Transradial PCI and Same Day Discharge: A Winning Team?

Editorial Comments

Eltigani Abdelaal, MD and Olivier F. Bertrand, * MD, PhD, FSCAI, Quebec Heart-Lung Institute, Quebec City, Canada

Faced with rising healthcare costs, and with an aging population, healthcare systems are increasingly challenged globally to reduce costs of healthcare delivery, without compromising access to contemporary therapies. Technical advances in percutaneous coronary intervention (PCI), together with evolution of adjunctive pharmacotherapy, have substantially increased its safety and success. With this in mind, a reduction in the length of hospital stay post PCI with same-day discharge (SDD) may lead to cost savings, and increased satisfaction, without compromise to patient’s safety. In this issue of CCI, Le Corvoisier et al. present a multicenter observational study that describes safety and feasibility of ambulatory SDD after transradial PCI (TR-PCI) in a selected cohort of stable angina patients [1]. Of the 370 patients screened, 220 were deemed eligible for SDD based on pre-specified criteria. At procedural level, there was reasonable procedural complexity as 20% underwent multi-lesion intervention, 15% underwent multi-vessel PCI, and 20% bifurcation stenting. Of all patients included, 97% were successfully discharged home after a 4-6 hr observation period post PCI. The authors reported no major ischemic or bleeding complications within 24 hr. Only four patients were kept overnight for clinical reasons, but none required re-intervention. The single case of access-site hematoma was managed conservatively. Virtually all patients in the present study were satisfied with SDD strategy. The authors describe cost savings with such a strategy, in a local setting, compared to conventional PCI with overnight stay (ON). The principal concerns post-PCI may be summarized into ischemic and bleeding complications. With the breakthrough in micro engineering technology and advent of stents, and evolution of pharmacotherapy, the ischemic risk is negligible in contemporary practice provided that excellent angiographic result is obtained, regardless to clinical presentation. Bleeding, subdivided into access-site or non access-site, remains the commonest non-cardiac complication in patients undergoing PCI. Femoral access is associated with 5% risk of vascular complications, and imposes a minimum period of strict bed rest post PCI, even with closure devices. On the other hand, transradial approach (TRA) to PCI is associated with > 70% reduction in access-site bleeding and vascular complications [2]. TRA promotes early mobilization and offers the distinct advantage of early discharge post PCI, without exposure to delayed vascular complications. Although TRA requires a definite learning curve, its use is increasing rapidly worldwide. Both in the setting of elective as well as PCI in patients with acute coronary syndrome (ACS), the majority of complications occur within the first 6 hr, with a flat hazard function thereafter, and virtually no unheralded complications in the window of 6-24 hr post PCI, indicating no added benefit beyond 6 hr of observation, a finding echoed in present study. Pioneering work in Europe in the early nineties showed SDD was safe in selected patients. From 2003 to 2005 the EASY study randomized 1,005 patients, the majority presenting with ACS, undergoing TR-PCI to either overnight hospitalization (ON) or SDD after 4-6 hr of observation [3]. All patients received maximal antiplatelet therapy including pre-treatment with clopidogrel and bolus of abciximab. The seven- event composite end point at 30-days and 1 year was equivalent in SDD and ON groups. The EASY study also reported a very low overall rate of REPLACE-2 major bleeding of 1.4%. This contrasts favorably with contemporary benchmark for current incidence of bleeding complications in the PCI studies using bivalirudin and femoral access. We have recently conducted a meta-analysis including five randomized and eight observational studies [4]. Although populations included in those studies of SDD were heterogeneous, one common theme often unites these studies, that is the 4-phase selection process of: clinical, angiographic and procedural criteria, post-procedural observation, and patient’s ability and willingness to go home with access to adequate social support. There are currently no defined criteria for eligibility to SDD post PCI. The recommendations in consensus paper published by SCAI on eligibility for SDD appear extremely conservative. Gilchrist et al. [5] contrasted their experience of SDD and >85% of their patients would not have qualified for SDD if SCAI criteria would have been strictly adhered to. Although SDD PCI is certainly ready for prime time, home discharge requires allocation of suitable resources and development of a structured program. Key to success is judicious selection of patients who would be eligible to this strategy, based on clinical and angiographic criteria, with prudence and adjudication in the high-risk spectrum. Seven essential components of a successful and safe outpatient program can be highlighted: 1. Triage criteria for eligibility prior to PCI 2. Successful uncomplicated procedure, with stable clinical condition post-PCI 3. Stable vascular access site 4. Optimum patient education before and after PCI, with emphasis on all aspects of medical therapy, and secondary prevention 5. Dedicated trained nursing and cath lab staff and infrastructure (radial lounge) 6. Medical contact (24 hr phone contact), to provide reassurance and act as safety net 7. Adequate social support

REFERENCES
1. Le Corvoisier P, et al. Ambulatory transradial percutaneous coronary intervention: A safe, effective and cost-saving strategy. Catheter Cardiovasc Interv 2013;81:15-23.
2. Bertrand OF, et al. Comparison of transradial and femoral approaches for percutaneous coronary interventions: A systematic review and hierarchical Bayesian meta-analysis. Am Heart J 2012;163:632-648.
3. Bertrand OF, et al. A randomized study comparing same-day home discharge and abciximab bolus only to overnight hospitalization and abciximab bolus and infusion after transradial coronary stent implantation. Circulation 2006;114:2636-2643.
4. Abdelaal E, et al. Same-day discharge compared to overnight hospitalization after uncomplicated percutaneous coronary intervention: A systematic review and meta-analysis. JACC Cardiovasc Interv, in press.
5. Gilchrist IC, Rhodes DA, Zimmerman HE. A single center experience with same-day transradial-PCI patients: A contrast with published guidelines. Catheter Cardiovasc Interv 2012;79:583-587.

Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Catheterization and Cardiovascular Interventions 81:24-25 (2013)