Dr. Seto, you were first author on the updates to SCAI’s guidelines for length of stay following PCI in 20181. What was the intent and impact?
Our committee was formed because the 2009 expert consensus recommendations from the Society for Cardiovascular Angiography and Interventions (SCAI) were felt by all to be overly conservative, and not reflective of the current evidence or practice of percutaneous coronary intervention (PCI). The 2009 recommendations excluded from same-day discharge (SDD) patients with any clinical factors (age >70, comorbidities, left ventricular ejection fraction [LVEF], diabetes mellitus [DM], chronic kidney disease [CKD]) and angiographic factors (multivessel or bifurcation stenting, long or multiple stents, proximal left anterior descending [LAD] stent). These factors, while associated with higher PCI risk, are typically not ameliorated with overnight observation. So our committee started from scratch and agreed that patients were ready to be discharged when they were at their baseline clinical state, had a successful procedure without complications, and had adequate medication, education, and social support. This largely removed most of the prior exclusions and empowers the clinician to make their best judgment as to when a patient was ready for discharge.
I think that the new recommendations were largely a relief to others, as it corrected prior recommendations that most people either weren’t aware of or disagreed with, and which were an impediment to starting SDD programs. The new document has helped spur the further development of SDD programs in the U.S., where the rate of SDD is much lower than in other countries, including Canada and the United Kingdom (U.K.). The document helps catch up with the latest in the evidence base for SDD, even as that evidence continues to grow beyond the document (for example, with recent U.K. practice, including atherectomy patients for SDD). The most important impact in the U.S. has been to help reduce the fear of litigation and thus the ‘defensive medicine’ practice of observing patients overnight when they don’t need it.
What are some key considerations if a facility is looking to start a same-day discharge program?
Starting a SDD program is largely win-win-win for patients, hospitals, and cath lab operators. Patients get to go home and be with their families, hospitals save scarce bed resources and do not incur unreimbursed observation costs after elective PCI, and cath lab physicians can potentially reduce unnecessary paperwork and pages associated with overnight observation. However, starting a SDD program should include some planning with regards to prompt provision of oral P2Y12 inhibitors prior to discharge, patient and caregiver education, and ensuring close follow-up. A written hospital policy should describe the criteria for SDD and to ensure that no patient who wants to be observed overnight is discharged against their preferences. Ideally, a facility starting a SDD program would have pharmacy provide medications to the patient bedside, and ensure sufficient nursing resources to educate patients on their disease, medications, and follow-up.
At what point in the process is the patient approved for SDD at your facility?
At the conclusion of the angiogram and PCI, the operator makes a decision regarding the potential for SDD after assessing the success of the PCI procedure (without complications), success of hemostasis, and confirming that the patient has a ride and lives with someone who can monitor him/her after the procedure.
Although many veterans appreciate the camaraderie of being in our facility, almost everyone given the option has preferred to sleep in their own bed once they have been reassured that it is safe to do so. (Specific to our facility, we do not have overnight cath lab services, but are surrounded by community facilities that do have overnight cath lab services, so ironically, in terms of acute stent thrombosis treatment delays, the patients could get to a community cath lab faster from home than through an inpatient transfer.)
The most common reasons for exclusion from SDD in our Veterans Affairs (VA) facility is inadequate social support, as many of our veterans live alone or are unable to get a ride. This is something we typically can assess prior to the procedure ending so that we know to request a bed in advance if necessary.
Once we have made the decision to pursue SDD and sent the patient to the recovery room, it is rare (<10%) for patients to be subsequently admitted. The main reason for admitting patients is typically hematomas, even radial hematomas, that require prolonged compression. These are typically discovered within 2-3 hours. We have had one patient with acute stent thrombosis within 1 hour of arrival to the recovery room, despite ticagrelor loading. These are consistent with two randomized trials which have described the absence of complications occurring between 6 and 24 hours after the procedure that would have otherwise been captured by an overnight stay.
What procedures are selected and how have currently available equipment/devices facilitated the growth of SDD?
Consistent with current consensus recommendations, we have discharged patients with almost all types of PCI including multivessel PCI, bifurcation disease, and chronic total occlusions. Similarly, we have successfully discharged patients with low ejection fraction or chronic kidney disease (after a period of hydration).
The current generation of equipment has made radial access and hemostasis straightforward, making the radial approach feasible for 95% of our procedures. With our success and low rate of crossover, we finally took off the training wheels and stopped routinely shaving the groin. We routinely use the Optitorque coronary diagnostic catheters, Tiger or Jacky tip shapes (Terumo), and have found the Heartrail guiding catheter, Ikari tip shape (Terumo) usable for selected left and right coronary procedures such as a multivessel instantaneous wavefree ratio (iFR) assessment. The Runthrough NS guidewire (Terumo) was a transformative product and has replaced all of our other workhorse wires for PCI.
We are routinely using the Glidesheath Slender 6 French (F) sheath (Terumo). With its 5F outer diameter, we have not experienced a significant frequency of spasm. Our veterans are predominantly male with larger arteries, and we select for ulnar or other access if the radial artery is small on vascular ultrasound. Together, these techniques have significantly reduced spasm as an issue for our procedures, such that we have been able to reserve vasodilators like verapamil and nitroglycerin for use only as needed.
What are some key considerations for hemostasis?
We have tried multiple products for hemostasis, but the standard is the TR Band compression device (Terumo). With its simplicity and clear air-filled bladder, patent hemostasis can be mostly assured. The natural loss of pressure over time I suspect would contribute to a lower radial artery occlusion rate.
At this point, the key considerations for hemostasis seem to be TR Band compression time versus heparin dosage, activated clotting time (ACT), sheath size, and the use of glycoprotein inhibitors. Hematomas and access site rebleeding or oozing occurs more frequently with higher heparin doses, ACT >300, and glycoprotein IIb/IIIa inhibitor (GPI) use. This is an active area of debate and research, with the recent SCAI transradial expert consensus update2 recommending at least 5000 units (or 50 U/kg) of heparin and a recent large, randomized study3 showing a lower rate of radial artery occlusion with 100 U/kg of heparin. Such doses would tend to increase the duration of TR Band compression device time required.
We know from the RAP and BEAT (Radial Artery Patency and Bleeding, Efficacy, Adverse evenT) trial4 that very prolonged (>4 hours) compression times are associated with more radial artery occlusion. In addition, compression times less than an hour tend to be associated with more bleeding and hematomas that, paradoxically, lead people to respond with over-compression that also leads to more radial artery occlusion. Somewhere between 60-120 minutes seems to be the consensus, with 90 minutes being the right balance, according to the CRASOC (Compression of Radial ArterieS without Occlusion) I, II, and III trials from France.5
We have been experimenting with shorter compression times with lower doses of heparin for diagnostic cases, and with and without the use of adjunctive hemostasis patches. In a multicenter pilot trial6, we noted that the addition of a potassium ferrate patch enabled us to remove the TR Band compression device at an average of 43 minutes compared with 160 minutes without the patch. This allowed for a reduction in time discharge of 51 minutes, which is a significant reduction in hospital resources.
Can you talk about the success of your facility in implementing SDD and important future needs?
According to a recent analysis7, the VA as a whole reached 9.7% SDD in 2016, with no difference in thirty-day readmission or mortality, and with a median cost savings of $1503 per patient. We reviewed one year of our cases and found that we discharged 25% of our PCIs on the same day. The program has been very well received by the hospital, which is intermittently short on beds, and by patients and their families. Before, we would have to confirm that patients would have a bed before proceeding with a simple PCI where the patient could have gone home. Intermittently, especially during flu season, we would have to bring the patients back for their PCI procedure (and would have no guarantee of a bed at that point, either). Now, we have reduced our cath lab’s impact on the hospital, which along with improved bed management in general, has greatly improved our bed availability such that there is always a bed available to us when needed.
SDD is well established and proven to be a cost-effective and patient-centered practice, so it is increasingly becoming a standard practice for elective PCI around the world. In order to move SDD further, the greatest need is more research and consensus on the duration and intensity of observation needed after PCI. Recovery after PCI in the U.S. often occurs in a recovery room or critical-care type area with a relatively high nurse staffing ratio, reflecting the risk of post-surgical and anesthesia complications. Six or eight hours of observation in such an intensive area could potentially approach the cost of an overnight bed in a regular ward. One cost-saving option may be to move to a ‘radial-lounge’ type of model with a lower intensity of nursing observation, reflecting the low complication rate after transradial PCI.
Another is to shorten the duration of recovery. It is clear from multiple observational and randomized studies that SDD is safe and effective compared with overnight observation, but the randomized studies only tested a 4-6 hour observation period. As we reduce the TR Band compression device time to 2 hours or less, there may be an opportunity from a hemostasis perspective to discharge a patient as early as 2 hours after PCI. Is this as safe as a 4-hour period? Probably, but more data on the timing of complications would be reassuring.
Disclosure: Dr. Seto reports he is a consultant to Terumo Medical, research grants from Philips and ACIST Medical, and honoraria/speakers bureau from
Terumo, Boston Scientific, OpSens, and Janssen.
Dr. Seto can be contacted at firstname.lastname@example.org.
- Seto AH, Shroff A, Abu-Fadel M, et al. Length of stay following percutaneous coronary intervention: An expert consensus document update from SCAI. Catheter Cardiovasc Interv. 2018 Oct 1; 92(4): 717-731.
- Shroff AR, Gulati R, Drachman D, et al. SCAI expert consensus statement update on best practices for transradial angiography and intervention. Catheter Cardiovasc Interv. 2019 Dec 27.
- Hahalis GN, Leopoulou M, Tsigkas G, et al. Multicenter randomized evaluation of high versus standard heparin dose on incident radial arterial occlusion after transradial coronary angiography: the SPIRIT OF ARTEMIS study. JACC Cardiovasc Interv. 2018 Nov 26; 11(22): 2241-2250. doi: 10.1016/j.jcin.2018.08.009.
- Aminian A, Saito S, Takahashi A, et al. Comparison of a new slender 6 Fr sheath with a standard 5 Fr sheath for transradial coronary angiography and intervention: RAP and BEAT (Radial Artery Patency and Bleeding, Efficacy, Adverse evenT), a randomised multicentre trial. EuroIntervention. 2017 Aug 4; 13(5): e549-e556.
- Dangoisse V, Guédès A, Chenu P, et al. Usefulness of a gentle and short hemostasis using the transradial band device after transradial access for percutaneous coronary angiography and interventions to reduce the radial artery occlusion rate (from the prospective and randomized CRASOC I, II, and III studies). Am J Cardiol. 2017 Aug 1; 120(3): 374-379.
- Seto AH, Rollefson W, Patel MP, et al. Radial haemostasis is facilitated with a potassium ferrate haemostatic patch: the Statseal with TR Band assessment trial (STAT). EuroIntervention. 2018 Dec 7; 14(11): e1236-e1242.
- Rymer JA, O’Donnell CI, Plomondon ME, et al. Same-day discharge among patients undergoing elective PCI: Insights from the VA CART Program. Am Heart J. 2019 Dec; 218: 75-83.