Heart: An American Medical Odyssey (20 page)

Before the procedure, I had reviewed Cheney’s images from the catheterization five years earlier, which I performed with Allan Ross. Now I was looking for what had changed.

The right coronary artery (the vessel that caused the 1988 heart attack) was still closed, but its right internal mammary artery bypass was wide open. The circumflex branch (the likely culprit of the 1978 and 1984 heart attacks) was also occluded, as was its bypass, both unchanged compared with the prior catheterization. When we injected dye into the left anterior descending (LAD) coronary artery, we found the problem: the LAD had been bypassed at surgery in 1988, but because the vessel had only moderate disease, the graft never properly developed and was closed, which we already knew. A large branch of the LAD called the diagonal coronary artery, supplying a significant segment of the front and side of the heart, had a tight new narrowing.

“Hey, Dick, do you see that?” I
said, trying to get the attention of Dick Katz who was watching on a monitor in the next room.

“See what?” Cheney responded.

“Oh, I’m not calling you, Dick,” I replied, embarrassed, and surprised that he was awake.

Cheney said, “You can call me Dick.”

“No, sir,” I said. “I’m talking to the Dick in the control room.”

Stop talking. You’ve just called at least one of them a dick.

Over the intercom, Katz told me that he did see the diagonal narrowing and he agreed that it was likely the cause of Cheney’s pain.

“I’m going to stent it,” I said.

•  •  •

In February 1978, a thirty-two-year-old Argentinean physician attended the Society of Interventional Radiology meeting in New Orleans where Dr. Andreas Gruentzig was presenting his new angioplasty procedure. Dr. Julio Palmaz, who had come to the United States the year before to do a radiology residency at the University of California, Davis, listened as Gruentzig described some of the potential complications from angioplasty and how an artery could abruptly close. Palmaz started to think of ways to solve the problem and came up with the novel idea of placing a metallic scaffold inside.

Dr. Palmaz spent years creating prototypes of his new “stent,” beginning with a meshwork of copper wire woven over a pencil in his home. He soon realized that to provide structural rigidity, the points where the wires crossed needed to be fixed, and eventually he crimped his sleeve of metallic meshwork onto an angioplasty balloon. When the balloon was inflated inside a tube, the stent expanded, becoming apposed to the wall, creating an internal scaffold.

While searching for ways to construct his device from a single piece of metal rather than woven stands of wire, Palmaz found a fragment of metal masonry mesh on the floor of his garage, the kind of material used to reinforce concrete or plaster. Two decades later, he described his discovery:

It was total serendipity. . . . I looked at it and thought, “This looks like what I’m trying to do here.” I grabbed it, cut out a small piece, then closed it by pushing it together and bouncing it on the table with a hammer. I realized that the staggered openings were staggered slots when it was closed. I thought, “Well, if I make this pattern in a tube, then, when a balloon expands, it will become a mesh.” And it’s made of a single material. This was the inspiration for the slotted stent.

Palmaz continued to work on stent designs but had difficulty funding his research. In 1985, now the chief of angiography at the University of Texas Health and Science Center in San Antonio,
Palmaz met Dr. Richard Schatz, a cardiologist at nearby Brooke Army Medical Center. Schatz knew that a major risk of coronary angioplasty was abrupt vessel closure, a potentially catastrophic event that occurred in 5 to 10 percent of patients, typically caused by balloon-induced disruption of the arterial lining. Also, almost half the vessels treated with angioplasty renarrowed within a few months of the initial procedure, a phenomenon called restenosis. Schatz recognized the need for a technology that might reduce these events. Later that same year, Schatz met Phil Romano at San Antonio’s Dominion Country Club. Romano, a prolific entrepreneur, was the founder of the Fuddruckers and Romano’s Macaroni Grill restaurant chains, and despite the protestations of his lawyer and accountant, he agreed to invest $250,000 in the stent project. Palmaz, Schatz, and Romano formed a business entity they called the Expandable Grafts Partnership, and on March 29, 1988, they were issued US patent 4,733,665 for an “expandable intraluminal graft, and method and apparatus for implanting an expandable intraluminal graft.” The patent abstract describes how the invention works:

An
expandable intraluminal vascular graft is expanded within a blood vessel by an angioplasty balloon associated with a catheter to dilate and expand the lumen of a blood vessel. The graft may be a wire mesh.

Johnson & Johnson licensed the new stent in 1988 agreeing to pay the partners $10 million in
addition to future royalties. With J&J pouring both money and intellectual resources into product development, clinical trials began for the Palmaz stent, now manufactured from tubes of stainless steel etched with staggered rows of rectangular slots that created diamond-shaped interstices when expanded. In 1991, the FDA approved the Palmaz stent for use in arteries supplying the leg, and in 1994 the Palmaz-Schatz stent was approved for use in the heart.

Cardiologists enthusiastically embraced the new technology, and the use of stents rose rapidly from 5 percent of interventional procedures in 1994 to almost 70 percent in 1997.
In 2009, there were almost 650,000 hospitalizations in the United States involving the implantation of a coronary stent. Stenting made angioplasty safer, vastly reducing the number of patients requiring emergency surgery because of a procedural complication such as a coronary dissection or abrupt occlusion, and enabled increasingly complex lesions to be treated without the need for coronary artery bypass surgery.

Phil Romano’s $250,000 gamble in 1985 would ultimately yield him well over $100 million.

•  •  •

When I see a patient in the clinic, I always start the appointment by asking about work, family, a recent trip—something personal. No one looks in the mirror and sees a “fifty-eight-year-old white male with atrial fibrillation” or a “seventy-two-year-old female status post LAD stenting,” and when they come to see me, I want them to know that I don’t see them that way either. I once received a card from a patient in whom I had recently repaired multiple coronary arteries. Taped inside was a vacation photo of the patient with his wife, and their two small children, everyone huddled close together in a happy family tangle of sunglasses and smiles. In little kid handwriting, his seven-year-old son wrote, “Thanks for fixing my dad’s heart,” a poignant reminder of how much there had been to lose.

In the cath lab, I try to make all of that disappear and focus
instead on the technical tasks: the artery to be punctured, the lesion to be crossed, the stent to deploy. I gazed down the table at Cheney and tried not to think about who he was, or his family waiting down the hall, or the election, and I consciously avoided looking through the leaded glass window at the control room filled with anxious medical center leadership.

My colleague Dr. Conor Lundergan joined me after a hurried drive from his home in Maryland, some of it on the shoulder of the road, and together we again reviewed the images looping on the video displays suspended from the ceiling. Conor agreed that we should fix the large diagonal, and I gave Julia a “shopping list” of equipment I wanted, most of which she had already set aside.

I told Cheney that we had identified the problem and were going to take care of it. Although he appeared to be sleeping, he immediately acknowledged what I said and responded, “Good.”

Take a deep breath; you’ve done this thousands of times.

I inserted a guide catheter (essentially, a one-meter-long, steel-reinforced, hollow tube with a shaped tip, roughly the diameter of a soda straw) into the sheath in Mr. Cheney’s right femoral artery and maneuvered it with the aid of fluoroscopy to the origin of his left main coronary artery. I then advanced a thin (.014-inch diameter) guide wire through the guide catheter into the left anterior descending coronary and out into its diagonal branch, the culprit for Cheney’s chest pain.

A diseased coronary artery is a slender structure that flexes in concert with the underlying beating heart and is filled with ragged outcroppings of calcified plaque, creating a moving three-dimensional environment. Manipulating a device inside an atherosclerotic coronary is like crawling through a tight cave filled with stalactites and stalagmites while the cave jumps up and down.

Without too much difficulty, we succeeded in wiggling the soft tip of the wire beyond the tight coronary narrowing into the relatively less diseased vessel segment downstream, step one in repairing the artery. Next we loaded the back end of the wire into the central lumen of the balloon, like threading a needle, except the eye is about the same diameter
as the thread, and then we slid the balloon over the wire into the coronary. With a bit of coaxing, the balloon slipped into the tightly restricted section of the diagonal. The inflation device, a large syringe with a screw-in plunger, filled with diluted X-ray dye, was connected to the balloon, and as we twisted the plunger clockwise, the 2.5-millimeter balloon expanded inside Dick Cheney’s coronary artery.

I checked the hemodynamic monitor and his pulse, blood pressure, and rhythm were all fine. I looked to my left down the table, and Cheney was sleeping.

So far so good.

After about a minute of dilation, the balloon was deflated and removed, and another set of pictures revealed a still narrowed, but somewhat improved, appearance of the vessel, step two.

The final part of the procedure was delivering and then expanding a stent in the diseased segment, a task that is sometimes easier said than done. Although a lot of engineering has gone into increasing stent flexibility, the metallic device has an intrinsically rigid architecture, and in order to pass it through an angulated vessel, either the artery or the stent has to bend. The more inflexible either structure is, the harder it is to deliver the device to the intended target.

We watched on the monitor as the stent entered the left main and then the LAD. It’s not so easy to see the actual stent, but the balloon on which it is crimped has visible markers at both ends, identifying the leading and trailing edges of the device. With a bit of effort, we were able to get the stent to make the ninety-degree turn into the diagonal, but there was a second acute bend to negotiate, and the stent would go no farther.

I backed the stent off a few millimeters and tried again. No luck. We removed the stent and re-dilated the artery with a balloon. Still, the stent would not pass. We changed to a different type of stent, but that too would not make the second turn into the short segment with the worst disease.

I don’t usually perspire much during a case because the rooms are kept cool, and I’ve performed these procedures so many times, but the scrubs
under my protective lead were soaked by now. As hard as I tried to tell myself that this was just another angioplasty, the growing crowd in the control room, the Secret Service outside the door, and the camera trucks outside the hospital were constant reminders that while the medicine might have been routine, nothing else was. Although the success rate for coronary interventions is very high, it’s not 100 percent, and occasionally a lesion can’t be fixed. There’s no shame in that. But in this particular case, to paraphrase NASA’s Gene Kranz, “failure was not an option.”

We had long since passed the two-hour mark, and I looked over again to see how Cheney was doing. I turned to Julia and asked her if we had any juice.

“Sure,” she said, as she went to the refrigerator outside the room, returning quickly with a small round container of apple juice, a flexible straw protruding from its foil cover.

“Here you go,” she said, offering Cheney the juice.

“Not him, Julia, me,” I said.

“Oh,” she said, pivoting away from the patient with a nervous laugh.

Sometimes it’s best to press the pause button. When an initial attempt to solve a problem fails, there’s a natural tendency to try the same approach over and over again, creating an endless, unsuccessful loop. I could feel some frustration beginning to fester, and I was also really thirsty. It was time to stop for a moment.

Julia slipped the straw under the side of my mask, and I downed the cold liquid in a single slurp.

Okay, let’s try something else.

After the brief time-out, we reentered the vessel with a different balloon in a slightly different place, hoping that the inflation would alter the internal geometry of the artery just enough to allow passage of the stent. Now when we advanced the stent, it slid into position, and when it did, I could sense the collective sigh of relief. After a half dozen clockwise turns on the inflation syringe, the stent was finally deployed. We were done.

I took off my gown and gloves and told Mr. Cheney what we had found
and what we were able to do. As I left the room, I told the Secret Service agents that we would be bringing him back to his room in a few minutes, and they immediately began talking quietly into the microphones clipped discreetly inside their jacket cuffs.

It was now after noon and while we were in the cath lab, Governor Bush had made a brief statement in Austin in which he said, “Dick Cheney is healthy. He did not have a heart attack.” The governor’s statement had been based on the first set of cardiac enzymes drawn shortly after Mr. Cheney’s arrival at the hospital, which were negative. The second set of enzymes, however, obtained a few hours later when we started the cath, specifically the highly sensitive troponin assay, was mildly elevated, indicative of a small heart attack. Governor Bush had not been told these results before he made his statement.

Alan Wasserman, Conor Lundergan, Gary Malakoff, and I went to talk with Mrs. Cheney who was waiting in an office in the hospital’s administrative suite. I told Mrs. Cheney that the findings were quite similar to the cath five years earlier with the exception of the diagonal, which we were able to repair with a single stent. We talked about the mildly elevated cardiac enzymes and her husband’s very favorable prognosis. There was some discussion as to who would brief the media, and ultimately it was decided that Dr. Wasserman would do it.