Percutaneous transluminal coronary angioplasty: technical aspects

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Percutaneous transluminal coronary angioplasty by high-volume and low-volume operators Article in Clinical Cardiology · March 1987 DOI: 10.1002/clc.4960100512 · Source: PubMed

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Clin. Cardiol. 10, 355-357 (1987)

Percutaneous Transluminal Coronary Angioplasty by High-Volume and Low-Volume Operators c

L. FINCI.M D.. B. MEIER,M D.. G.

STEFFENINO, M.D..

P.

URBAN, M.D..

J . NOBLE,M.D., J . GABATHULER, M.D.,

W . RUTISHAUSER. M.D.

Cardiology Center, University Hospital, Geneva, Switzerland

Summary: We retrospectively compared the results of percutaneous transluminal coronary angioplasty (PTCA) of three low-volume operators (1.3 PTCAs/month) to those of a relatively high-volume operator (14.9 PTCAs/month) in 396 consecutive procedures (358 patients). PTCA for multiple vessels, total occlusions, or evolving acute myocardial infarction had been excluded. For low-volume operators experienced assistance was considered present when the high-volume operator participated as second operator. The three low-volume operators performed 42, 38, and 24 FTCAs, respectively. Success rates per procedure for these operators were 88 % , 84 % , and 83%. and the complications rates 5%, 3 % , and 13%, respectively. The success rates for assisted vs. nonassisted procedures were 89% vs. 88%, 100% vs. 7 8 % , and 90% vs. 71 %, and the complications rates were 6% vs. 4'36, and 0% vs. 21 %, respectively. The high-volume operator performed 292 PTCAs, with a success rate of 93 %, and a complication rate of 5 %. The cumulated success rate of the three low-volume operators of 85% was significantly (p < 0.05) lower than the 93 % success rate of the high-volume operator, while the complication rates of 6% and 5 % , respectively, were not significantly different. Low-volume operators in an experienced center can perform PTCA safely even without assistance by a highvolume operator. However, their success rate is lower.

Introduction Experience of the operator performing percutaneous transluminal coronary angioplasty (PTCA) has been shown to have a favorable inference on the success rate.' However, the issue remains c o n t r o ~ e r s i a l ,after ~ ~ ~recent reports suggested that results of low-volume operators are comparable to those of high-volume ~ p e r a t o r s . ~ . ~ We compare the results of PTCA of three low-volume operators to those of a relatively high-volume operator in the same nonprofit university hospital.

Methods Patients

Between August 1983 and May 1986,647 PTCA procedures were performed in our institution. There were 101 multivessel PTCAs, 100 FTCAs for chronic total occlusion, and 50 FTCAs for evolving myocardial infarction. These procedures were excluded. The remaining 396 procedures represent the material of the present study. There were 359 patients, 320 males (89%), and 39 females ( l l % ) , with a mean age (+SD) of 5 5 + 9 years. Repeat PTCA accounted for 36 cases. It was equally represented in both groups. Technique

Key words: angioplasty , coronary, percutaneous; operators, high-volume, low-volume; single-vessel angioplasty

Address for reprints: Bernhard Meier, M.D. Cardiology Center University Hospital 12 I I Geneva 4, Swi17erland Received: November 7. 1986 Acceprcd: December 10, 1986

PTCA was performed using a steerable guidewire system. In the majority of cases the femoral approach, and a biplane x-ray equipment with digital still frames and electronic markers were used. All patients received at least 10,OOO U of heparin intravenously and most of them received nitrates, calcium antagonists, and aspirin before and during PTCA. Operators

The procedures were performed by four operators: three low-volume operators with 1.3 PTCAdmonth, and onc

Clin. Cnrdiol. Vol. 10, May 1987

356

relatively high-volume operator performing 14.9 PTCAs/nionth. All had previous experience in both coronary angiography (minimum 300 procedures) and PTCA (assistance and/or performance in a minimum of 50 procedures) prior to this study. The high-volume operator had pcrfonned or assisted in more than 1000 PTCAs. Experienced assistance during PTCA was considered to be present when the high-volume operator participated as second operator. Help provided by experienced fellows or technicians was not considered. Definition of Success

PTCA was considered successful when the following conditions were fullfilled: angiographic improvement of the stenosis to a nonsignificant degree ( < 60%of diameter reduction), improvement of transstenotic pressure gradient ( 5 30 mmHg), and absence of a major complication such as death, myocardial infarction (Q wave), and emergency coronary artery bypass surgery. Statistical analysis

Data were analyzed using the chi-square test. A significance level of p