Emergency operation after failed angioplasty

J

THORAC CARDIOVASC SURG

1988;96:198-203

Emergency operation after failed angioplasty A group of patients with failed angioplasty who then required emergency coronary bypass was compared with a historieally matched group of patients who had had elective bypass grafting. The two groups were wen matched in age, sex, ejection fraction, and New York Heart Association classification and in the incidence of diabetes and hypertension. Significant differences were found in the prevalence of mortality (12% versus 1.5%~ hemorrhage (28% versus 13%~ cardiac tamponade (10.5% versus 1.5%~ myocardial infarction (28 % versus 9 % ~ and length of hospital stay (15.3 days versus 13.4 days). Cardiogenic shock carries the worst prognosis; four of the five patients with this condition died. Because emergency operation after failed angioplasty carries with it significant postoperative morbidity and mortality, this procedure cannot be considered equivalent to elective coronary bypass grafting.

Victor Parsonnet, MD, FACC, Daniel Fisch, MS, Isaac Gielchinsky, MD, FACC, Mark Hochberg, MD, S. Mansoor Hussain, MD, FACC, Ravi Karanam, MD, Laura Rothfeld, and Louise Klapp, RN, Newark, N.J.

In a letter to the Editor in the New England Journal of Medicine, 1 a patient who had had a successful percutaneous translurninal coronary angioplasty (PTCA) maintained that he "had nothing to lose" with this procedure, because he could always have had an immediate surgical bypass if the PTCA had failed. Apparently, it was his understanding that if emergency bypass grafting (CABG) became necessary after the PTCA, it could be done at essentially the same risk as an elective operation. In our experience this assumption is not correct; patients who require immediate CABG after a failed PTCA seen. to fare far worse than patients undergoing elective operations. To evaluate the results at our institution more objectively, we embarked on a retrospective analysis of failed PTCA procedures that led to emergency operations, comparing the results to matched historic control groups of patients who had had elective CABG operations. Methods A failed PTCA that required emergency operation was defined as one in which the patient had intractable pain From the Department of Thoracic and Cardiovascular Surgery. Newark Beth Israel Medical Center. Newark. N.J .. and The University of Medicine and Dentistry of New Jersey, Newark. N.J. Received for publication July 2. 1987. Accepted for publication Dec. 1. 1987. Address for reprints: Victor Parsonnet, M.D.. Department of Surgery. Newark Beth Israel Medical Center. 201 LyonsAve.. Newark, NJ 07112.

198

Table I. Angioplasty (PTCAj performed and related emergency operations from 1980 through October 1986

Year

No. of PTCAs

1980 1981 1982 1983

7 16 13 31

1984 1985 1986* Total

162 367 362 958

No. of emergency operations

TI12 22 23 67

Percent of emergency operations

10/67

=

14.9'7,

7.4% 5.9% 6.3'k

7.0%

'Ten months.

associated with persistent electrocardiographic changes. cardiac tamponade, cardiogenic shock, or radiologically visible occlusion of the target artery. Excluded from this classification were PTCAs in which the failures were due to inability to traverse the lesion with the balloon. or to unsuccessful dilatation but without untoward symptoms or electrocardiographic changes. All but one of the PTCA procedures were elective; in one an intraaortic balloon was used within 2 hours before the PTCA for new unstable angina. A control series of surgical patients was selected by computer search for major matches consisting of sex. age ( ± 5 years), New York Heart Association classification. left ventricular ejection fraction (± 5%), diabetes, and hypertension. There were equal numbers of patients in the failed angioplasty group (failed PTCA) and the group of matched controls (elective CABG). The groups were then compared with regard to their preoperative status and the intraoperative and postop-

Volume 96 Number 2 August 1988

erative course. Considerations included the volume of blood replacement, the use of inotropic drugs, the ~eed for .a postoperative intraaortic balloon, major postoperative com~h­ cations, length of stay, and final outcome. Postoperative hemorrhage was defined as blood loss from the chest tubes greater than 200 ml per hour for 4 hours and the need for infusion of blood products, whether or not surgical reexploralion was performed. Results From January 1980 through October 1986, 958 PTCAs were performed, 709 (74%) of them in the past 2 years. Sixty-seven patients (7%) required emergency operation. After an initial failure rate of 15% over the first 4 years, in which only a small number of PTCAs was performed, the failure rate fell to 7.0% over the last 3 years (Table 1).* The vessels dilated were as follows: the left anterior descending and right coronary arteries were involved with almost equal frequency, 42% and 36%, respectively. In the seven cases of two-vessel dilatation, the left anterior descending was dilated in all, and the right and circumflex arteries were dilated in three and four, respectively. The left anterior descending was the target vessel in five of these, and the right and circumflex arteries in one each. Failures were due to arterial dissection with or without occlusion in 36 cases (54%) and complete occlusion without evident dissection in 26 cases (39%); there were three cases of spasm alone and two perforations into the pericardia I cavity. Fifty-nine of the patients (88%) went directly from the catheterization room to the operating room within an average interval of 26 minutes; seven were sent to the recovery area first and then to operation within 4 hours; one went first to the coronary care unit for II hours. The latter eight patients were mildly symptomatic and were held for observation until there was a sudden acceleration of symptoms and signs. The preoperative status of the two groups was almost identical except for a history of previous myocardial infarction, more common in the elective CABG group, and obesity, more common in the failed PTCA group (Table 11). There were no significant differences in the duration of ischemic arrest or in the total time on cardiopulmonary bypass. More CABG procedures were performed in the elective CABG group, 2.6 versus 1.9 in the emergency PTCA group (p < 0.001, Table III). The internal mammary artery was used much more frequently in the elective group. Patients having elective CABG also required vasopressor agents less often and

'During the first 9 months of 1987 there were 12 failed PTCAs in 492 cases (2.4%).

Emergency operation after failed angioplasty

I99

Table II. Comparison of preoperative status Failed PTCA Factor Age (mean) Sex, male/female NYHA class III

IV Ejection fraction (mean) Diabetes Hypertension Smoking Obesity Elevated cholesterol Prior infarction

(n

= 67)

Elective CABG (n

= 67)

57.2 ± 1.0 49/18

57.6 ± 1.0 49/18

64 (96%) 3 (4o/c) 50.6 ± 1.1

64 (96%) 3 (4%) 47.1 ± 1.5

12 (18%) 30 (45%) 33 (49%) 15 (22o/c) 10 (15%) 24 (36%)

13 31 41 5

(19%) (58%) (61%) (7.5%) 6 (9%) 38 (57%)

p Value'

<0.02 <0.02

NYHA. New York Heart Association. 'All not significant except where noted.

had less need for blood or blood products. The difference in utilization of blood products was significant. Complications were significantly more frequent in the failed PTCA group, notably acute myocardial infarction, postoperative hemorrhage, and cardiac tamponade (Table IV). The intraaortic balloon was used in 22 patients: one before the PTCA, 16 immediately afterward, and five after emergency operation; the intraaortic balloon was needed postoperatively in only three patients in the elective group. There was no significant difference in the prevalence of arrhythmias. Thirtyseven (55%) of the elective CABG patients were entirely free of complications (even the most trivial), as compared to 26 (39%) in the emergency group (P> 0.05). Accordingly, the length of stay for the surviving patients was longer by 2 days in the emergency situation. The difference in operative mortality was significant; there were eight deaths in the post-PTCA group and one in the elective group (p = 0.0015, Table V). Discussion and summary The results of failed PTCA have not gone unquestioned, controversial issues having been raised independently by Willman,' Kouchoukos,' and Giuliani.' Fifteen articles (including our ownj>" have been published in which the frequency and the results of post-PTCA emergency CABG were evaluated (Table VI). In the reviewed literature, a total of 15,802 PTCAs have been reported, of which 902 required emergency operation (5.7%). Fifty-one of 868 (5.9%) of these patients died after the operation; information was not available on another 38. Dorros and associates," in a separate analysis of the first 1500 patients in a multicenter PTCA study, found an emergency operation rate of

The Journal of Thoracic and Cardiovascular Surgery

Parsonnet et al.

200

Table ID. Comparison of intraoperative findings Failed PTCA In = 67)

Elective CABG In = 67)

P Value

No. of vessels bypassed

26 24 14 3

I 2 3

4 5

(39%) (36%) (21%) (4.5%)

1.9 ± O.ll 6 (9%) 88.1 ± 5.6 31.7 ± 2.9 37 (55%) 5.2 ± 0.5 63 (94%)

Average no. of bypasses No. of patients with IMA grafts Time on cardiopulmonary bypass (min, mean) Time of ischemic arrest (min, mean) Requirement for vasopressors Packed RBCs (units) Pa tients requiring blood or blood products

4 (6%) 27 (40%) 28 (42%) 6 (9%) 2 (3%) 2.6 ± 0.1 33 (49%) 93.2 ± 3.6 39.9 ± 1.9 30 (45%) 3.3 ± 0.4 57 (85%)

NS

<0.001 <0.001 NS

<0.02 >0.05 NS 0.0026 >0.05 NS

IMA. Internal mammary artery; RBCs. red blood cells.

Table IV. Postoperative complications in groups I and II Complicat ions Acute myocardial infarct Hemorrhage Arrhythmias (YT, YF. SYT) Pulmonary Cardiac tamponade Cardiac arrest Acute renal failure lABP complication (ischemic leg) Multisystem failure Sepsis Cardiogenic shock Conduction defects requiring pacing Freedom from major complications

Table V. Discharge disposition of groups I and II (length of stay was calculated only for the surviving patients)

Failed PTCA

Elective CABG

In = 67)

P Value

19 (28%)

6 (9%)

<0.01

19 (28%) 9 (13%)

9 (13%) II (12%)

<0.05

In = 67)

NS

8 7 4 3 2

(12%) (10.5%) (6%) (4.5%) (3%)

4 (6%) 1 (1.5%) 0 2 (3%) 0

2 2 I 1

(3%) (3%) (1.5%) (1.5%)

0 0 I (1.5%) 0

NS NS NS NS

37/67 (55%)

>0.05

26/67 (39%)

NS

<0.05 0.06 NS NS

SVT. Supraventricular tachycardia; VF. ventricular fibrillation; VT. ventricular tachycardia.

6.8%. The operative mortality rate in the group requiring emergency operation was 6.9% and major complications occurred in 42%. The results of our study were much like those reported by Dorros and colleagues as well as those summarized from the literature. The tables document the differences that were found between emergency procedures on patients having failed PTCA and matched (historical) control patients (Tables II and III). The cases were similar in all respects except that previous infarction was more common in the

Length of stay (days) Discharge status: Well Fair Died

Failed PTCA

Elective CABG

P Value

15.3 ± 1.1 (n = 66)

13.4 ± 0.7 (n = 59)

0.051

52 (78%) 7 (10.5%) 8 (12%)

65 (97%) I (1.5%) 1(1.5%)

<0.001 0.0015

elective group. If anything, that could have slanted the results against the elective group. The number of CABGs and the frequency of use of the internal mammary artery were greater in the elective operations, probably because of the relative lack of urgency in that group. It was not possible to match the two series perfectly in terms of precise vessel involvement, because cases were not selected prospectively and because elective single bypasses were exceedingly rare. Matching the cases by every other objective factor, as shown in Table II, was the best that could be accomplished. A subjective review of the arteriograms of all the cases by the surgeons, and the application of our own scoring system, indicated that the two series were similar in most respects. Often, however, the surgeons bypassed more vessels than those performing the PTCAs had intended to dilate. The latter were interested in "culprit" vessels, whereas the surgeons were more concerned with complete revascularization. The complications in the elective group that the computer had chosen (Table IV) revealed an infarct rate of 9%, a frequency of postoperative hemorrhage of

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Emergency operation after failed angioplasty

August 1988

20 1

Table VI. Summary of PTCA failures and emergency operations reported in the literature First author"

PTCAs

Emergency operations

Bredlau' Acinapura" Akins' Brahos' Cowley' Killen'" Pelletier" Reul" Smith" Norell" Page"

3.502 198 125 323 3,079 3,000 265 518 510 69 750 600 74 1,831 958 15.802

92 (2.7%) 21 (10.0%) 11 (8.8%) 68 (21.0%) 202 (6.6%) 115 (3.8%) 35 (13.2%) 70 (13.5%) 48 (9.4%) 13 (19.0%) 31 (4.1%) 38 (6.3%) 10 (13.5%) 81 (4.4%) 67 (7.0%) 902 (5.7%)

Kabbani" Fournial" Golding" Parsonnet Totals

A MIs 47 (51%) 8 (38.1%) ~t ~t

83 46 10 23 16 3 13

(41.1%) (40.0%) (28.6%) (32.8%) (33.3%) (23.1%) (41.9%) ~t

2 (20.0%) ~t

19 (28.3%) 170 (5.9%)

Deaths 2 (2.0%) 0 0 3 (4.4%) 13 (6.4%) 13 (11.3%) 0 4 (5.7%) 2 (4.2%) 1(8.0%) 3 (10.0%) ~t

0 2 (2.5%) 8(11.9%) 51 (18.8%)

AMI. Acute myocardial infarction. 'Only the latest reports from an institution were selected. For example. a detailed study of 866 ?TeAs by Murphy and colleagues from Emory University" was not tabulated because it was superseded by that of Bred!au and associates.' t~o information given.

13%, and a mean length of stay of 13.4 days, values that are worse than those found in our overall results in the past few years. We have no explanation for the high complication rates in this specific cohort. * In any event, the PTCA group had more major complications. In addition to a high mortality rate, postoperative hemorrhage and acute myocardial infarction were more common. The reasons for more frequent bleeding, tamponade, and blood product utilization in this setting have not been studied; presumably the differences were related to the emergency and often hurried nature of the operation, the coexistence of cardiogenic shock, and the use of aspirin in some of the patients in the PTCA group. There were 19 infarcts (28%) as compared with six in the elective group (9%). The infarct rate reported in the literature was similar, ranging from 10% in one study" to a high of 49%.5 The mean infarct rate in the 12 reports in which such data were given was 24%, again a value similar to our own. Further differences in the two groups were less striking but nevertheless interesting because the trends wereconsistent. A complication-free course (55% versus 'During the past 3 years the operative mortality and infarction rates in 363 elective CABO operations in good and fair risk patients were 1.1% and 3.3%, respectively. The postoperative hemorrhage rate was 3.3%. The total number of CABG procedures during that period was 1857 (of 2436 cardiac operations).

39%) and less use of blood and blood products were more characteristic of the control group. Furthermore, the discharge status of the elective CABG patients was excellent in 97% of the survivors as compared to 78% of the control group. Transit time from the moment a decision was made to refer the patient for operation was short, ranging from 15 to 75 minutes (average 26 minutes). Although the interval from onset of ischemia to revascularization was not recorded, there was no evidence that delay in transportation to the operating room affected the outcome. Eight of the PTCA failure patients (12%) died during the same hospitalization, compared to one in the control group (p = 0.OOI5)(Table VII). Four of the eight patients were in cardiogenic shock. An intraaortic balloon was inserted preoperatively in the four patients in shock and would have been used in a fifth were it not for the presence of severe aortoiliac disease. Eventually she required transthoracic intraaortic balloon support to be weaned from cardiopulmonary bypass. All of these patients had large myocardial infarcts. Two of the patients who died could not be weaned from cardiopulmonary bypass; the others survived from 1 to 21 days, dying of a combination of postoperative problems. Although 50% of the patients who died were in cardiogenic shock before the operation, shock occurred in only 8.5% of the survivors (p < 0.(01). Thus the occurrence of post-PTCA cardiogenic shock carried an ominous prognosis. In recognition of the dire nature of the complications of

202

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Parsonnet et at.

Table VII. Summary of operative deaths Patient No.

Age (yr)

Sex

I

2

51 75

M M

Circ LAD

Thrombus Thrombus x2

3

46

M

RCA

Dissection and spasm

4

66

M

Circ

Spasm

5

62

F

Circ

6

59

M

LAD

Dissection of circumflex Probable thrombus

Vessel

7

68

M

LAD

8

67

F

RCA

Cause

Dissection and perforation Thrombus

Clinical status

Preop [ABP

Cardiogenic shock Severe pain; ECG changes Severe pain; ECG changes Severe pain; ECG changes AV block; Cardiogenic shock AV block; Cardiogenic shock Severe pain; ECG changes Vent tachycardia; CPR; cardiogenic shock

Transmit time (min)

Yes No

30 20

Yes

20

No

75

Not possible (PVD) Yes

15 15 (from

Died after (days)

Causers) of death

10 4

Multisystem failure VF, sudden

21

Tamponade and cardiac arrest Multisystem failure Cardiogenic shock

0

Cardiogenic shock

recovery room) No

15

0

Cardiogenic shock

Yes

20

II

Multisystem failure

Circ, Circumflex coronary artery; CPR, cardiopulmonary resuscitation; LAD, left anterior descending coronary artery; PVD, peripheral vascular disease; RCA, right coronary artery; VF, ventricular fibrillation.

PTCA, newer techniques and methods have been developed that can restore or maintain blood flow beyond the occluding lesion. A catheter with entrance and exit pathways proximal and distal to the lesion is one such device. Methods of instilling oxygenated blood via catheters passed through the obstruction also have been used. Intracoronary streptokinase has been recommended as well." Whether these techniques will affect the outcome of the emergency CABG operation is still uncertain. Single-vessel bypasses are indicated relatively rarely (less than 2.0% of elective bypasses at our institution). Even without surgical treatment, the long-term outlook for most patients with single-vessel disease is relatively benign. The operative mortality in patients with mild angina, near normal ventricular function, and singlevessel disease is 0% (no deaths in only six such cases). PTCA failure, on the other hand, converts a relatively benign condition into one that may lead to emergency operation in 6% of cases, following which the operative results are much worse. Emergency CABG after failed PTCA is associated with a significant increase in morbidity and mortality, increased length of stay, and increased utilization of material, personnel, and (in consequence) financial resources. The data suggest that it is inappropriate to equate emergency CABG after a failed PTCA with elective CABG.

We wish to thank Drs. John Ciccone, Mia Parson net, and Alan D. Bernstein for their constructive criticisms of the manuscript. REFERENCES 1. Percutaneous coronary angioplasty vs bypass surgery. Letter to the Editor. N Engl J Med 1985;313:590. 2. Willman VL. Percutaneous transluminal coronary angioplasty, a 1985 perspective. Circulation 1985;71:189-92. 3. Kouchoukos NT. Percutaneous transluminal coronary angioplasty: a surgeon's view. Circulation 1985;72:11447. 4. Giuliani ER. Percutaneous transluminal coronary angioplasty. J Am Coli Cardiol 1985;6:992-4. 5. Bredlau CE, Roubin GS, Leimgruber PP, DouglasJS, King SB, Gruentzig AR. In-hospital morbidity and mortality in patients undergoing elective coronary angioplasty. Circulation 1985;72:1044-52. 6. Acinapura AJ, Cunningham IN, Jacobowitz 11, et al. Efficacy of percutaneous transluminal coronary angioplasty compared with single-vessel bypass. J THORAC CARDIQ. VASC SURG 1985;89:35-41. 7. Akins CW, Block Pc. Surgical intervention for failed percutaneous transluminal coronary angioplasty. Am J Cardiol 1984;53:108C-IIC. 8, Brahos GJ, Baker NH, Ewy HG, et al. Aortocoronary bypass following unsuccessful PTCA: experience in 100 consecutive patients. Ann Thorac Surg 1985;40:7-10. 9. Cowley MJ, Dorros G, Kelsey SF, Van Raden M, Detre KM. Emergency coronary bypass surgery after coronary

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angioplasty: The National Heart, Lung, and Blood Institute's percutaneous transluminal coronary angioplasty registry experience. Am J Cardiol 1984;53:22C-6C. 10. Killen DA, Hamaker WR, Reed WA. Coronary artery bypass following percutaneous transluminal coronary angioplasty. Ann Thorac Surg 1985;40:133-8. 11. Pelletier LC, Pardini A, Renkin J, David PR, Hebert Y, Bourassa MG. Myocardial revascularization after failure of percutaneous transluminal coronary angioplasty. J THORAC CARDIOVASC SURG 1985;90:265-71. 12. Reul GJ, Cooley DA, Hallman GL, et al. Coronary artery bypass for unsuccessful percutaneous transluminal coronary angioplasty. J THORAC CARDIOVASC SURG 1984; 88:685-94. 13. Smith CW, Hornung CA, Sutton JP, Allen WB, Yarbrough JW. Coronary bypass for failed angioplasty. Circulation 1984;70(Pt 2):11254. 14. Norell MS, LyonsJ, Layton C, Balcon R. Outcome of early surgery after coronary angioplasty. Br Heart J 1986;55:223-6. 15. Page US, Okies JE, Colburn LQ, Bigelow JC, Salomon NW, Krause AH. Percutaneous transluminal coronary angioplasty. J THORAC CARDIOVASC SURG 1986;92:84752.

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16. Kabbani SS, Bashour IT, Jones R, et al. Surgical experience following percutaneous transluminal coronary angioplasty. Texas Heart Inst J 1984;11:112-6. 17. Fournial G, Marco J, Gouel Y, Bernies M, Bernadet P, Berhoumieu F. L'angioplastie des arteres coronaires. Arch Mal Coeur 1983;76:859-63. 18. Golding LAR, Loop FD, Hollman JL, et al. Early results of emergency surgery after coronary angioplasty. Circulation 1986;74(Pt 2):III26-9. 19. Murphy DA, Craver JM, King SB. Distal coronary artery dissection following percutaneous transluminal coronary angioplasty. Ann Thorac Surg 1984;37:473-7. 20. Dorros GJ, Cowley MJ, Simpson J, et al. Percutaneous transluminal coronary angioplasty: report of complications from the National Heart, Lung, and Blood Institute PTCA registry. Circulation 1983;67:723-30. 21. Schofer J, Krebber HJ, Bleifeld W, Mathey 00. Acute coronary artery occlusion during percutaneous transluminal coronary angioplasty: reopening by intracoronary streptokinase before emergency coronary artery surgery to prevent myocardial infarction. Circulation 1982; 66:1325-31.