Percutaneous coronary intervention (PCI) without on-site surgical support is as safe as PCI at centres that have access to surgical support, according to a new consensus statement from the Society for Cardiovascular Angiography & Interventions (SCAI), released this week.
The recommendation comes after a review of data from across randomised controlled trials, observational studies, and international experience. The statement, published in the Journal of the Society for Cardiovascular Angiography & Interventions (JSCAI) and JACC: Cardiovascular Interventions, explains that adequate operator experience, appropriate clinical judgment and case selection, and facility preparation are essential to a safe and successful PCI programme with no-SOS—surgery on site.
PCI with no-surgical support was once considered high-risk, SCAI notes in a press release, despite that it has been performed with “acceptable” outcomes for nearly four decades. In 2007, SCAI published an initial consensus statement on the procedure within this setting, with the last update in 2014.
“Since we released the last consensus statement in 2014, same-day discharge after elective PCI has increased to 28.6% of all PCIs and 39.7% of radial PCIs in the USA,” said Cindy Grines (Northside Hospital Cardiovascular Institute, Atlanta, USA), chair of the writing group and SCAI past president. “Elective PCI in no-SOS settings have increased in volume and complexity. Concurrently, there have been operators performing PCI in office-based laboratories (OBLs) and ambulatory surgery centres (ASCs) with positive outcomes. Thanks to improvement in PCI safety and several global studies in recent years, we now know that PCI at ASCs may improve access, patient satisfaction, and reduce costs.”
According to SCAI:
- Elective PCI in settings with no-SOS has increased in volume and complexity (extending beyond the simple lesion recommendations in the 2014 document). In addition, PCI is now being performed outside of the hospital setting, in office-based laboratories (OBLs) and ambulatory surgery centres (ASCs).
- Several new studies in the USA and abroad have demonstrated that PCIs performed at no-SOS centres have very low rates of complications and similar outcomes to PCIs performed at surgical centres.
- Despite increase in age, comorbidities, and lesion complexity, the rate of periprocedural complications has remained constant, or declined, with rates of emergency surgery as low as 0.1% in many series.
- Complex PCI, including unprotected left main, is being performed in some no-SOS centres, with no increase in major adverse cardiovascular events or emergency coronary artery bypass graft surgery (CABG) compared with PCI at surgical centres.
- The SCAI writing group proposes a new PCI treatment algorithm that expands the type of cases that can be performed with no-SOS compared with its 2014 document, with consideration of the patients’ clinical and lesion risk, the operator experience (both recent and accumulated), and the experience and rescue capabilities of the site.
- In the USA, there are considerable financial savings (to insurers and Medicare) for PCI to be performed in ASC and OBL settings, thus out-migration of procedures from hospitals should be anticipated.
This expert consensus statement was endorsed by the American College of Cardiology (ACC), American Heart Association (AHA), British Cardiovascular Intervention Society (BCIS), Canadian Association of Interventional Cardiologists (CAIC), and Outpatient Endovascular and Interventional Society (OEIS).
