Same-day discharge (SDD) has been shown to be as safe as routine overnight stay following percutaneous coronary intervention (PCI) in selected patients with chronic coronary syndromes or low-risk acute coronary syndromes. , SDD was associated with lower hospital costs and given the safety profile, patient comfort and cost effectiveness, the broader use of SDD may increase the overall value of PCI care. Although the rates of SDD vary widely across the hospitals, the proportion of patients with SDD after PCI increased continuously over the last 2 decades. Chronic total occlusions (CTO) are a common finding in patients undergoing coronary angiography. Registries of contemporary patients undergoing coronary angiography showed that between 15% and 20% of patients had at least one CTO. Although, the success rate of CTO PCI exceeds 80% to 90% in the hands of expert operators and specialized centers, current ACC/AHA/SCAI guidelines for coronary artery revascularization gave PCI a weak recommendation (class IIb, level of evidence B) for the treatment of CTO in patients with refractory angina on medical therapy after treatment of non-CTO lesions. CTO PCI carries a higher risk of complications compared with non-CTO PCI. A number of consensus documents have standardized indications, technical aspects, procedural success and outcome definitions of CTO PCI. ,,, Several studies have assessed the feasibility, safety or outcomes of SDD versus overnight stay in patients undergoing CTO PCI. ,,,, Current practice of CTO PCI reflects considerable technical progress in techniques and devices, which expands the use of this treatment strategy to patients with an ever-increasing degree of complexity. In the light of these practice-changing developments, a reassessment of safety (and outcomes) of SDD after CTO PCI in contemporary patients is required.
In a recent issue of American Journal of Cardiology , Kumar et al assessed the SDD strategy in terms of feasibility, safety and correlates of 30-day outcomes by performing a retrospective analysis of 1,273 patients undergoing CTO PCI in a single center between 2019 and 2023. The primary endpoints were major adverse cardiac and cerebrovascular events (MACCE)–a composite of all-cause death, myocardial infarction, stroke or target vessel revascularization–or rehospitalization at 30 days. Overall, 352 patients (27.6%) underwent SDD. Patients with SDD were of younger age and had a lower comorbidity burden, better renal function and left ventricular systolic function than patients with overnight stay. First arterial access site was femoral less often in patients with SDD and these patients had shorter procedure duration and fluoroscopy times, shorter stenting length, more frequent use of intravascular imaging and higher procedural success. The 30-day rate of MACCE/rehospitalizations was lower in patients with SDD (4.3% vs 7.7%), which was mostly driven by rates of rehospitalization (3.1% vs 6.0%) with no significant difference in the rates of MACCE (1.1% vs 2.0%). The body mass index, Charlson comorbidity index and antegrade dissection/re-entry use, but not SDD, correlated independently with the 30-day risk of MACCE/rehospitalization. Recursive partitioning analysis identified a lower comorbidity burden, preserved renal function and distance to the PCI center (≤17.4 miles) as correlates of lower risk for adverse outcomes in patients with SDD. The authors concluded that SDD after CTO PCI is feasible and safe in the low-risk contemporary patients who achieved procedural success.
The study by Kumar et al has notable strengths. The study included contemporary patients who were well characterized in terms of baseline cardiovascular risk, CTO lesions, techniques used for recanalization of CTOs and technical/procedural success. Over the years, considerable progress has been made in techniques and devices used to treat CTOs. The advances in technology and increased operators’ experience have improved the success rates of CTO PCI, yet they have also led to a higher incidence of periprocedural/in-hospital complications, likely due the use of PCI in higher-risk patients and more complex CTO lesions. In fact, the use of antegrade dissection/re-entry, an aggressive recanalization strategy, correlated independently with the higher risk of 30-day adverse outcomes. The study by Kumar et al is reassuring in that it showed that SDD could be safely applied in contemporary patients with current-day CTO PCI technology and lesion complexity. The technical (88%) and procedural (84%) success were within the range of outstanding results achieved by experienced operators and specialized CTO centers. The use of intravascular imaging to guide CTO PCI in slightly more than 80% of patients reflects the best practice in using this technology to guide complex PCI, as are CTO PCI procedures. The intravascular imaging guidance could be highly indicated during CTO PCI due to complexity of CTO lesions (often with various degrees of calcification) which could secure a better stent apposition, fewer complications and better subsequent outcomes. Finally, the recursive portioning analysis, a statistical approach that allows an outcome assessment in progressively more homogeneous groups, offers novel findings in terms of identification of patients with SDD with higher odds of better outcomes. This analysis identified the distance to the PCI center (≤17.4 miles) as a correlate of lower risk of adverse outcomes among patients with SDD. Although the risk after PCI is highest within the first 6 hours after the procedure and the risk is markedly reduced from this time point to 24 hours, periprocedural risk may last longer after CTO PCI due to complexity of intervention, underlying the need for this precautionary measure.
As the authors do well to emphasize the study has a number of limitations. The most important limitation is the retrospective observational study design. The significant differences in the baseline risk and comorbidities between patients with SDD or overnight stay may have impacted the decision to leave the hospital and clinical outcomes to a degree comparable to that of the technical/procedural success. As shown by multivariable analysis, comorbidity burden, but not SDD per se, was associated with the 30-day outcomes. Nevertheless, confounding inserted by this design weakness is shared with almost all prior studies. The differences in the 30-day outcomes between patients with SDD or overnight stay were almost entirely driven by a higher rate of rehospitalizations in patients with overnight stay. Thus, it could have been of particular interest to dissect the cause(s) of rehospitalizations to understand whether they were late complications of CTO PCI or had another origin. Notably, this information was not provided. When outlining the rationale for the study, the authors correctly emphasized a number of limitations of the prior studies. However, the current study did not have a more advanced design and the main findings appear to differ little from the findings of prior studies. In this regard, the main study findings are mostly confirmatory rather than novel. The finding that the distance to a PCI center could influence the decision to SDD after CTO PCI is a novel contribution; however, it remains poorly defined in the setting of current study and needs further dedicated assessment. Finally, the cost effectiveness of CTO PCI with SDD versus overnight stay in contemporary patients was not addressed. This could have been desirable considering that hospital costs for CTO PCI are on the rise.
Overall, the study by Kumar et al and almost all previous studies ,,,, showed that baseline cardiovascular risk/comorbidities and procedural success underlay the decision to SDD after CTO PCI. This clinical judgement proved correct in that the SDD was at least as safe as overnight stay after CTO PCI. However, the significant differences in the cardiovascular risk and the likelihood of residual (unaccounted for) confounding affecting differently the outcomes of patients with SDD or overnight stay after adjustment in multivariable models emphasize the need to assess the safety and efficacy of SDD after CTO PCI on a randomized basis. In some studies, a SDD strategy was pursued in all patients undergoing CTO PCI and SDD was defined as the primary end point even after using large bore vascular access, known to predispose for vascular complications. In addition, in almost all previous studies, a small portion of patients without procedural success or with procedure related complications underwent SDD. The SDD strategy has been assessed on a randomized basis after PCI in patients with chronic coronary syndromes or low-risk acute coronary syndromes. Thus, current evidence appears to support undertaking a randomized multicenter study to assess safety and efficacy of SDD after CTO PCI, at least in patients at a low-to-intermediate risk and with procedural success, without major ethical concerns, particularly if radial artery is used for vascular access.
CRediT authorship contribution statement
Gjin Ndrepepa: Conceptualization, Writing– original draft, Writing– review & editing.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Funding: None
References
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