Emergency coronary artery bypass surgery after failed percutaneous coronary intervention

The incidence of patients subjected to emergency coronary artery bypass graft (CABG) after percutaneous coronary intervention (PCI) is decreasing due to improvement of PCI technique and device technology. The aim of our study is to evaluate cases subjected to emergency CABG after complicated PCI to determine incidence, indications and results of surgery and to compare them with other emergency cases which are not related to angioplasty or stenting.

From April 1999 to December 2005, 1 200 patients who underwent PCI were analysed. Those patients who developed complications related to PCI and required surgical intervention were included (PCI group N.=31). These patients were compared with other emergency cases not related to PCI (non-PCI group N.=48). The selection of these patients was based on the criteria of the Society of Thoracic Surgeons.

The incidence of PCI complications which necessitated emergency surgical intervention was 2.6%. The main indication was due to unsatisfactory angioplasty with ongoing myocardial ischemia (68%), stent thrombosis (13%), dissection (10%) retained angioplasty wire (6.5%), and perforation (3%). The incidence of cardiogenic shock, ongoing ischemia, acute infarction <24 h and the use of intra-aortic balloon pumps were similar among both groups. But the incidence of preoperative cardiac arrest was more in PCI patients (41.9% vs 22.9%, P=0.07). The timing of surgical intervention after termination of PCI varied from immediate transfer to 12 h (mean 3.4+/-3) while, in the non-PCI patients, the time was from 5-24 h (mean 13.3+/-6). Completeness of revascularization was similar among both groups. However, the mean number of grafts per patient was more in non-PCI group (2.4+/-0.9 vs 2.0+/-0.8, P=0.25). In-hospital mortality was 12.9% among PCI patients in comparison to 10.4% in non-PCI group (P=0.73). The combined incidence of major postoperative morbidity was more among PCI patients. Nevertheless, the difference was not significant except for acute renal failure.

Emergency coronary artery bypass grafting among patients with PCI complications and those patients not related to PCI is associated with high mortality and morbidity. Although, the percentage of mortality and morbidity was more among PCI patients the difference between both groups was not significant. Surgical backup and collaboration between cardiologist and surgeons is needed to reduce delay in management and patients transfer to obtain the best surgical outcome.