Wilson J M, Dunn E J, Wright C B, Bailey W W, Callard G M, Melvin D B, Mitts D L, Will R J, Flege J B
J Thorac Cardiovasc Surg. 1986 Mar;91(3):362-70.
From November, 1980, to May 1985, 699 patients have undergone percutaneous transluminal coronary angioplasty of 784 lesions at our institutions. Simultaneous surgical standby was available on all cases. One hundred twenty-four patients (18%) underwent immediate myocardial revascularization; 45 (6%) were operated on because the lesion could not be dilated. Seventy-nine patients (11%) underwent immediate operation for an acute complication of angioplasty: coronary occlusion in 45, dissection in 29, coronary perforation in three, and atrial perforation in one. Fourteen patients (18%) required cardiopulmonary resuscitation en route to the operating room, and 10 patients (20%) had insertion of an intra-aortic balloon pump in the cardiac catheterization laboratory. The average time from complication to reperfusion was 87 minutes, ranging from 40 to 165 minutes. An average of 2.0 grafts per patient (ranging from one to five grafts per patient) were performed. Of those 79 patients who underwent operation for an acute complication, one died (1.3%), 31 patients (39%) had a myocardial infarction according to enzyme criteria (creatine kinase-myocardial band greater than 40 IU), and 17 patients (22%) had new Q waves on the electrocardiogram. Good results are related to minimizing the time the myocardium is ischemic. No patient in whom reperfusion was begun in less than 75 minutes had a Q wave infarction or a creatine kinase-myocardial band level greater than 40 IU. Simultaneous surgical standby is the only method allowing immediate access to surgical facilities. A standby team of eight persons and equipment were immediately available for emergency bypass grafting for an average of 3.6 hours (range 1.3 to 5.4 hours per angioplasty attempt). The patient charges for this simultaneous standby were $632.00 per angioplasty attempt, or $442,278.00 for the entire series. The actual cost of the standby was over $1,700.00 per attempt totaling $1,188,843.00 for the 699 patients. This underestimation of the cost of surgical standby has occurred in other series, because little mention has been made of this cost in the published reports on the cost effectiveness of angioplasty. In terms of time demands, over 2,500 hours were spent by surgeons standing by for the 699 attempts. Simultaneous surgical standby is the most effective means of limiting the time the myocardium is ischemic after an angioplasty complication. However, this method is costly, necessitating more of a financial and time commitment than generally anticipated. Future studies of the cost effectiveness of angioplasty should include the cost of surgical standby with accurate per-patient cost accountability.
从1980年11月至1985年5月，我院699例患者接受了784处病变的经皮腔内冠状动脉成形术。所有病例均有外科手术备用支持。124例患者（18%）接受了即刻心肌血运重建；45例（6%）因病变无法扩张而接受手术。79例患者（11%）因血管成形术的急性并发症接受了即刻手术：冠状动脉闭塞45例，夹层分离29例，冠状动脉穿孔3例，心房穿孔1例。14例患者（18%）在前往手术室途中需要心肺复苏，10例患者（20%）在心脏导管室插入了主动脉内球囊泵。从并发症发生到再灌注的平均时间为87分钟，范围为40至165分钟。每位患者平均进行2.0支移植血管（每位患者1至5支移植血管）的手术。在这79例因急性并发症接受手术的患者中，1例死亡（1.3%），31例患者（39%）根据酶学标准（肌酸激酶心肌带大于40 IU）发生心肌梗死，17例患者（22%）心电图出现新的Q波。良好的结果与尽量缩短心肌缺血时间有关。在缺血时间少于75分钟内开始再灌注的患者中，无一例发生Q波梗死或肌酸激酶心肌带水平大于40 IU。同时进行外科手术备用支持是能够立即获得手术设施的唯一方法。一个由八人组成的备用团队和设备随时可供紧急进行旁路移植手术使用，平均每次血管成形术尝试的备用时间为3.6小时（范围为1.3至5.4小时）。每次血管成形术尝试患者为此同时备用支持的费用为632.00美元，整个系列的费用为442,278.00美元。实际的备用支持费用每次尝试超过1,700.00美元，699例患者总计1,188,843.00美元。在其他系列研究中也出现了对手术备用支持费用的低估情况，因为在已发表的关于血管成形术成本效益的报告中很少提及这一费用。在时间需求方面，外科医生为699次尝试待命花费了超过2500小时。同时进行外科手术备用支持是限制血管成形术并发症后心肌缺血时间的最有效方法。然而，这种方法成本高昂，需要比一般预期更多的资金和时间投入。未来关于血管成形术成本效益的研究应包括手术备用支持的成本，并进行准确的患者个体成本核算。
