**2.1. Cardiac catheterization**

One of the earliest descriptions of cardiac catheterizations was done by Steven Hales, an English chemist, botanist and animal physiologist who cannulated the carotid artery and the jugular vein to access the left and right-sided chambers of the heart respectively in the 17th

century [1]. It was through some of this initial work, that he was able to make the first measurements of blood pressure, describe systole and diastole, characterize the volumes of the heart through wax cast work and correctly describe the function of the aortic and mitral valve [1]. Interestingly, the first human cardiac catheterization was by a Urologist by the name of Werner Forssmann [2]. He performed right heart catheterization on himself in 1929 by advancing a cannula through the left antecubital vein via cut-down access into the right atrium [2].

(ACEI)/Angiotensin Receptor Blocker (ARB). This combined therapy addresses not only patient symptoms but also modifies the disease process such that prognosis is vastly improved [7]. The growth in our understanding the impact of lifestyle modification has also played a

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Due to advances in medical therapy, patients that are now considered for revascularization are also older and have accrued more co-morbidities [9]. These co-morbidities render the interpretation of relevant symptoms more difficult. For example, in a diabetic patient with chronic obstructive lung disease (COPD), it may be difficult to distinguish between dyspnea as an anginal equivalent versus that caused by the underlying pulmonary pathology. The severity of the patients' COPD may also complicate the eligibility for CABG as a mode of revascularization [10, 11]. In fact, in a recent clinical trial comparing CABG versus PCI in complex CAD, significant burden of co-morbidities was the most common reason that patients

Angioplasty has significantly evolved over the last several decades with respect to four principle areas. First, operator training has advanced from informal training courses to 1-2 year formal clinical fellowships [12, 13]. Second, the equipment to perform PCI has signifi‐ cantly improved from plain old balloon angioplasty (POBA) to second-generation drugeluting stents (DES) and supporting devices to improve PCI outcomes (filter wires, thrombectomy in ST elevation acute coronary syndrome (STEACS), and rotational arthrecto‐ my) [14, 15]. Third, vascular access has evolved from brachial cut-downs with large caliber sheaths (7-8 FR) to increasingly common radial access with smaller caliber sheaths (5 and 6 FR) [5, 15-18]. Finally, concomitant medications have become more sophisticated, from Aspirin (ASA) alone to combination antiplatelets resulting in reduced stent thrombosis [19]. Restenosis has remained in the forefront of limitation to PCI[20]. However, the challenges with restenosis have been significantly reduced with advancement in DES technology [21-23]. Concerns with the thrombosis rates in the setting of discontinuation of dual antiplatelet therapy (DAPT) after DES have been addressed by second-generation DES, which have dramatically reduced this clinical problem [24]. These advances have been paralleled by an increasing use in complex

From the standpoint of CABG, we have over the years learned the benefits of arterial grafting with the internal mammary artery (IMA) in improving survival [26]. A high long-term patency rate of left internal mammary artery (LIMA) after revascularization of the LAD is well established and is estimated at 88 percent at 10 to 15 years [26]. More recently, to circumvent particular risks associated with sternotomy, there has been some investigation of revasculari‐ zation of the LAD with the LIMA using a minimally invasive direct coronary artery bypass (MIDCAB) technique [26]. In the setting of multivessel disease (MVD), there has been some

were felt not to be suitable for CABG and hence entered into the PCI registry [9].

coronary artery disease including left main (LM) disease[25].

**3.4. Advances in surgical techniques**

central role in how we manage patients with CAD [8].

**3.2. Changing clinical patient profile**

**3.3. Advances in angioplasty**

### **2.2. Selective coronary angiography and angioplasty**

The credit of the first true selective coronary angiogram and much of the initial correlations between angina pectoris and coronary anatomy has to be granted to Mason Sones, a Pediatric Cardiologist, who at the time of discovery was working out of the Cleveland clinic [3-5]. In 1958, whilst performing non-selective aortogram on a patient, Sones inadvertently engaged the right coronary artery [2].

The original technique of angioplasty was born out earlier work by a Vascular Radiologist by the name of Charles Theodore Dotter [6]. Andreas Gruentzig, now known as the father of modern day coronary angioplasty, learned the Dotter technique from a German Radiologist Eberard Zeitler while doing a clinical fellowship in the Radiology Department of Aggertalclinic in Engelskirchen, Germany [6]. He had adopted the Dotter concept of using the balloon approach for angioplasty [6]. After experimenting with a number of materials performed the first procedure in 1977 in a man with stenosis of his left anterior descending artery (LAD) using a polyvinyl chloride balloon mounted onto the Dotter catheter [6].
