reported that right heart catheterization and measurement of cardiac output in two subjects.Except for these few early studies, application of cardiac catheterization to study the circulation in normal and disease states was fragmentary until the work of Andre Cournand and Dickinson Richards, who separately and in collaboration produced a remarkable series of investigations of right heart physiology in humans [2].In 1947, Dexter reported his studies on congenital heart disease and passed the catheter to the distal pulmonary artery, describing "the oxygen saturation and source of pulmonary capillary blood" obtained from the pulmonary artery wedge position [3].Subsequent studies from Dexter's laboratory [4] and by Werko elaborated the use of this pulmonary artery wedge position and reported that pressure measured at this position was a good estimate of pulmonary venous and left atrial pressure.During this exciting early period, catheterization was used to investigate problems in cardiovascular physiology by McMichael and Sharpey-Shafer in England.Lenegre and Maurice in Paris and Warren, Stead, Bing, Dexter, Cournand and others in the United States [5][6][7][8][9].Further developments came rapidly in the 1950s and 1960s.Retrograde left heart catheterization was first reported by Zimmerman and others [10] and Limon-Lason and Bouchard in 1950.The percutaneous (rather than cut-down) technique was developed by Seldinger in 1953 and was soon applied to cardiac catheterization of both the left and right heart chambers [11].Trans-septal catheterization was first developed by Ross [12] and Cope [13] in 1959 and quickly became accepted as a standard technique.Selective coronary angiography was reported by Sones and others in 1959 and was perfected to remarkable excellence over the ensuing years [14].Coronary angiography was modified for a percutaneous approach by Ricketts and Abrams [15] in 1962 and Judkins [16] in 1967.In 1970, Swan and Ganz introduced a practical balloon-tipped, flow-guided catheter technique enabling the application of catheterization outside the laboratory [17].Better radiographic imaging techniques and less toxic radiographic contrast agents have been developed progressively, as many numbers of diagnostic catheterizations has performed (Figure 8).In 1977, Grüntzig and others introduced the technique of balloon angioplasty, known as percutaneous transluminal coronary angioplasty (PTCA) [18].

Equipments for coronary angiography
In the l960s, great strides were made in the quality of image amplification, particularly with the introduction of the cesium iodide tube.Simultaneously, powerful generators capable of millisecond exposures and high contrast levels were developed.Cine cameras evolved into dependable instruments with fine-quality lenses that provide extraordinarily good resolution in modern 35-mm cine angiocardiography.Videotape recording techniques improved strikingly.Instantaneous playback of tape-recorded images has afforded great utility and safety in determining whether desired anatomic and physiologic information has been attained, thereby precluding additional unnecessary studies (Figure 8).The introduction of angled views for the study of congenital and acquired heart disease was an important technical innovation [19].Equipment companies responded with engineering advances that made angled views relatively simple: the C-arm, the U-arm, and the parallelogram.Recently, the development of non-invasive angiography device is advancing.Echocardiography, scintigraphy, cardiac computed tomography and cardiac magnetic resonance imaging play increasingly important roles in the evaluation of the heart and great vessels, non-invasively.It is already an established technique for the evaluation of congenital heart disease, cardiac tumors and disorders of the aorta and pericardium.They can evaluate ventricular function and regurgitation of blood across heart valves.

Conclusion
Medicine moves so fast that its evolution tends to be forgotten.In particularly, techniques that have become an integral part of the standard device of diagnosis or therapy are passed to each new generation of physicians and trainees.We perform them without their having sense of efforts involved in the initial development of those techniques.In this one decade, we would be astonished at how far the field has come and how much information can be gathered on the structure and function of the heart from diagnostic imaging.A century is a short time in the history of medicine, but it has been an eventful lifetime.

70Fig. 1 .
Fig. 1.The chest film from "The Röntgen Rays in Medical Work".Book Company.1896."In this book, his remarks concerning contrast studies are intriguing.In teaching the anatomy of the blood vessels, the X-ray opens out a new and feasible method.The arteries and veins of dead bodies may be injected with a substance opaque to the X-ray and thus, their distribution may be more accurately followed than by any possible dissection.The feasibility of this method applies equally well to the study of the structures and organs of the dead body.To a certain extent, therefore, X-ray photography may replace both dissection and vivisection, and in the living body, the location and size of a hollow organ may be ascertained by causing the subject to drink a harmless fluid more or less opaque to the X-ray, or an effervescing mixture which will cause distention, and then taking the picture.In 1920, a radiographic atlas devoted only to the systemic arteries of the body was published in England, "The X-ray atlas of the systemic arteries of the body.London: Balliere, Tindall, and Cox, 1920," by Orrin.The reproductions showed blood vessels in cadavers with great clarity (Figure3).In 1910, Franek and Alwens introduced a suspension of bismuth and oil into the hearts of dogs and rabbits directly through the large veins and observed the passage of droplets from the heart into the lungs.In 1922, the work of Sicard and Forestier represented the next major

Fig. 2 .
Fig. 2. A roentgenogram made by Haschek and Lindenthal after the injection of Teichman's mixture into the blood vessels of an amputated hand (Haschek E. Lindenthal O'F.A contribution to the practical use of the photography according to Röntgen.Wien Klin Wochenschr 1896:9:63.).

Fig. 3 .
Fig. 3. Reproduction of a 1920 roentgenogram of a cadaver after the injection of opaque medium into the cerebral vessels (Orrin HC.The x-ray atlas of the systemic arteries of the body.London: Balliere, Tindall, and Cox,1920.).

Fig. 5 .
Fig. 5.The first femoral arteriogram obtained in a human subject.Brooks used sodium iodide as a means of demonstrating the vessels of the lower extremities in 1924(Brooks B. Intraarterial injection of sodium iodide.JAMA 1924; 82:1016.).

Fig. 7 .
Fig. 7.The first documented cardiac catheterization.At age 25, while receiving clinical instruction in surgery at Eberswalde, Werner Forssmann passed a catheter 65 cm through one of left antecubital veins until its tip entered the right atrium.He then walked to the radiology department where this roentgenogram was taken (Klin Wochenschr 1929;8:2085.Springer-Verlag, Berlin, Heidelberg, New York).