Surgical standby for percutaneous transluminal coronary angioplasty: A survey of patterns of practice

To determine patterns of surgical standby for percutaneous transluminal coronary angioplasty (PTCA), a questionnaire was mailed to 196 US institutions in which PTCA and coronary artery bypass grafting (CABG) are performed regularly. Eighty-nine responses (46%) were received and comprise this report. Of responding institutions, the mean number of hospital beds was 615. In 1987, these institutions performed a mean of 337 PTCAs and 558 open-heart surgical procedures. The rate of emergency CABG for PTCA complications (occlusion, dissection, or coronary perforation) was 4.4% ± 0.3%, whereas the rate of urgent CABG (within 24 hours) for PTCA failure was 3.7% ± 0.6%. The incidence of emergency CABG for PTCA complications was higher (5.1% ± 0.6%) among low-volume PTCA centers (less than 250 cases per year) than at high-volume centers (more than 250 cases per year) (3.7% ± 0.3%; p < 0.05). The most common pattern of surgical backup was to maintain an open operating room on standby ( 57 89, 64%), and the second most common pattern was to make the next open operating room available, allowing operating room access within 1 to 3 hours ( 21 89, 24%). Nearly a third of institutions ( 26 89, 29%) maintained a flexible backup arrangement according to PTCA risk. Routine pre-PTCA patient evaluation by surgeon and/or anesthesiologist occurred in 38% ( 34 89). Fees for standby services were charged by 51% of surgical teams ( 45 89), 39% of anesthesia teams ( 35 89), and 38% of operating room facilities ( 34 89). Thirty-seven percent of surgeons ( 33 89) were dissatisfied with their present standby arrangements; sources of dissatisfaction included poor communication with cardiologists about high risk or possibly inappropriate PTCA cases, waste of operating room resources, and inadequate compensation. In summary, although PTCA infrequently requires emergent surgical revascularization, many institutions still maintain an open operating room on standby. The economic burden of this support frequently is not compensated. This survey describes current practices of surgical standby for PTCA and encourages closer examination of the total cost of PTCA.