Guidelines for surgical standby for coronary angioplasty: should they be changed?

Aortocoronary bypass surgery has been an option for treating coronary artery occlusive disease since the late 1960s; in that sense, it has been “standing by” for three decades as a backup for failed cardiologic treatments. In the late 1970s, balloon angioplasty was introduced for treating coronary artery disease. This procedure is performed in a radiology suite (the catheterization laboratory), on an awake patient, in the absence of effective circulatory support. In the early days of coronary angioplasty, catheter devices were far from reliable, entailing a high risk of coronary dissection, plaque disruption, elastic recoil, clot formation and other serious complications. To improve the safety of catheter coronary interventions, the founder of balloon angioplasty, Dr. Andreas Gruntzig, initiated the practice of having a cardiovascular suite and appropriate personnel (including a surgical team) ready and available next to the catheterization laboratory during coronary angioplasty. In their 1982 guidelines (2), the American Heart Association (AHA) and the American College of Cardiology (ACC) endorsed Gruntzig’s original practice when they recommended that obligatory surgical standby be available for all coronary angioplasty procedures. Even during the early years, however, it became clear to experienced angioplasty operators that active surgical standby was not strictly necessary for most of the patients treated at large, highly experienced cardiovascular centers (3). The literature contains a few reports (reviewed by Wharton et al.), concerning the safety, efficacy and cost-efficiency of performing elective coronary angioplasty in hospitals that lack a cardiovascular surgery department. This practice has never become established, at least in the U.S., and controlled prospective multicenter trials have never been carried out to validate its safety. Currently—mainly because of medical, legal and institutional concerns—the accepted standard is still to perform coronary angioplasty only at institutions that offer cardiovascular surgical services on the same premises. This requirement was reiterated in 1993 by the ACC and AHA guidelines (4). In most U.S. cardiovascular centers, however, it has become common practice to rely on preoperative risk assessment and to institute different degrees of surgical standby (in some cases virtual, in other cases actual), especially in light of cost-efficiency considerations.