Dr. Bilazarian -- Thank you for your commentary on this important issue, especially in these days where "over-stenting" is in itself a news topic. I agree that much of the separation between the diagnostic cath and the PCI goes back to the earlier days of POBA, where there were no stents to bail out a collapsed or dissected artery, so proceeding with a revascularization was something that needed more preparation for all.

 I think all would agree that stents have made the procedure safer, making the medical issues around Ad-Hoc PCI less important. But, outside of the reimbursement issues, which are big ones, I also agree that it is not necessarily in the patient's best interests to separate the procedures because of the problems and complications inherent in vascular access and vascular closure devices -- although, as you obviously know from your practice, the radial approach DOES reduce bleeding complications, especially in anticoagulated patients.

I'd like to think that a conversation, such as the one you had with your engineer/patient, could take place PRIOR to the diagnostic cath, so that everyone, cardiologist, patient and family, are all on board with where things might go and are prepared for a stent. This would also help minimize the problems seen with implanting DES in patients who may be needing surgery in the near future, who cannot afford a year of DAPT or who may have metal allergies.

I don't think any patient unless they have an intstent retenosis or similar associated lesion should undergo an ad hoc intervention unless they have an ACS pattern of presentation or are having a STEMI for obvious reasons without physiologic assessment for same before the cath is performed. What ensues, is in many cases marginally  significant lesions are intervened upon and then the scenario of recurrent interventions with each subsequent admission with CP then ensues. This process has led to many interventions in these instances with numerous follow-up caths etc that would normally not be needed and in fact increase the cost of care and risk to the patient without any real benefit. AUC need to be adopted across the board with outcomes comparing the results of such a pattern of practice used to dictate how this very aggressive approach to evaluation and management versus a truly evidenced based approach to same to define what is best approach. The literature doesn't support as hoc intervention in this secanrio without the concept of proven ischemia. The general medical community needs to be educated better about this topic. Thanks DKraus--Memphis Tn.

I appreciate the comments by Dr Cohen - I do find it difficult to discuss every nuance of possible issues that might arise e.g.  multiple Type A lesions vs.more complex lesion morphlology, sidebranch issues etc until angiography is performed.  I tell patients that answereing all the "what ifs" is like asking the auto mechanic to desribe how much work is involved befre the hood is opened. 

I think this speaks to the power of angiography as a diagnostic tool compared to clincial assessment and stress testing.  It is not infrequent that patietns have significantly more (or less) CAD than we would predict prior to cath.

 The challenge of DES and BMS I find to be an easier discussion with patietns since the setting in which I might use a DES over BMS and the clincial circumstances (compliance/adherence, PBM drug coverage) can be asesed prior to the procedure and plainly discussed.

I appreciate Dr. Kraus's concerns - I think as cardiologist in dealing with our patients individually and as community of interventionalists we should be extremely concerned about implantation of a permanent device in our patients and be confident that the benefit is substantail and risk is acceptable, prior to proceeding.  My concern (and main reason for posting on this topic) is that the ad hoc PCI discussion seems to have grown out of a concern about inapproprite stenting that has occurred in some states and is currently in the news.  There may be some overlap but I think the ad hoc and inappropriate use issues are seperate. We certainly want to eliminate inappropriate stenting as a specialty for obvious health and economic reasons.  But I think eliminating ad hoc PCI essentailly penalizes patients (economically and with higher procedural risks) when the indications are appropriate.  The law (rule)  abiders will pay a price because of the excesses of some physicians.

Dr. Bilazarian,

Thank you for your thoughtful post and subsequent comments. I agree that, when done by a conscientious physician with appropriate indications, ad hoc PCI is appropriate and indeed desirable. I always spend time discussing issues regarding DAPT, risks and benefits of PCI and the DES vs BMS issue with patients prior to any elective procedure and find that, with very few exceptions, patients are very eager to have an ad hoc PCI and do not want to come back for a separate procedure. Time spent in such discussions beforehand is very valuable and establishes rapport with the patient which allows for any additional minor refinements to this plan to be made "on the table" after angiography is completed. I always avoid ad hoc PCI for complex problems and certainly when the risk in my judgment is more than "usual" unless for a STEMI. I also completely agree that the problem of inappropriate intervention is a separate issue from ad hoc PCI because most patients having ad hoc PCI should have clear symptoms or clear evidence of ischemia documented prior to the angiogram or have FFR or similar study done on the table after angiography but before the PCI.

Regards