PCI without surgical backup: shall we do it?

PCI done without on-site cardiac surgery backup was shown to be as safe as procedures done with on-site backup in several registries. Yes, it is safe and efficacious, but many still raise a question “does any patient prefer to have angioplasty done at a center without surgical backup?"

Then shall we open a cath-lab where there is no surgical backup? In 2011, CMS-TH, Bharatpur established a cath-lab without any surgery backup. Should it be done? I personally agree that there is a desperate need for PCI with no matter surgery backup in remote areas where transit to regional centers is unreliable and awkward. If a patient with acute STEMI collapses in our ER, then can we take a risk to refer him to a surgical backup center that is approximately 6 hours far? So, I believe primary PCI facility should be available in a timely manner irrespective of surgical backup.

What if the patient needed an emergency CABG? I argue, emergency CABG is required in only 0.2% of cases. In one study, the rate of emergency coronary bypass surgery, which was needed by 0.3% of patients treated at centers without surgical backup, and by 0.4% of those treated with on-site backup.

In an effort to evaluate the introduction of PCI care at hospitals without onsite cardiac surgery, the state of California instituted a pilot program comparing PCI results in six pilot and 120 non-pilot facilities. The results of the study were recently released on March 29, 2014—ACC 14.

The study concluded that while pilot without onsite cardiac surgery hospitals performed proportionately more primary PCIs than onsite hospitals and showed a significantly better PCI composite safety endpoint, the pilot without onsite cardiac surgery hospitals had worse composite efficacy endpoints than non-pilot hospitals. Offsite hospitals perform more primary and fewer elective PCIs than Onsite hospitals. Moreover, emergency CABG rates were low in both Offsite and Onsite hospitals reducing the need for Onsite Cardiac Surgery. [PCI-CAMPOS study]

We recently published a paper in JNMA.

Dubey L, et al. Percutaneous coronary intervention without onsite cardiac surgery backup. J Nepal Med Assoc 2013;52(189):267-71

We concluded that despite having no cardiac surgery backup, in-hospital mortality and other complications following PCI were acceptable in our cardiac catheterization laboratory.