• Ad Hoc PCI: Take an Intra-Procedural "Time-Out"

    November 24, 2014

    By: Henry S. Jennings, MD, FSCAI and Jayant Bagai, MD, FSCAI

    To avoid disaster, decision-making in the interventional cath lab sometimes needs to happen emergently and quickly. Alternatively, the most common and important decisions that we invasive/interventional cardiologists make on a daily basis – those as to whether to proceed with ad hoc PCI based on the diagnostic study findings – allow for everyone involved to take a brief pause and consider relevant issues. This has increasing importance in the contemporary era, which is characterized by heightened awareness of appropriate use criteria, patient safety, quality outcomes and shared decision making between patients and providers. An extra time-out is particularly germane if there is an intra-procedural change in operator, from a strictly invasive diagnostic/non-interventional cardiologist to a second interventional cardiologist who may not have met the patient or thoroughly reviewed the entire clinical scenario in detail.

    The Society for Cardiovascular Angiography and Interventions published key position papers on this evolving issue in 2000, 2004 and 2013. (1–3) The most recent of these includes a number of useful graphics, such as a decision-making flow algorithm that can be incorporated into an additional intra-procedural "time-out." This diagram is an ideal complement to a checklist for clinical decision support.

    We encourage all cath lab operators to review SCAI's 2013 publication. To facilitate review and sharing of the publication and its graphics, we suggest you download the paper and urge you to review Figure 1, the decision-making flow algorithm. You can also download an abbreviated checklist constructed by the SCAI-QIT team. We invite you to share these documents with your teams and consider posting the checklist in your cath labs.

    In most high-risk situations (e.g., left main disease/equivalent, last remaining native vessel/graft, three-vessel disease with high SYNTAX score, complex bifurcation lesion such as Medina 1, 1, 1, chronic total occlusion) deferring ad hoc intervention may be prudent and allow for shared decision making/informed consent as to lesion-specific risks, benefits and outcomes. Other subtle considerations that arise and that are not specifically addressed in the attached checklist/flow diagram include –

    • whether the lesion is a recurrent in-stent restenosis,

    • whether there is a need for concomitant long-term oral antithrombotic therapy (e.g., atrial fibrillation, mechanical prosthetic valve, etc.),

    • whether any patient-specific parameters might still justify PCI even if AUC classification does not (e.g., pre-renal transplant, pre-liver transplant, etc.), and

    • whether the patient might be potentially eligible for an ongoing clinical trial that might be of benefit and require additional pre-procedural informed consent.

    The salient points that the checklist prompts us to ponder before proceeding are as follows:


    Ad Hoc PCI/Stent Intra-procedural Checklist Questions

    Has there been adequate informed consent about the possibility of ad hoc PCI/intervention?
    If the clinical scenario is SIHD, is the target lesion angiographically significant and/or consistent with prior noninvasive functional study, and if not, do additional assessments such as FFR/IVUS need to be made?
    What is the Appropriate Use Criteria classification/score?
    Is the anatomy high-risk, and is there a need for additional consent for lesion subset or need for Heart Team/Shared Decision-Making?
    Is the anatomy and clinical scenario one where there would be survival advantage to CABG or one where there is little to be gained from ad hoc immediate PCI?
    Is the proper equipment available in the facility, and is the intended interventionalist the appropriate one to perform the intervention?
    Is there a risk of excess radiation (total air kerma at the reference point > 5 Gy) or excess contrast (> 3.7 x eGFR)?
    Have there been any peri-procedural complications with the diagnostic study, and are hemodynamics optimized?
    Is there an issue with operator/patient fatigue?
    Has the patient been adequately pre-treated with aspirin, a P2Y12 inhibitor, and statin?
    Are there any issues (need for other surgical or invasive procedures over the next 12 months, patient non-adherence to/inability to afford prolonged DAPT, ongoing need for chronic oral anticoagulation) that impact prolonged DAPT for 12 months and hence DES vs BMS stent selection?
    Is there a scheduling/patient justice issue that impacts the ad hoc decision process (e.g., limited facility capability to care for more emergent/urgent pending cases)?


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    References

    1. Blankenship JC, Gigliotti OS, Feldman DN, Mixon TA, Patel RA, Sorajja P, Yakubov SJ, Chambers CE. Ad hoc percutaneous coronary intervention: a consensus statement from the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2013 Apr;81(5):748-58. doi: 10.1002/ccd.24701. Epub 2012 Nov 29.

    2. Blankenship JC, Klein LW, Laskey WK, Krone RJ, Dehmer GJ, Chambers C, Cowley M. SCAI statement on ad hoc versus the separate performance of diagnostic cardiac catheterization and coronary intervention. Catheter Cardiovasc Interv. 2004 Dec;63(4):444-51.

    3. Blankenship JC, Mishkel GJ, Chambers CE, Hodgson JM, Holmes DR, Sheldon W, Schweiger MJ, Cowley MJ, Popma JJ. Ad hoc coronary intervention. Catheter Cardiovasc Interv. 2000 Feb;49(2):130-4.