Surgery
Urgent coronary bypass surgery for failed percutaneous coronary intervention in the stent era: Is backup still necessary?

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Abstract

Background Current practice guidelines for performance of percutaneous coronary intervention (PCI) in the United States mandate availability of on-site surgical backup. With the decreasing frequency of urgent coronary bypass surgery (UCABG) with newer technologies, it is unclear whether such backup continues to be necessary. Methods A database of 5655 consecutive patients undergoing PCI at a single center between August 1, 1992, and December 31, 1997, was analyzed. Outcomes were determined as well as clinical, lesion, and procedural characteristics of patients during 4 time periods preceding and during use of coronary stenting. Results Frequency of UCABG for failed PCI decreased from 2.2% to 0.6% in the most recent time period (P <.01) with no change in incidence of in-hospital death or myocardial infarction. Incidence of stenting progressively increased to 72% in the latest period. Patients requiring UCABG had a higher prevalence of acute coronary syndromes (95%) and type B lesions (79%), but these characteristics were also common in patients who did not undergo UCABG. Although coronary stents were available during the last 3 periods studied, only 30% of UCABG patients had lesions or complications amenable to stenting, and stenting attempts in these patients were all unsuccessful. Despite stenting and use of perfusion balloons and intra-aortic balloon pumps, only 40% of patients having UCABG were stable and pain free on transfer to the operating room. Conclusions Although use of UCABG for a failed PCI is currently very low, there are no satisfactory predictors, patients requiring UCABG are frequently clinically unstable, and availability of stenting does not reliably eliminate the need for UCABG or result in a decrease in mortality. This small group of patients continues to require readily available surgical standby. (Am Heart J 2001;142:190-6.)

Section snippets

Methods

Use of UCABG for a failed interventional procedure was evaluated in a series of 5655 consecutive patients undergoing PCI between August 1, 1992, and December 31, 1997, at the Beth Israel Deaconess Medical Center West Campus by 7 experienced operators, each of whom performed 150 to 300 PCI procedures annually. Four time periods were defined according to availability and use of coronary stents:

  • August 1, 1992–July 31, 1993: 1090 patients with 1377 lesions treated before the use of any stents

  • August

Results

Clinical and lesion characteristics of all patients having interventions during the 4 periods are shown in Tables I and II.

. Clinical characteristics of patients undergoing PCI by time period

Empty CellTime periodP value
I (8/1/92-7/31/93) (n = 1090)II (8/1/93-3/31/95) (n = 1646)III (4/1/95-12/31/96) (n = 1785)IV (1/1/97-12/31/97) (n = 1134)
Median age (y)60.258.961.260.5.8
Female399 (36.6)593 (36.0)623 (34.9)407 (35.9).9
Unstable angina803 (73.7)1136 (69.0)1265 (70.9)782 (69.0).04
Acute MI36 (3.3)43 (2.6)105

Discussion

Our experience demonstrates a significant decrease in use of UCABG over the time period 1992-1997 from 2.2% to 0.6%. This was associated with no apparent consistent change in patient clinical characteristics and with an increase in lesion complexity and seems most likely the result of an increasing frequency of coronary stenting, 72% in the latest time period. A decreased incidence of UCABG has been reported from other institutions with availability of bail-out2, 4 and more routine stenting.3

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Reprint requests: Samuel J. Shubrooks, Jr, MD, FACC, Beth Israel Deaconess Medical Center, 110 Francis St, Boston, MA 02215. E-mail: [email protected]

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