Stand-by versus stent-by during percutaneous transluminal coronary angioplasty

To evaluate the impact of a more liberal use of endoluminal stenting on the incidence of emergency coronary artery by-pass grafting, we analyzed our attitude toward abrupt or threatened closure after percutaneous transluminal coronary angioplasty from 1986 through 1993. In 3083 procedures performed, 204 (6.6%) patients had abrupt or threatened closure. The incidence of closure or threatened closure remained stable during the 8 years, ranging between 5% (1986) and 8% (1987) (p = 0.89). Endoluminal stent implantation was attempted in 92 patients and successfully achieved in 90 (98%), and emergency bypass grafting had to be performed in 41 patients. The proportion without adverse end point (death or myocardial infarction) was higher in the patients treated by endoluminal stenting than in patients treated with bypass grafting (71/90 (79%) patients vs 17/41 (40%) patients, respectively; p < 0.0001). The use of bailout stenting gradually increased from 0.4% (1986) to 5.6% (1993) of all procedures (p = 0.0001), whereas the incidence of emergency bypass grafting decreased from 2.7% (1986) to 0.7% (1993) (p = 0.04). Meanwhile, the incidence of myocardial infarction remained stable between 5.6% (1988) and 1.8% (1992) (p = 0.1), and death rates decreased from 1.4% (1988) to 0.2% (1993) (p = 0.05). It is concluded that "stent-by" is a highly effective therapeutic approach (79% in the present study) toward closure after coronary angioplasty and that, although surgical "stand-by" is certainly mandatory for selected cases, routine stand-by is questionable.