Cardiovascular procedure volume growth (interventional and surgical)

Cardiovascular surgical and interventional procedures are performed to treat conditions causing inadequate blood flow and supply of oxygen and nutrients to organs and tissues of the body. These conditions include the obstruction or deformation of arterial and venous pathways, distortion in the electrical conducting and pacing activity of the heart, and impaired pumping function of the heart muscle, or some combination of circulatory, cardiac rhythm, and myocardial disorders. Specifically, these procedures are:

  • Coronary artery bypass graft (CABG) surgery;
  • Coronary angioplasty and stenting;
  • Lower extremity arterial bypass surgery;
  • Percutaneous transluminal angioplasty (PTA) with and without bare metal and drug-eluting stenting;
  • Peripheral drug-coated balloon angioplasty;
  • Peripheral atherectomy;
  • Surgical and endovascular aortic aneurysm repair;
  • Vena cava filter placement
  • Endovenous ablation;
  • Mechanical venous thrombectomy;
  • Venous angioplasty and stenting;
  • Carotid endarterectomy;
  • Carotid artery stenting;
  • Cerebral thrombectomy;
  • Cerebral aneurysm and AVM surgical clipping;
  • Cerebral aneurysm and AVM coiling & flow diversion;
  • Left Atrial Appendage closure;
  • Heart valve repair and replacement surgery;
  • Transcatheter valve repair and replacement;
  • Congenital heart defect repair;
  • Percutaneous and surgical placement of temporary and permanent mechanical cardiac support devices;
  • Pacemaker implantation;
  • Implantable cardioverter defibrillator placement;
  • Cardiac resynchronization therapy device placement;
  • Standard SVT & VT ablation; and
  • Transcatheter AFib ablation

For 2016 to 2022, the total worldwide volume of these cardiovascular procedures is forecast to expand on average by 3.7% per year to over 18.73 million corresponding surgeries and transcatheter interventions in the year 2022. The largest absolute gains can be expected in peripheral arterial interventions (thanks to explosive expansion in utilization of drug-coated balloons in all market geographies), followed by coronary revascularization (supported by continued strong growth in Chinese and Indian PCI utilization) and endovascular venous interventions (driven by grossly underserved patient caseloads within the same Chinese and Indian market geography).

Venous indications are also expected to register the fastest (5.1%) relative procedural growth, followed by peripheral revascularization (with 4.0% average annual advances) and aortic aneurysm repair (projected to show a 3.6% average annual expansion).

Source: MedMarket Diligence, LLC; “Global Dynamics of Surgical and Interventional Cardiovascular Procedures, 2015-2022,” (Report #C500).

Geographically, Asian-Pacific (APAC) market geography accounts for slightly larger share of the global CVD procedure volume than the U.S. (29.5% vs 29,3% of the total), followed by the largest Western European states (with 23.9%) and ROW geographies (with 17.3%). Because of the faster growth in all covered categories of CVD procedures, the share of APAC can be expected to increase to 33.5% of the total by the year 2022, mostly at the expense of the U.S. and Western Europe.

However, in relative per capita terms, covered APAC territories (e.g., China and India) are continuing to lag far behind developed Western states in utilization rates of therapeutic CVD interventions with roughly 1.57 procedures per million of population performed in 2015 for APAC region versus about 13.4 and 12.3 CVD interventions done per million of population in the U.S. and largest Western European countries.

Source: MedMarket Diligence, LLC; “Global Dynamics of Surgical and Interventional Cardiovascular Procedures, 2015-2022,” (Report #C500).


Global Cardiovascular Procedures report #C500 details the current and projected surgical and interventional therapeutic procedures commonly used in the management of acute and chronic conditions affecting myocardium and vascular system.

Interventional and Surgical Cardiovascular Procedure Volumes

Cardiovascular diseases (CVDs) are a variety of acute and chronic medical conditions associated with an inability of the cardiovascular system to sustain an adequate blood flow and supply of oxygen and nutrients to organs and tissues of the body. The CVD conditions may be manifested by the obstruction or deformation of arterial and venous pathways, distortion in the electrical conducting and pacing activity of the heart, and impaired pumping function of the heart muscle, or some combination of circulatory, cardiac rhythm, and myocardial disorders.

These diseases are treated via the following surgical and interventional procedures:

  • Coronary artery bypass graft (CABG) surgery;
  • Coronary angioplasty and stenting;
  • Lower extremity arterial bypass surgery;
  • Percutaneous transluminal angioplasty (PTA) with and without bare metal and drug-eluting stenting;
  • Peripheral drug-coated balloon angioplasty;
  • Peripheral atherectomy;
  • Surgical and endovascular aortic aneurysm repair;
  • Vena cava filter placement
  • Endovenous ablation;
  • Mechanical venous thrombectomy;
  • Venous angioplasty and stenting;
  • Carotid endarterectomy;
  • Carotid artery stenting;
  • Cerebral thrombectomy;
  • Cerebral aneurysm and AVM surgical clipping;
  • Cerebral aneurysm and AVM coiling & flow diversion;
  • Left Atrial Appendage closure;
  • Heart valve repair and replacement surgery;
  • Transcatheter valve repair and replacement;
  • Congenital heart defect repair;
  • Percutaneous and surgical placement of temporary and permanent mechanical cardiac support devices;
  • Pacemaker implantation;
  • Implantable cardioverter defibrillator placement;
  • Cardiac resynchronization therapy device placement;
  • Standard SVT & VT ablation; and
  • Transcatheter AFib ablation

In 2016, the cumulative worldwide volume of these procedures is projected to approach 15.05 million surgical and transcatheter interventions. This will include:

  • roughly 4.73 million coronary revascularization procedures via CABG and PCI (or about 31.4% of the total),
  • close to 4 million percutaneous and surgical peripheral artery revascularization procedures (or 26.5% of the total);
  • about 2.12 million cardiac rhythm management procedures via implantable pulse generator placement and arrhythmia ablation (or 14.1% of the total);
  • over 1.65 million CVI, DVT, and PE targeting venous interventions (representing 11.0% of the total);
  • more than 992 thousand surgical and transcatheter heart defect repairs and valvular interventions (or 6.6% of the total);
  • close to 931 thousand acute stroke prophylaxis and treatment procedures (contributing 6.2% of the total);
  • over 374 thousand abdominal and thoracic aortic aneurysm endovascular and surgical repairs (or 2.5% of the total); and
  • almost 254 thousand placements of temporary and permanent mechanical cardiac support devices in bridge to recovery, bridge to transplant, and destination therapy indications (accounting for about 1.7% of total procedure volume).

Below is illustrated the overall global growth for each of the major categories of procedures through 2022.

Source: MedMarket Diligence, LLC; Report #C500.  (Full report available online.)

There is considerable variation in the growth of cardiovascular procedures globally, but most growth is coming out of Asia/Pacific. For example, within the area of venous interventions, the growth in the use of endovenous ablation for chronic venous insufficiency is markedly higher in Asia/Pacific than in other regions, though the U.S. will remain the largest volume of these procedures.

Source: MedMarket Diligence, LLC; Report #C500.  (Full report available online.)


“Global Dynamics of Surgical and Interventional Cardiovascular Procedures, 2015-2022” (Report #C500), published August 2016. See description, table of contents, list of exhibits at link. Available for purchase and download from link.

Percutaneous Transluminal Angioplasty and Stenting Reconsidered

Originally developed by the Swiss physician Andreas Gruentzig as a less traumatic alternative to CABG, and first performed in the U.S. in 1978, percutaneous transluminal coronary angioplasty (PTCA) has soon emerged as a mainstream revascularization modality, particularly well-suited for singular concentric coronary artery occlusions.

PTCA is a minimally invasive procedure intended to restore normal (or nearly normal) blood circulation in occluded coronary arteries through a radial dilation of atherosclerotic plaque and its compression against arterial wall with transluminally-placed inflatable balloon.

In PTCA procedure, occluding coronary lesion is first crossed with appropriate guidewire, which is typically inserted under fluoroscopic guidance through a puncture in femoral artery and brought to the treatment site via iliac artery and aortic tree. A special balloon-tipped catheter is then deployed over the guidewire across the targeted lesion and repeatedly inflated to provide a required reopening of the arterial lumen. The catheter is then withdrawn and arterial puncture is secured with the use of external pressure aids or special vascular puncture closure device.

Despite some indisputable benefits of “plain old balloon angioplasty,” its ultimate clinical efficacy was seriously compromised by the disappointingly high rate of restenosis that ran as high as 50% at six months and typically required re-intervention. Introduction of coronary bare metal stents (BMS) in the early 1990s allowed to partially alleviate that problem by reducing the average restenosis rate by about one-half. Stents also helped to virtually eliminate many of the complications of conventional angioplasty, such as abrupt and unpredictable collapse and closure of the vessel, which resulted in emergency bypass surgery.

Since the introduction of bare metal coronary stents, the usage of angioplasty expanded considerably, supplanting CABG as the most commonly employed modality of myocardial revascularization.

By the beginning of the past decade, though, growth in PTCA and coronary stenting caseloads started to slow down in the U.S., Europe, and Japan reflecting significant penetration of technically feasible CAD indications and a disappointingly high rate of post-PTCA and in-stent restenosis. The problem of restenosis represented a single major handicap of coronary angioplasty/stenting, which hampered its ultimate clinical outcomes and often forced a revision and eventual conversion to bypass surgery.

In the opinion of many leading clinicians and industry’s analysts, introduction of drug-eluting stents (DES) represented the single most important innovation in endovascular therapy, since the advent of stenting and angioplasty that was bound to have a revolutionary impact on interventional cardiology practices.  In addition to effectively remedying the nagging problem of coronary restenosis (by reducing its rates to mid-low digit figures), the drug-eluting devices also enabled interventional cardiologists to successfully manage coronary indications and patient caseloads that were traditionally deemed unsuited for angioplasty and stenting. The latter include treatment of small diameter vessels, long and bifurcated lesions, left main artery and multivessel disease, as well as expanded coverage of high-risk patient cohorts with advanced diabetes, renal insufficiency/failure and recent major AMI.

Unfortunately, in the middle of the past decade, one could witness a gradually growing concerns about relatively high incidence (compared to BMS) of late and very late stent thrombosis (often leading to AMI and death) and overall safety of DES, that have prompted several warning letters, but were generally ignored due to initial exuberance about superb antirestenotic performance of DES technology. Following a release of disturbing findings from several major studies in 2006, the cited concerns appeared to reach a “critical mass” bringing the safety issues to the forefront of renewed DES debates and ultimately prompting a very significant decline in DES usage and cumulative PCI procedure volumes in the U.S. and Europe.

In the view of many leading clinicians, the higher propensity of drug-eluting stents to late (and very late) thrombosis is stemming from the very nature of current DES technology which is focused primarily on prophylaxis of binary restenosis via distortion and inhibition of natural healing processes involving neointimal outgrowth. The latter, by definition, lead to a significantly delayed epithelialization and protracted stent struts exposure to the blood stream, which have been identified as the main sources of thrombogenicity. According to multiple IVUS and pathology studies, incomplete endothelialization of DES (with associated bare strut exposure and device malapposition) is commonly observed at 3 to 4 years post-implantation, in contrast to full epithelial coverage of BMS occurring at 5 to 6 months after stent placement.

Early termination of dual (aspirin-clopidogrel) antiplatelet regimens due to patient’s non-compliance, serious complications, or other reasons appears to represent another major contributing factor to onset of late thrombotic events. Based on available data, the vast majority of DES-related thrombosis episodes tend to occur at 1.0 to 3.5 years post-implantation, or after the recommended 12-month period of dual antiplatelet therapy. According to clinical literature, other factors implicated in the occurrence of late and very late DES thrombosis include presence of inflammatory polymer on stent, incomplete drug elution, rate of drug elution, cytotoxicity of chosen drug, as well as poor DES patient selection (e.g., utilization of DES in high-risk diabetics, and their off-label uses in small diameter vessels, patients with long and bifurcated lesions, etc.).

Most of the cited problems were effectively addressed by the next-generation DES devices that combine sophisticated cobalt and platinum alloy stenting platforms and biodegradable drug coatings with super-low-profile delivery and minimally traumatic deployment systems.

It is assumed that clinical efficacy and utility of DES technology would be significantly enhanced with the advent of specialty bifurcation-targeting devices, vascular healing-focused biopharmaceutical coatings, and in increased adoption of fully biodegradable stenting systems.


For forecasts of off-pump CABG, on-pump CABG, primary PCI with stenting, and drug-eluting stent-based PCI procedures (separately for U.S. Western Europe, Asia/Pacific and Rest of World), as well as all major cardiovascular surgical and interventional procedures, see Report #C500, “Global Dynamics of Surgical and Interventional Cardiovascular Procedures, 2015-2022.”