The Trials and Tribulations of Percutaneous Coronary Intervention in Hospitals Without On-site CABG Surgery

Abstract

Historically, on-site coronary artery bypass grafting (CABG) surgery was not only required for percutaneous coronary angioplasty but operating rooms were also usually on standby until the angioplasty procedure was deemed successful. 1 In the 1980s, abrupt and subacute closure of the coronary artery at the angioplasty site due to dissection and associated thrombus, were not uncommon and 5% to 10% of patients required emergency CABG or CABG surgery within 24 hours. 2 Bail-out coronary stenting, for which stents are used to treat a dissection or abrupt closure after balloon angioplasty, revolutionized percutaneous coronary interventions (PCIs) by preventing periprocedural myocardial infarction and reducing the need for emergency CABG surgery. Subsequent randomized trials showed that primary stenting (stenting as a primary strategy) offered greater procedural success and lower rates of restenosis than balloon angioplasty and bail-out stenting. 3,4 More recently, with primary stenting, the risk of requiring emergency CABG surgery is now 10 times lower than it was in the early balloon angioplasty era (<0.5%). 5,6 Events are rare, because stents and other technologies successfully treat all but the most catastrophic complications of PCI.The move to establish PCIs in hospitals without on-site CABG surgical facilities started with several trials that showed better outcomes with primary PCI than with thrombolytic therapy for ST-elevation myocardial infarction (STEMI). 5 These benefits were expected because PCI is a more definitive treatment for the culprit coronary lesion and because thrombolytic therapy has defined risks of hemorrhagic stroke. Initial studies demonstrated that a strategy of transferring patients to centers with CABG surgery for primary PCI resulted in better outcomes than local treatment with thrombolysis. 7 Subsequently, in the Atlantic Cardiovascular Patient Outcomes Research Team (C-PORT) study, 8 better outcomes were achieved with local PCI in centers without CABG surgery than with thrombolytic therapy. Although no randomized trial tested primary PCI in centers without CABG surgery vs transfer for PCI in centers with CABG surgery, supporters argued that local PCI would permit more rapid and greater access to primary PCI for patients with STEMI. U.S. Department of Veterans Affairs VA Author ManuscriptVA Author Manuscript VA Author ManuscriptHowever, transportation time is less of an issue for PCI among the much larger pool of patients with non-STEMI and stable angina. For these patients, PCI in hospitals without onsite CABG surgery is based on patient convenience and the low absolute risk of death and emergency CABG surgery in carefully selected patients. Also, providing PCI services offers other benefits for an institution such as prestige in the community and the promise of handsome remuneration from procedural, professional, and hospitalization fees.Numerous registry studies comparing PCI outcomes in centers with or without CABG surgery show similar rates of in-hospital mortality and emergency CA...

SCAI/ACC/AHA Expert Consensus Document: 2014 Update on Percutaneous Coronary Intervention Without On-Site Surgical Backup

“…PCI programs bring prestige to an institution, and STEMI is one of the most prestigious diseases for treatment. 50,51 The push to develop rapid STEMI care has led many to currently advocate for EMS bypassing non-PCI hospitals; there is even consideration being given to triaging patients based on D2B metrics. Exclusion from providing STEMI care might be a lesser financial concern than the loss of downstream revenue from additional testing in patients suspected of having an acute coronary syndrome.…”

SCAI/ACC/AHA Expert Consensus Document

“…Per‐case revenue margins for PCI are typically higher than the overall hospital operating margins, and PCI improves the hospital case mix index. PCI programs bring prestige to an institution, and STEMI is one of the most prestigious diseases for treatment . The push to develop rapid STEMI care has led many to currently advocate for EMS bypassing non‐PCI hospitals; there is even consideration being given to triaging patients based on D2B metrics.…”

Current state of the performance of percutaneous coronary intervention in centres without on‐site cardiac surgery

“…Before the widespread adoption of stents, complications of balloon angioplasty required backup cardiac surgery. Historically, on‐site coronary artery bypass grafting (CABG) surgery was not only required for percutaneous coronary angioplasty, but operating rooms were also usually on standby until the angioplasty procedure was deemed successful . Potential complications of percutaneous coronary intervention (PCI) include flow‐limiting coronary dissections, coronary artery perforation and tamponade, abrupt vessel closure (especially of a large side‐branch) and thrombosis.…”

“…In the 1980s, abrupt and subacute closure of the coronary artery at the angioplasty site due to dissection and associated thrombus were not uncommon and 5% to 10% of patients required emergency CABG or CABG surgery within 24 hours …”

“…2 In the 1980s, abrupt and subacute closure of the coronary artery at the angioplasty site due to dissection and associated thrombus were not uncommon and 5% to 10% of patients required emergency CABG or CABG surgery within 24 hours. 1 Advances in pharmacotherapy and interventional techniques have changed the landscape of PCI. Steerable guide wires, new anti-platelet therapies, and most importantly, coronary artery stents have resulted in an increase in the success rate of PCI procedures.…”