1 / 44

DAY-CASE PCI

DAY-CASE PCI. Ray Wainwright King’s College Hospital. DAY-CASE PCI. CAT-WAG 24 CAT-WAG 12 CAT-WAG 4. DAY-CASE PCI. ELECTIVE PCI “HOT” IN-HOSPITAL TRANSFERS ALL-IN-ONE CA and PCI. DAY-CASE PCI. BACKGROUND

morwen
Download Presentation

DAY-CASE PCI

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. DAY-CASE PCI Ray Wainwright King’s College Hospital

  2. DAY-CASE PCI CAT-WAG 24 CAT-WAG 12 CAT-WAG 4

  3. DAY-CASE PCI • ELECTIVE PCI • “HOT” IN-HOSPITAL TRANSFERS • ALL-IN-ONE CA and PCI

  4. DAY-CASE PCI BACKGROUND • ACUTE CORONARY INCIDENTS RARE IF : STENT OPTIMALLY EXPANDED NO ANGIOGRAPHIC PREDICTORS OF STENT OCCLUSION • EARLY AMBULATION RADIAL APPROACH REDUCED HEPARIN 5000 UNITS REDUCED SIZE OF GUIDE CATHETERS MORE EFFECTIVE GROIN MANAGEMENT e.g. Femostop, Angioseal • DAY-CASE DISCHARGE POSSIBLE IF: EARLY AMBULATION RISK OF BLEEDING MINIMAL

  5. OUTPATIENT CORONARY STENT IMPLANTATIONKIEMENEIJ, F JACC 1997 OPEN, PROSPECTIVE, SINGLE-CENTRE STUDY OF TRANS-RADIAL PALMAZ-SCHATZ CORONARY STENTING ON DAY-CASE BASIS • STUDY COHORT 100 PTS (53% OF ALL) MAY 94 - JULY 95 44 WARFARIN 1 WEEK PRIOR (INR > 2.5) 56 TICLOPIDINE 250mg b.d. ALL PATIENTS HEPARIN 10,000 UNITS ASPIRIN 500 MG IV NATIVE VESSEL 60 PTS RE-STENOSIS 20 PTS VEIN GRAFT 19 PTS SUB-OPTIMAL POBA 1 PT

  6. PATIENT EXCLUSIONS PRE-PROCEDURAL REASONS • UNSTABLE ANGINA • INR < 2.5 • POOR CLINICAL CONDITION • SOCIAL CIRCUMSTANCES PROCEDURAL REASONS • TRANSIENT VESSEL CLOSURE • RESUSCITATION • PROLONGED CHEST PAIN • PERSISTENT ECG CHANGES • SUB-OPTIMAL STENT DEPLOYMENT • SIDE-BRANCH OCCLUSION • ENTRY SITE COMPLICATIONS • ABSENCE OF STABLE 6HR OBSERVATIONS

  7. OUTPATIENT CORONARY STENT IMPLANTATIONKIEMENEIJ, F JACC 1997

  8. OUTPATIENT CORONARY STENT IMPLANTATIONKIEMENEIJ, F JACC 1997

  9. OUTPATIENT CORONARY STENT IMPLANTATIONKIEMENEIJ, F JACC 1997 Results • 188 pts 88pts remained in hospital • 100 pts 125 stents to cover 110 lesions • No cardiac or bleeding events within 24 hrs 2 week FU • 1 pt re-admitted with bleeding aortic aneurysm • 1 pt sub-acute stent thrombosis • 1 pt angina and anaemia treated with blood transfusion 1 month FU • No complications

  10. Health warning ! The next slide is not for those of nervous disposition

  11. OUTCLAS pilot study(OUTpatient Coronary Low-Profile Angioplasty Study)Slagboom et al., Cath Cardiovasc Intervent 2001 Inclusions • Stable and unstable angina (I &II) • Type A & B lesions • Multivessel disease and multivessel PCI if at best one vessel remained unstented

  12. (OUTpatient Coronary Low-Profile Angioplasty Study)Slagboom et al., Cath Cardiovasc Intervent 2001 Exclusions • AMI • Unstable angina (III) • Type C lesion • Chronic total occlusion • Multivessel PTCA without stenting • Expected haemodynamic collapse in case of reocclusion • Last remaining vessel or unprotected LMCA • Intra-coronary thrombus • Negative Allen test

  13. (OUTpatient Coronary Low-Profile Angioplasty Study)Slagboom et al., Cath Cardiovasc Intervent 2001 159 pts (29%) • 106pts (66%) OP group • 53pts kept in for 24 hrs

  14. Criteria for 24-hr Inhospital Management Suboptimal PTCA • Dissection • Perfusion balloon for suboptimal result • Suboptimal stent result • Intracoronary thrombus • (Major) side branch occlusion General • In-lab transient closure • Resuscitation • Prolonged chest pain • Persistent ECG changes • Haemodynamic collapse during balloon inflation • Multivessel PTCA • Entry-site complication

  15. Endpoints Primary (all within 24 hrs after successful PTCA) • Cardiac death • Emergency CABG • Myocardial infarction • Re-PTCA • Unstable angina • Major entry site complication Secondary • cost-effectiveness • Patient comfort

  16. Results

  17. TRIAGE OF PATIENTS FOR SHORT TERM OBSERVATION AFTER ELECTIVE CORONARY ANGIOPLASTYKoch et al., Heart 2000 • 1015 pts (1510 lesions) (48%) Jan 95 – May 97 • Femoral approach 6F Stent usage <30% • Pre-treatment Aspirin 100 mg orally • Heparin 5000 u • Ticlopidine 250 mg one month • Haemostasis manual compression • Observed for 4 hrs without telemetry before return to base hospital within 40 mile radius

  18. TRIAGE OF PATIENTS FOR SHORT TERM OBSERVATION AFTER ELECTIVE CORONARY ANGIOPLASTYKoch et al., Heart 2000 • Procedural success 91.2% • Short-term observation (4 hrs) 922/1015 pts (90.8%) no complications Back transfer to referring hospital used as a surrogate for early discharge • Prolonged observation 87/1015 pts (8.6%) 40 pts complications

  19. PATIENTS SELECTED FOR PROLONGED OBSERVATION Koch et al., Heart 2000 • Severe dissection with failed stent • Occluded side branch • Evidence of thrombus/no reflow • Vessel perforation by guide wire • Suspected CVA • Other (operator’s discretion)

  20. Multivariate preprocedural predictors of prolonged observation

  21. Multivariate predictors of complications

  22. Patients, prolonged observations and complications by total risk score

  23. TRIAGE OF PATIENTS FOR SHORT TERM OBSERVATION AFTER ELECTIVE CORONARY ANGIOPLASTYKoch et al., Heart 2000 • Selection for prolonged observation to anticipate subsequent complications can be performed on the immediate post-procedural findings, irrespective of “high-risk” clinical or morphological characteristics. • Triage of patients as in this study may facilitate early discharge and OP angioplasty in the majority (90% pts) scheduled for elective PCI

  24. Departments of Cardiology, John Radcliff Hospital,OxfordAdrian Banning et al., • 487 elective pts stable angina Feb 99-Feb 01 • Mean age 61yrs (42-79) • 376 M : 111 F • Smoker 39 pts (8%) • Hypertension 297 pts (61%) • Diabetes 59 pts (12%)

  25. Departments of Cardiology, John Radcliff Hospital,OxfordAdrian Banning et al., • Clopidogrel pre-loading 300mg • 6F guide catheter via femoral route • Weight-adjusted heparin • Stent must be used • Routine sheath removal (manual compression) • Mobilised 2-4 hrs post procedure • Closure device 51pts(10%) only for poorly controlled BP or high risk of bleeding

  26. Departments of Cardiology, John Radcliff Hospital,OxfordAdrian Banning et al., • 2 vessel disease 40 pts (8%) • Graft 16pts (3%) • Stented 472 pts (97%) • POBA 15 pt (3%)

  27. Departments of Cardiology, John Radcliff Hospital,OxfordAdrian Banning et al., OUTCOMES • Primary success 448 pts (92%) • Mortality 0 • Emergency CABG 0 • Non-fatal MI 3 pts (0.6%) • 30 day mortality 0 • 30 day re-admission 29 pts (6%) • Minor haemorrhage 23 pts (5%) • Major haemorrhage 0 • Same day discharge 409 pts (84%)

  28. Departments of Cardiology, John Radcliff Hospital,OxfordAdrian Banning et al., Non-discharges 78 pts (16%) • Sub-optimal result 49 pts • Abciximab 19 pts • Haemorrhage 10 pts

  29. DAY-CASE PCI • ELECTIVE PCI • “HOT” IN-HOSPITAL TRANSFERS

  30. Departments of Cardiology, John Radcliff Hospital,Oxfordand Northampton General Hospital, NorthamptonAdrian Banning at al Single DGH experience of pts with NSTEACS Diagnosis Cardiac chest pain with either dynamic ECG changes or raised troponin Inclusions NSTEACS with: • High- risk ECG features and raised troponin • Presentation < = 6weeks post MI • Refractory to medical therapy • Positive symptom-limited pre-discharge ETT

  31. Departments of Cardiology, John Radcliff Hospital,Oxfordand Northampton General Hospital, NorthamptonAdrian Banning et al., Exclusions (likely to have multi- vessel disease) • Octogenarians • IDDM • PVD • Known multi-vessel from previous angiography • Pulmonary oedema, significant hypotension • Symptoms > 1 yr unless ECG suggestive of target lesion • Elevation of cardiac enzymes > twice upper limit • Contra-indication to Gp IIb/IIIa inhibitors

  32. Departments of Cardiology, John Radcliff Hospital,Oxfordand Northampton General Hospital, NorthamptonAdrian Banning et al., Over 9 months 50/122 pts transferred to regional centre (50 miles, 1 hr), had angiography + PCI and returned same day. Clopidogrel 300mg loading dose then 75 mg/dy for one month if stent PCI 6F guide, low dose heparin 2500-5000 units, IV abciximab Haemostasis Manual compression 34 (68% ) Angioseal 16 (32% ) Mobilised 2 hrs after procedure Transfer back to DGH - trained volunteer ambulance service (St John’s) with nurse escort Discharged from DGH next day

  33. Departments of Cardiology, John Radcliff Hospital,Oxfordand Northampton General Hospital, NorthamptonAdrian Banning et al., • 122 pts referred of whom 50 satisfied criteria and were transferred. • Mean TIMI risk score 3.9 • 2 pts CABG • 3 pts medical therapy

  34. Departments of Cardiology, John Radcliff Hospital,Oxfordand Northampton General Hospital, NorthamptonAdrian Banning et al., Discharge • 36 pts next day • 8 pts after 2 days • 1 pt after 5 days At 30 days • TVR 2% (repeat PCI) • Death or MI 0% Femoral puncture complications • 3 haematomata, 1 false aneurysm

  35. Other UK centres • Royal Victoria Hospital, Blackpool David Roberts • Hairmyres, East Kilbride Keith Oldroyd • St Mary’s Hospital, London Wynn Davies, Rodney Foale

  36. King’s College Hospital • All-in-one day case arteriography and follow-on PCI • 56 pts 42 M:14F mean age 62yrs (+/-14) • Stable or recent onset angina • 50 pts single vessel disease • 6 pts two vessel disease • 62 vessels - all treated with one stent • Clopidogrel 300mg • 6F femoral approach 5000 units heparin • Closure with Angio-seal

  37. King’s College Hospital Results • Primary angiographic success 51 pts (91%) • 5 pt failures (9%) - all occluded vessels • 55pts(98%) successfully discharged same day • No mortality or MI • 1 pt acute stent thrombosis 30 mins post procedure. Successfully treated with further stent and abciximab. No rise in cardiac enzymes.

  38. COSTS Standard management Day-case angiogram + re-admission for in-patient PCI £3,500 Strategy 1 Day-case angiogram + re-admission for day-case PCI £3,120 Strategy 2 One-stop day-case angiogram + PCI £2,850

  39. SAVINGS • Assume 1000 pts per annum Strategy 1 50% pts £380 x 500 = £190,000 (5%) 80% pts £380 x 800 = £304,000 (8.6%) Strategy 2 50% pts £650 x 500 = £325,000 (9.2%) 80% pts £650 x 800 = £520,000 (14.8%)

  40. PRE-REQUISITES FOR DAY-CASE PCI 1) High procedural success rate 2) Low risk of abrupt vessel closure 3) Low risk of access site bleeding 4) Successful early ambulation

  41. DAY-CASE PCI Conclusions • Obvious way to overcome CAT-WAG 4 • Possible way to mitigate increased cost of introducing drug eluting stents • Use stents but avoid ‘novel’ stents on the day • Issues over Reopro • Issues over informed consent • BCIS promotion of this activity via guidelines and/or trials

  42. IS IT SAFE? YES

More Related