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Delays to CABG After Failed PCI: What Are the Risks?

This study's findings support current guideline recommendations for on-site emergency surgical back-up for elective PCI.

Urgent coronary artery bypass grafting (CABG) after failed percutaneous coronary intervention (PCI) is becoming less common thanks to recent improvements, including stent use (Journal Watch Cardiology Dec 6 2002). The progress has helped to fuel interest in both primary and elective PCI performed at centers without cardiac surgery capabilities. Now, researchers in Canada have retrospectively reviewed data from 45 patients who underwent urgent CABG within 24 hours after failed PCI; the 45 represent 0.7% of PCIs performed at one center from April 1996 to December 2000.

The researchers prespecified three criteria to identify patients with a high likelihood of being harmed by hospital transfer-related delay to CABG: hemodynamic instability, severe ischemia, or coronary perforation with effusion or tamponade. Eleven patients (24%) met at least one of the criteria.

Among the 45 patients, reasons for CABG referral included extensive dissection (45%), vessel occlusion (15%), perforation (6%), inability to recross (15%), and stent embolization (9%). Elective PCI was more common among patients who met the prespecified criteria (45%) than among patients who did not (29%). Before CABG, 31 patients (69%) were stabilized with an intra-aortic balloon pump, and 2 were in a prearrest status. After CABG, 8 patients (18%) experienced MIs, and 2 died.

Comment: Although fewer than 1% of PCI patients now need urgent CABG, the present data suggest that about one quarter of this subset need it so urgently that transfer-related delays could cause harm. The data support current ACC/AHA recommendations for on-site emergency surgical back-up for elective PCI. Previous studies documenting the safety of elective PCI at centers without on-site surgery have been limited by small size, voluntary reporting, and lack of data auditing. Considering the prospect of elective PCI performed at such centers, the editorialists ask, "Is the extra risk something you would accept for your PCI?"

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology April 2, 2004

Citation(s):

Lotfi M et al. Impact of delays to cardiac surgery after failed angioplasty and stenting. J Am Coll Cardiol 2004 Feb 4; 43:337-42.

• Original article (Subscription may be required)
• Medline abstract (Free)

Dehmer GJ and Gantt DS. Coronary intervention at hospitals without on-site cardiac surgery: Are we pushing the envelope too far? J Am Coll Cardiol 2004 Feb 4; 43:343-5.

• Original article (Subscription may be required)
• Medline abstract (Free)