Unclogging arteries an outpatient procedure

Reluctance

Doctors have been reluctant to adopt the outpatient method but "this is the kind of study that’s going to turn the trend,” said Dr. Timothy Gardner, a Delaware cardiologist who heads the meeting committee but had no role in the research.

"Insurers are getting cranky” about hospital costs and will be enthused about ways to cut them, he said.

Patients, however, might not like being rushed out the door. Some may view it as the cardiac equivalent of "drive-through deliveries,” where new moms are sent home the day they give birth.

Angioplasty is one of the most common medical techniques in the world. About 600,000 are done each year in the United States alone.

Through an artery in the leg near the groin, doctors snake a tube to blockages that are clogging vessels and preventing them from supplying enough blood to the heart. A tiny balloon is inflated to flatten the crud, and a mesh scaffold called a stent is left behind to prop the artery open.

Two kinds of complications can occur: bleeding from the leg incision and reclogging of the heart artery.

To avoid the first type, Canadian researchers led by Dr. Olivier Bertrand of Laval Hospital Research Center in Quebec did angioplasty a different way — using an artery in the arm near the wrist instead of one in the leg — which greatly reduces bleeding.

Next, they tested the need to keep patients overnight by giving half of those in the study a single dose of anti-clotting medication and sending them home 4 to 6 hours afterward. The other half got standard treatment: the single dose plus a 12-hour intravenous one given overnight in the hospital.

Six months later, the rates of major bleeding, heart attacks or need for repeat procedures to treat blockages were nearly identical in the two groups: 30 among the 504 patients given the single drug dose versus 28 in the other 501.

The combination of arm angioplasty and single-dose drug treatment "is extremely safe,” Bertrand said.

The study was funded by Eli Lilly and Co., Bristol-Myers Squibb and Sanofi-Aventis, makers of ReoPro, the anti-clotting drug used in the experiment. Bertrand said he had no financial ties to the companies.

Outpatient angioplasty is common in France, Japan, Canada, Germany, much of South America and Australia, and is growing in popularity around the United States.

Dr. Elizabeth Nabel, director of the National Heart, Lung and Blood Institute, thinks it’s a good trend for people with simple, routine blockages who are having the procedure in non-emergency situations.

"It helps reduce costs of unnecessary hospitalization,” she said. Lowering hospital costs can offset the expense of drug-coated stents that in recent years became the standard of care because they cut the chances that an artery will reclog. That risk is now less than 0.1 percent, she said.

However, many doctors remain leery of outpatient angioplasty.

"My view is that we’re not ready for that,” said Dr. Eric Topol, a cardiologist at the Cleveland Clinic.

The arm approach holds promise, but doctors trained to use the leg artery may be reluctant to learn it, he said.

The Society of Interventional Radiology’s guidelines note that studies so far have found no greater rate of complications, but the group still recommends angioplasty patients be kept overnight.

In a related development, the heart association, the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions released new guidelines saying angioplasty should never be done in medical facilities lacking the capability to do cardiac surgery should it become necessary.

A growing number of free-standing medical facilities offer the artery-clearing procedure without surgical backup.

The guidelines also set a goal of having the artery cleared within 90 minutes of the patient’s arrival at the hospital.

Also at the conference, Dr. Volker Schachinger and colleagues from Goethe University in Frankfurt, Germany, reported encouraging results from the first large, rigorous test of giving patients injections of stem cells from their bone marrow to try to repair damage caused by a heart attack.

Improvement

In the study of 200 people, those who received the marrow cells had about a 6 percent improvement in heart pumping capacity four months later versus a 3 percent improvement for those given a dummy treatment.

However, specialists cautioned that there was no way to tell whether the marrow cells or something else had caused this improvement, or whether it would last.<