Dehmer_subbed.qxp 20/4/09 4:22 pm Page 69
Interventional Cardiology
Percutaneous Coronary Intervention without On-site Surgical Back-up
Gregory J Dehmer, MD, FACC, FAHA, FACP, FSCAI
Professor of Medicine, Texas A&M University College of Medicine, and Director, Cardiology Division, Scott & White Clinic, Temple
Abstract
Although accepted in several countries, in the US the performance of percutaneous coronary intervention (PCI) without on-site surgical
back-up remains controversial. The current US guidelines do not endorse elective PCI in facilities without on-site surgical back-up, but
acknowledge that primary PCI for ST-segment elevation myocardial infarction (STEMI) is acceptable under carefully regulated and monitored
circumstances. In the US, survey data indicate that either primary PCI alone or primary and elective PCI without on-site surgery is currently
being performed in all but seven states, and the number of patients treated in this setting is increasing. Several recent reports continue to
document the safety of PCI without on-site surgical back-up, but have limitations as these data are from retrospective reviews or prospective
registries. Although it appears that primary and elective PCI without on-site surgery is safe, it is not clear that this is the best way to deliver
PCI care to the majority of patients.
Keywords
Angioplasty, myocardial infarction, stents, emergency care, coronary artery bypass surgery, guidelines
Disclosure: The author has no conflicts of interest to declare.
Received: January 9, 2009 Accepted: February 6, 2009
Correspondence: Gregory J Dehmer, MD, Scott & White Clinic, 2401 South 31st Street, Temple, TX 76508. E:
gdehmer@swmail.sw.org
The use of percutaneous coronary intervention (PCI) for coronary artery Percutaneous Coronary Intervention without
revascularization has grown considerably since the first balloon On-site Surgery in the US
angioplasty in 1977. Improvements in equipment and drug therapies plus Data are not easily found on the performance of PCI at facilities without
the development of coronary artery stents have all contributed to the on-site surgical back-up in the US. In 2007, the Society for Cardiovascular
growth of PCI as an alternative to surgical revascularization. Compared Angiography and Interventions (SCAI) published an Expert Consensus
with the early days of balloon angioplasty, when 1–2.5% of patients died Document on the topic of PCI without on-site surgical back-up that
and 1.9–5.8% required urgent coronary artery bypass graft (CABG) contained survey data on the performance of PCI without on-site surgery
surgery, recent data from high-volume centers show an in-laboratory in the US.
15
This is a dynamic situation as some states have changed their
mortality rate of 0.2% or less and a 0.3–0.6% incidence of urgent CABG.
1–4
regulations since that initial survey. An updated US map now shows only
As the safety and outcomes of PCI have steadily improved, the seven states where neither primary nor elective PCI is allowed without
indications for the procedure have also expanded. PCI is now the on-site surgery, nine states where only primary PCI is allowed, and 34
preferred therapy for patients with ST-segment elevation myocardial states where both primary and elective PCI without on-site surgery are
infarction (STEMI), and in this setting is called primary PCI.
5
However, the performed, although in some states it is allowed only as part of a research
superior outcomes of primary PCI are adversely affected by time delays study or demonstration project (see Figure 1). The number of patients
that may be encountered before the patient arrives in the cardiac receiving PCI at facilities without on-site surgery in the US is unknown, but
catheterization (cath) laboratory.
6–8
To avoid the inherent delays that recent data from the CathPCI™ Registry of the National Cardiovascular
occur when transferring patients and to extend this therapy to a larger Data Registry (NCDR™) suggest the number is increasing.
16
number of patients, some facilities began to perform primary PCI in the
absence of on-site cardiac surgery and reported excellent outcomes.
9,10
Guideline Statements About Percutaneous
As the number of patients with STEMI at any location is relatively small, Coronary Intervention without On-site Surgery
some facilities also started performing elective PCIs in an effort to Guidelines documents for PCI procedures have been published by
maintain proficiency among the support staff and to have adequate professional organizations within the US and abroad (see Table 1).
17–25
procedure volumes to justify the operation of such programs.
11–13
Current guidelines from professional organizations in the US do not
Although accepted in many countries abroad, the performance of PCI endorse elective PCI in facilities without on-site surgical back-up, but
without on-site cardiac surgery remains controversial in the US.
14
acknowledge that primary PCI for STEMI is acceptable under carefully
© TOUCH BRIEFINGS 2009 69
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100