Meier B, Urban P, Dorsaz P A, Favre J
Cardiology Center, University Hospital, Geneva, Switzerland.
JAMA. 1992 Aug 12;268(6):741-5.
To assess the predictability of need for emergency surgery after coronary balloon angioplasty.
Nonrandomized intervention study.
Nonprofit university hospital.
Prior to balloon angioplasty, 1000 consecutive patients were assigned to either the "standby" group (189 patients [19%]) or the "no-standby" group (811 patients [81%]). Patients in the standby group (intervention coordinated with cardiac surgery) included all operable patients undergoing angioplasty of their largest coronary arteries that were not currently or previously totally occluded or collateralized; the no-standby group consisted of the remainder of patients.
Allocation to coronary angioplasty with or without surgical standby.
Need for bypass surgery, occurrence of myocardial infarction, and mortality from complications of angioplasty.
Bypass surgery immediately after angioplasty was done in one patient in each group (standby, 0.5%, vs no-standby, 0.1%). The frequency of infarction was 5% vs 4%, respectively. All eight deaths occurred in the no-standby group (1.0%), but none of them were consequences of a lack of surgical standby. They occurred in situations in which bypass surgery would not have changed the outcome (two cardiac failures late after technically successful angioplasty for postinfarct cardiogenic shock, one in-laboratory rupture of an unrecognized ventricular pseudoaneurysm, and one protamine reaction), secondary to acute problems late after successful angioplasty (two sudden deaths and one vessel occlusion in an inoperable patient), or despite surgery (one patient with left main stem dissection).
Performing roughly 80% of coronary angioplasties without surgical standby did not increase patient risk. Coronary angioplasty without surgical backup, albeit not an ideal setting, appears ethically feasible in selected patients if dictated by logistic considerations.
评估冠状动脉球囊血管成形术后急诊手术需求的可预测性。
非随机干预研究。
非营利性大学医院。
在球囊血管成形术前，1000例连续患者被分为“备用”组（189例患者[19%]）或“无备用”组（811例患者[81%]）。备用组患者（与心脏外科协调干预）包括所有接受最大冠状动脉血管成形术且目前或既往未完全闭塞或形成侧支循环的可手术患者；无备用组由其余患者组成。
分配接受有或无手术备用的冠状动脉血管成形术。
搭桥手术需求、心肌梗死发生率以及血管成形术并发症死亡率。
血管成形术后立即进行搭桥手术的患者，每组各有1例（备用组，0.5%；无备用组，0.1%）。梗死发生率分别为5%和4%。所有8例死亡均发生在无备用组（1.0%），但均非缺乏手术备用所致。死亡发生在搭桥手术无法改变结局的情况下（2例因梗死后心源性休克在技术成功的血管成形术后晚期发生心力衰竭，1例未识别的心室假性动脉瘤在实验室破裂，1例鱼精蛋白反应），继发于成功血管成形术后的急性问题（2例猝死和1例不可手术患者的血管闭塞），或尽管进行了手术（1例左主干夹层患者）。
约80%的冠状动脉血管成形术在无手术备用的情况下进行并未增加患者风险。无手术备用的冠状动脉血管成形术，尽管并非理想情况，但如果出于后勤考虑，在特定患者中从伦理角度看似乎是可行的。
