When a Surgeon Doesn’t Want Surgery

Michael S. Lee and Kamran Shamsa

A colleague of mine referred me a delightful 89-year old retired general surgeon. He suffered an NSTEMI at an outside hospital and underwent cardiac catheterization, which revealed severe stenosis of the distal left main artery, mid left anterior descending artery, distal left circumflex artery, and a chronic total occlusion of the right coronary artery supplied by collateral circulation from the left system.  He was stabilized with medical therapy and was discharged so he could seek a second opinion at our institution.  I reviewed the coronary angiogram with the patient and his 3 sons and told them that CABG is the gold standard for the treatment of left main disease.  We also discussed the potential benefits of PCI, which include the lower risk of stroke and periprocedural death as well as less recovery time.  We reviewed the available data regarding stent thrombosis and restenosis, the requirement of dual antiplatelet therapy for at least one year given that the plan was to use a drug-eluting stent, the risk of bleeding from the vascular access complications, and the risk of contrast-induced nephropathy.  The patient contacted me the following day stating that he wanted to proceed with PCI, and had cancelled his planned appointment with the cardiac surgeon that week.   The referring cardiologist a few days later notified me that the cardiac surgeon that was scheduled to see the patient was upset that the patient, who he had never met, preferred a nonsurgical approach to revascularization. I assume that the cardiac surgeon was trying to look out for the best interest of the patient and edify my cardiology colleague. However, given that the volume of surgical revascularization continues to decrease and the data supporting the safety and efficacy of unprotected left main artery PCI accumulate, there will be an obvious reactionary push back by surgeons who now have to share their once-coveted territory.

In the very elderly, the value and preciousness of every day is particularly magnified.  The recovery time for an 89-year old with severe chronic kidney disease would likely have been prolonged had he undergone CABG, he would likely need to go to a nursing home facility to recover, and may require several more months before he would be able to resume full activities of daily living.

Ultimately, the patient underwent successful PCI with drug-eluting stents in the left anterior descending artery, left circumflex artery, and crush stenting of the distal left main bifurcation and was ambulating later that afternoon. He was kept an extra day for intravenous hydration to decrease the risk of contrast-induced nephropathy and was discharged home 2 days after his PCI. One week post procedure, the patient was seen in clinic.  Renal function had remained stable, and functional status much improved.

He was planning a golf outing the upcoming weekend.

Oyama J and Lee M. Unprotected Left Main PCI: Status Report 2013.  J INVASIVE CARDIOL 2013;25(9):478-482

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