Percutaneous Transluminal Coronary Angioplasty Without On-Site Surgical Facilities W. Peter Klinke, MD, and William Hui, MB, BS
Percutaneous transluminal coronary angioplasty (PTCA) is associated with a low risk of serious complications, the most important of which is acute coronary occlusion needing emergency surgery. There is a consensus among many cardiologists and cardiac surgeons that all PTCA procedures need on-site surgical backup. A task force report on PTCA by the American College of Cardiology/American Heart Association mandates the presence of an on-site cardiovascular surgical team. Since 1981, we have performed PTCA without the benefit of on-site surgery but with backup surgery provided at a regional cardiac surgical center located 6 kilometers away. Up to the end of 1991,762 patients have undergone 647 PTCAs. Most patients had l-vessel angioplasty (64.6%). The primary success rate since 1981 was 76%, and from January 1990 to December 1991 it was 87% (n = 313). Complications included death in 7 patlentr (O.S%), myocardial infarction in 16 (2.1%) and emergency. surgery in 12 (1.6%). Surgical backup was provided on a next available operating room basis. The average time from decision to transfer to onset of surgery was 194 minutes (range 75 to 320). All patlents survived surgery, but 42% developed a new Q-wave myocardial infarction. These patients were followed up until the end of 1991, and are all alive. The results are similar to those reported from centers with and without on-site surgery. With careful selection of patients and a formal, coordinated plan for backup surgery, PTCA can be safely performed without on-site surgery. (Am1 Cardiol 1992;70:1520-1525)
he prevalence and acceptance of percutaneous transluminal coronary angioplasty (PTCA) as a method of treating coronary heart diseasehas resulted in the increasingly widespreaduse of this proce dure throughout the world. In the United States, approximately 1 million PTCAs have beenperformed and now surpass(on a yearly basis) the number of coronary artery bypass surgeries. A successfulPTCA procedure usually improves angina symptoms and functional status often associatedwith long-term benefit in many patients.‘** PTCA is associatedwith a low risk of serious complications, the most important of which is acute coronary occlusion. In the presenceof well-developedcollateral circulation, the consequencesmay be minimal. However, many patients will have severe angina and evolving myocardial infarction, shock and even death. Recently, the Subcommittee on Coronary Angioplasty of the American College of Cardiology/American Heart Association published guidelines concerning performance standards for PTCA.3 Recommendationsfor management of complications of PTCA included the mandatory presenceof an on-site cardiovascular surgical team. A recent report of PTCA complications occurring in a hospital without on-site surgery encouraged us to review and report our own IO-year experience.4
T
METHODS Patient population: PT.CA is performed at 2 teach-
ing hospitals in Edmonton: the University of Alberta Hospitals, and the Royal Alexandra Hospital. From July 1981 to December 1991, 762 patients underwent PTCA at the Royal Alexandra Hospital. Patient selection included those with stable angina pectoris undergoing elective PTCA, and those needing urgent PTCA for unstable angina, developing acute myocardial infarction, postmyocardial infarction angina and postthrombolytic therapy. In most cases, historical and angiographic findings were reviewed by weekly cineangiograms, and a consensuswas needed as to the appropriatenessof PTCA in each case.Furthermore, outside opinions from other angioplasty cardiologists and cardiovascular surgeons were sought in difficult cases. Patients whose clinical or angiographic characteristics were thought to place them in a high-risk group or who would be more appropriately treated with atherectomy or stents were referred to other centers for PTCA. Data collectii: Baseline demographic, angiographic and procedural data including complications were From the Royal Alexandra Hospital, Edmonton, Alberta, Canada. recorded prospectively on standardized forms. AngioManuscript received May 20, 1992; revised manuscript received and grams before and after PTCA were qualitatively estiacceptedJuly 21, 1992. mated by an experienced angiographer. The maximal Addressfor reprints: W. Peter Klinke, MD, Division of Cardiology, 6-227Royal Alexandra Hospital, 10240Kingsway Avenue, Edmonton, stenosisobservedin multiple views was used as the prePTCA stenosis.Over the last 2 years,we classifiedthese Alberta T5H 3V9, Canada. 1520
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
DECEMBER 15. 1992
stenosesinto 4 groups according to a modification, suggested by Ellis et a1,5of the American College of Cardiology/American Heart Association classification of lesion morphology (types A, B 1, B2 and C). A successful PTCA procedure was defined as a reduction of the predilatation stenosis by 150% or a residual stenosis
Percutaneous transluminal coronary angioplasty (PTCA) is associated with a low risk of serious complications, the most important of which is acute coronary occlusion needing emergency surgery. There is a consensus among many cardiologists and cardiac surgeons that all PTCA procedures need on-site surgical backup. A task force report on PTCA by the American College of Cardiology/American Heart Association mandates the presence of an on-site cardiovascular surgical team. Since 1981, we have performed PTCA without the benefit of on-site surgery but with backup surgery provided at a regional cardiac surgical center located 6 kilometers away. Up to the end of 1991,762 patients have undergone 647 PTCAs. Most patients had l-vessel angioplasty (64.6%). The primary success rate since 1981 was 76%, and from January 1990 to December 1991 it was 87% (n = 313). Complications included death in 7 patlentr (O.S%), myocardial infarction in 16 (2.1%) and emergency. surgery in 12 (1.6%). Surgical backup was provided on a next available operating room basis. The average time from decision to transfer to onset of surgery was 194 minutes (range 75 to 320). All patlents survived surgery, but 42% developed a new Q-wave myocardial infarction. These patients were followed up until the end of 1991, and are all alive. The results are similar to those reported from centers with and without on-site surgery. With careful selection of patients and a formal, coordinated plan for backup surgery, PTCA can be safely performed without on-site surgery. (Am1 Cardiol 1992;70:1520-1525)
he prevalence and acceptance of percutaneous transluminal coronary angioplasty (PTCA) as a method of treating coronary heart diseasehas resulted in the increasingly widespreaduse of this proce dure throughout the world. In the United States, approximately 1 million PTCAs have beenperformed and now surpass(on a yearly basis) the number of coronary artery bypass surgeries. A successfulPTCA procedure usually improves angina symptoms and functional status often associatedwith long-term benefit in many patients.‘** PTCA is associatedwith a low risk of serious complications, the most important of which is acute coronary occlusion. In the presenceof well-developedcollateral circulation, the consequencesmay be minimal. However, many patients will have severe angina and evolving myocardial infarction, shock and even death. Recently, the Subcommittee on Coronary Angioplasty of the American College of Cardiology/American Heart Association published guidelines concerning performance standards for PTCA.3 Recommendationsfor management of complications of PTCA included the mandatory presenceof an on-site cardiovascular surgical team. A recent report of PTCA complications occurring in a hospital without on-site surgery encouraged us to review and report our own IO-year experience.4
T
METHODS Patient population: PT.CA is performed at 2 teach-
ing hospitals in Edmonton: the University of Alberta Hospitals, and the Royal Alexandra Hospital. From July 1981 to December 1991, 762 patients underwent PTCA at the Royal Alexandra Hospital. Patient selection included those with stable angina pectoris undergoing elective PTCA, and those needing urgent PTCA for unstable angina, developing acute myocardial infarction, postmyocardial infarction angina and postthrombolytic therapy. In most cases, historical and angiographic findings were reviewed by weekly cineangiograms, and a consensuswas needed as to the appropriatenessof PTCA in each case.Furthermore, outside opinions from other angioplasty cardiologists and cardiovascular surgeons were sought in difficult cases. Patients whose clinical or angiographic characteristics were thought to place them in a high-risk group or who would be more appropriately treated with atherectomy or stents were referred to other centers for PTCA. Data collectii: Baseline demographic, angiographic and procedural data including complications were From the Royal Alexandra Hospital, Edmonton, Alberta, Canada. recorded prospectively on standardized forms. AngioManuscript received May 20, 1992; revised manuscript received and grams before and after PTCA were qualitatively estiacceptedJuly 21, 1992. mated by an experienced angiographer. The maximal Addressfor reprints: W. Peter Klinke, MD, Division of Cardiology, 6-227Royal Alexandra Hospital, 10240Kingsway Avenue, Edmonton, stenosisobservedin multiple views was used as the prePTCA stenosis.Over the last 2 years,we classifiedthese Alberta T5H 3V9, Canada. 1520
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
DECEMBER 15. 1992
stenosesinto 4 groups according to a modification, suggested by Ellis et a1,5of the American College of Cardiology/American Heart Association classification of lesion morphology (types A, B 1, B2 and C). A successful PTCA procedure was defined as a reduction of the predilatation stenosis by 150% or a residual stenosis
