SCAI Expert Consensus Statement Supports Safety of PCI Without On-Site Surgery

A new expert consensus statement from the Society for Cardiovascular Angiography & Interventions (SCAI) suggests that percutaneous coronary intervention (PCI) without surgery on site (no-SOS) is as safe as PCI at centers with on-site surgery.¹

The statement indicates factors to a safe and successful PCI program with no-SOS included adequate operator experience, appropriate clinical judgment and case selection, and facility preparation.

“The economic benefits of PCI with no-SOS have driven and will continue to drive payers toward the migration of PCI to the ambulatory setting,” wrote corresponding author Arnold H. Seto, MD, Long Beach VA Health Care System and vice-chair of the SCAI writing group. “This expert consensus statement summarizes the evidence supporting PCI with no-SOS and provides the community with the guidance necessary for this transition.”

Updated in 2014, the prior document summarized new literature, reviewed existing guidelines and other publications related to PCI with no-SOS, and recommended best practices and requirements for facilities performing PCI with no-SOS. But limits in research and practice of PCI with no-SOS led to conservative recommendations for both case selection and practice.

After the publication of the 2014 consensus statement, however, same-day discharge after elective PCI has increased to 28.6% of all PCIs and 39.7% of radical PCIs in the United States in 2017. Newer studies in both the US and abroad have demonstrated that PCI performed at no-SOS centers have low rates of complications and similar outcomes to PCIs performed with surgery on site. But consolidation of surgical services within health systems has resulted in high-quality PCI centers restricted from performing complex PCI due to the perceived need for on-site surgery.

The writing committee thus revised the 2014 document to update the available data, reconsider the type of cases that could be undertaken without on-site surgical backup, review data regarding which patients are at higher risk, and recommend patient selection criteria based on risk, operator experience, and facility capabilities.

The statement highlighted key points within the 2014 document.

It indicated elective PCI in settings with no-SOS has increased in volume and complexity, which has extended beyond the simple lesion recommendations in the 2014 documents. PCI is additionally now being performed outside of the hospital setting, in both office-based laboratories and ambulatory surgical centers.

Meanwhile, several new studies in the United States and abroad prove that PCI performed at no-SOS centers have very low rates of complications and similar outcomes to PCIs performed at surgical centers. Despite the increases 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.

Additionally, complex PCI, including unprotected left main, has been performed in some no-SOS centers, with no increases in major adverse cardiovascular events or emergency coronary artery bypass graft surgery compared with PCI at surgical centers.

The writing group additionally proposed a new PCI treatment algorithm to expand the type of cases that can be performed with no-SOS compared with the prior document in 2014. It considered a patient’s clinical and lesion risk, operator experience (both recent and accumulated), and the experience and rescue capabilities of the site.

Within the United States, investigators cited considerable financial savings (to insurers and Medicare) for PCI to be performed in ambulatory surgery centers and office-based laboratory settings, noting out-migration of procedures from hospitals should be expected.

The SCAI 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).

References

1. Grines CL, Box LC, Mamas MA, et al. SCAI expert consensus statement on percutaneous coronary intervention without on-site surgical backup. Journal of the Society for Cardiovascular Angiography & Interventions. 2023:100560. doi:10.1016/j.jscai.2022.100560