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Angioplasty Without Surgical Backup

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Ongoing discussion about whether or not hospitals without on-site cardiac surgery should perform angioplasties.

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Current Postings on This Page (30):

• Hi my hospital want to carry out an angiogram for diagnosis but cannot offer stenting. Should I risk this procedure twice?
angiophobe, Suffolk, UK, October 13, 2011

• Bruce in Canada -- In remote areas, some hospital systems have instituted helicopter transport, which can get a heart attack victim to a cath lab usually within the 90 minute window. There is evidence that there still may be a benefit to getting a patient to the cath lab within a few hours, but the longer one waits, the more chance there is that the heart muscle can die ("time is muscle"). Once the MI is over, there's not much that an angioplasty or stent can do except open up a blocked artery that may help feed other parts of the heart. But each individual is different.
Angioplasty.Org Staff, Angioplasty.Org, October 10, 2012

• I live in an area where we only have internist working in the ER. We have no heart specials only internist. These professionals all have there own speciality lung etc. The nearest Heart Unit is 4 hours away by Ambulance or plane. I would like to know the time frame to stint [stent] a person. I know 90 minutes, but if 4 hours what damage is expected, 8 hours what is expected damage. I know it comes down to EKG issue but there must be some guide line (time frames). As the night of MI I was told by initial doctor that I am having a major heart attack. So what is required to ship of hospital. Also if stable should they not of shipped me as I could not take the thrombolytic Treatment due to bleeding in colon, and at this point there is nothing else they could do.
Bruce Ramsay, Canada, October 3, 2011

• AM from Connecticut -- That's an excellent question. We will look into this and post our research back to this topic.
Angioplasty.Org Staff, Angioplasty.Org, March 25, 2011

• any idea how many centers exist around the country that offer angioplasty without open heart backup? Is there a list somewhere?
AM, Simsbury, Connecticut, USA, March 25, 2011

• Wrig -- the original study was called C-Port or Atlantic C-Port and was instituted and run by Dr. Tom Aversano a decade ago (Dr. Aversano contributed some of the original posts to this Forum Topic). A number of hospital systems have adopted some of its methods, in close collaboration with their state medical boards, and localities. The study did not "allow" groups of hospitals to do pangioplasty without surgical backup, but studied those that did to see what outcomes were. One of the big advances in interventional cardiology was the introduction of stents. The most common complication of angioplasty that required surgical repair was a collapsed artery. Stents have made that complication virtually disappear.
Angioplasty.Org Staff, Angioplasty.Org, February 10, 2011

• What is the name of the current study on this question that is allowing groups of hospitals to do angioplasty without open heart backup? Supposedly it will have its data gathering done by May, 2011 and then publish within 18 months...
Wrig, Avon Lake, Ohio, USA, February 10, 2011

• i am an interventional cardiologist in southern california,we have a diagnostic lab and about 30min away an interventional lab. we suddenly found that we had no standby in the entire county. would any one place an elective patient on the table of cath, without any cardiothoracic surgeon. the closest on being 3 hrs away at best. the local cardiothoracic surgeons would not give any back up due to lack of contract.
Jessie Uppal, Kaiser, Riverside, California, USA, December 6, 2009

• We have been doing primary angioplasty for 11 years at our community hospital in Massachusetts and have NEVER caused a patient to need emergent bypass. We have sent pt's who need it immediately for left main disease rarely and we place an intraortic balloon pump and transfer without difficulty. We are now involved in the MASSCOMM trial whereby we are doing elective angioplasty without surgery on site (SOS). I think the knowledge and skill of the entire team makes the difference, not just the services of the hospital!!!!!!
Theresa RN, BSN, CCRN, CNH cath lab, Norwood Massachusetts, USA, July 8, 2007

• It seems to me that the original topic question needs to distinguish between emergency procedures, or PTCA to tackle advanced occlusions. I have had two stent procedures, about 4 months apart. One was an emergency procedure to treat an acute occlusion causing a massive MI. The second was an elective procedure to treat a CTO detected during the first. While the CTO was a candidate for PTCA/stenting, ultimately the procedure failed during final inflation of the stent. I rapidly developed tamponade from bleeding, and was rushed down the hall to surgery for an emergency CABG. I just think it is important to be clear on limits and boundaries as PTCA becomes ever more capable of dealing with ever more difficult situations. In an emergency MI situation, it may well be that having onsite PTCA capability outweighs the risk. But that does not mean that non-emergency procedures should also be done. Given the cost of setting up and running a cath lab, I'd worry that there would be administrative pressure to expand the services offered to enhance cost recovery (especially if the number of emergency cases was well below the lab's operating capacity), possible at the expense of the best interests of patients.
Mike, Virginia, USA, August 16, 2006

• My mother has passed away while doing angioplasty (left coranry artery). Cardiologist (Dr. Rajakantan, Sri Lanka) wanted to do a emergency bypass, but they were not ready even couldn't find a surgeon. My experience -- don't do this if you are not ready for an emergency bypass.
Indika, Technology Institute, Sri Lanka, June 19, 2006

• I am a director of a diagnostic cath lab doing aprox 400 cases a year. We have an open open heart facility 10 minutes away. I would like to know if it would even be possible to do intervention at our facility. What's my first step. The physicians and staff have all done intervention elsewhere. I am getting tired of transfering patients when we could have easily fixed their problem on our table.
James J Rookey, Parkway Regional Medical Center, N Miami Florida, September 27, 2005

• Yes,You are doing excellent job.

• I would call to everyone's attention the largest study to date on this topic, just presented at today's American Heart Association meeting. The results: there is no difference in the mortality rates from emergency angioplasty at hospitals with or without surgical backup. The article can be found here.
Angioplasty.Org Staff, Angioplasty.Org, USA, 17 November, 2002

• We started a primary PTCA program in Oct. 2000 & have had excellent outcomes. We used the Exeter, NH model/PAMI-No SOS Trial. CA state law allows only primary angioplasty without surgical backup, elective currently must have backup. We set our program up in the form of a study, with clear inclusion/exclusion parameters. We collect data on each case & do regular case reviews. We built a very solid foundation which will expand into a larger cardiac program.
Karen Dynek MSN, RN, CCRN, ValleyCare Medical Center, Pleasanton/CA/USA, 3 Aug 2001

• I have been performing acute angioplasty asa first line of treatment for acute mi for last 4 years.Recently we started this program in a centre w/o sos. In last 1 year 21 cases have been done without any in hospital mortality. We reffered one patient with LMC stenosis and total LAD occlusion to nearby surgical centre.I strongly feel that acute angioplasty can be performed without sos.
Dr Pramod Kumar, Maharaja Agarsain Heart Institute and Research Centre, New Delhi, Delhi, India, 15 Apr 2000

• For those of you who are doing PTCA without backup, where do you look for reimbursement - private or medicare? We would like to start-up here in Florida - 1500 diagnostics per year with 4 MD's doing PTCA at sister hospital 30 minutes away....
E. Korjack for B. CarterOak Hill Hospital, Florida, USA, October 16, 1999

• In the opinion of my government, PTCA procedures for interventional angioplasties cannot be performed in a medical center without a cardiac surgery unit in stand-by
Etienne Pelfrene, Department of Health, Brussels, BELGIUM, August 24, 1999

• I would not want to be part of the percentage of the people who do not have an hour to save my life if the PTCA fails. I work in a hospital that offers PTCA as well as OHS and have seen many emergency OHS (Open Heart Surgery) patients go to surgery. Thank goodness we had surgery to save their lives. My question would be are we saving a few bucks by not transfering these patients to a facility that can provide OHS should it become necessary? I hope not.
Elaine Mahony, Morton Plant Mease Health Care, Florida, USA, August 11, 1998

• I am a cardiologist in a rural setting and have diagnostic cath without interventional due to our volume (500 diagnostics/yr). I want our patients to get the best treatment and find that sometimes tPA doesn't cut it and rescue or primary PTCA are less than ideal due to transport time and because our referral University isn't quite geared up for it. I now find myself wondering if it isn't time to set aside our standard of CABG and PTCA in the same center. Stents and support devices do represent a step forward and may tip the scales enough to change policy. I read this forum with keen interest. I also note Osler's quote : "The greater the dogmatism, the greater the ignorance."
Stew Pollock, MD, USA, July 27, 1998

• Ohio has had strict Certificate Of Need (CON) laws governing cath labs and requiring a Open Heart unit to do PTCA. I was administrator at cath lab of 1400 case/yr & no O.H.; cardiologists traveled 30 miles away to do PTCA (often at 9PM or later). We trained our cath lab staff in PTCA support by rotations at hospital that was receiving our referrals & started emergent PTCA program to save lives (sorry if that sounds greedy). Before stents, we did 6-12 per year. First case was Chief of Radiology who came to ER with AMI, was immediately taken to cath lab (while transport was called), arrested on table, had PTCA done, and recovered with no damage noted by ECG. State Dept. of Health reported us to Physician Review Organization (PRO) for revocation of all Medicare funding. PRO reviewed our charts & those of two other sites doing emergent PTCA and recommended other high-volume, non O.H. sites in Ohio begin similar program TO SAVE LIVES. The Dept. of Health buried the report and did nothing against the hospital. The programs continue.
Marshall Maglothin, The Heart Center, Akron General Medical Center, Ohio, USA, April 20, 1998

• For our clinical trial, health care regulators in both Maryland and Massachusetts granted waivers for this procedure. It is clear that the pressure to perform primary angioplasty without on-site cardiac surgery is growing: our trial gives the states a chance to study the issue (imagine, evidence-based medicine) before deciding whether or not to open the flood gates. It should also be noted that some states do not have regulations which prohibit primary angioplasty at hospitals without on-site cardiac surgery (eg. North Carolina).
Tom Aversano, M.D., Atlantic C-PORT Project, Johns Hopkins, Maryland, USA, March 2, 1998

• My questions to the labs that currently perform PTCA w/o surgical back up is how do you do this when your state license is granted for only diagnositic procedures?
Joe Thornton R.T., Director of Imaging Services, Bessemer Carraway Medical Center, Bessemer, Alabama, USA, February 18, 1998

• In our hospital, we do not have a cardiac surg program. However in our cath lab (open 10 years), we have always done emergency ptca. This is only done in a patient who has received thrombolytics and who has not reperfused and is not doing well, or has a contraindication to thrombolytics and who is not doing well. We feel especially since the introduction of stents, that PTCA is safe and efficacious. We have cardiac surg 30 min north and south of us.
James D. Miller RN, Affiliated Health Services, Mt. Vernon, WA, January 26, 1998

• We are conducting a clinical research project which, in part, randomizes AMI patients between thrombolytic tx and primary angioplasty at hospitals without on-site cardiac surgery. Anyone interested in hearing more, please contact me via email or at 410-955-3996.
Tom Aversano, M.D., Atlantic C-PORT Project, Johns Hopkins, Maryland, USA, August 13, 1997

• We perform approximately 11,000 procedures per year with 6,000 being interventional. In 1996 less than 10 patients were taken emergently for CABG (Thanks to the new "Stent" Attitude) If you are located within reasonable distance of a CABG center with reliable air or ground transport, I don't see a major deterent to your program.
jh, Allegheny General Hospital, Pennsylvania, USA, July 24, 1997

• I started a program such as you describe in 1982 in Indiana and again had to deal with emergency PTCA in totally occluded vessels producing an acute MI while a surgical program was being established. It is possible, desirable and feasible to do so. The emotional response you see recorded when this idea is expressed ought to be ignored. Study of the merits of the idea has not yet been done. It would require comparing the outcome of 100-150 patients treated with emergency angoiplasty at your facility to the outcome of 100-150 patients referred from your facility for treatment. Such a study is likely to deteriorate into an argument on the quality of the outcome you got in the patients referred out (someone will argue the program you refer to gets substandard results. Research results would only be applicable to your set of circumstances probably . The additional time delay trying to refer patients out from a facility with a cath lab can be expected to result in a penalty to morbidity and/or mortality which outweighs any penalty imposed by lower case loads in your lab. If your cardiologist is experienced and well trained, the patients would benefit from angioplasty of totally occluded vessels causing an acute MI right then. I would be happy to pass on the experiences I have had in setting up a program such as you describe and I can pass on the names of hospital administrators and a cath lab supervisor who helped me do it.
Stephen Young, M.D., "The Heart Doctor", USA, July 12, 1997

• Emergency PTCA has gained world wide acceptance and the number of cases that really need Emergent CABG are very rare. The mortality of CABG in an AMI setting is very high. We perform 1000 procedures per year and we actually do PTCA to almost all patients that come to our center with an AMI. If a patient can not be "opened" we prefer not to operate him on. We are not in the USA but if you have a Hospital with open heart surgery at 20 or 30 minutes far, you can do it. Just let the ACC says the last word.
Sergio Mejia, M.D., Ph.D., "Santa Marνa" Cardiovascular Center, Medellin, COLOMBIA, July 3, 1997

• Operators and hospitals working at that volume of PTCA's should not be doing PTCA's let alone Emergency cases. All of the current data supports this and only self serving rationalization and greed can allow this.
David E., interventional cardiologist, USA, June 4, 1997

• I am a director of a lab , also in a Southern state (USA), that performs approximately 700 cases per year. Of these 700 approximately 40% need some type of intervention! I would also like to know if the the ACC is going to make a recommendation on this issue? Our lab is located on the edge of a major metro area but draws many of our patients from outside the metro area. Emergent PTCA would be very beneficial to our patient population.
Joe Thornton R.T. (R)(CV), Bessemer Carraway Medical Center, Bessemer, Alabama, USA, April 24, 1997

• I am a supervisor of a cardiac cath lab in a Southern state (USA) that is about to start an emergency PTCA program in our facility. Our facility does not offer an open heart program, but our cardiologist is trained in interventional cardiology and feels emergency PTCA should be offered. Will the ACC take a positive stance on this issue, or simply ignore the patients' needs in smaller communities?
posted by Kristin Yandell, lab supervisor, USA, April 5, 1997

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