Editorial Comment

Flying Pigs and OtherPossibilities

David A. ClarkClinical Professor of Medicine,Stanford, California

It is widely accepted that the amount of radiation thatthe patient, physician, and laboratory personnel receiveeither on a case or monthly basis is important in assessingthe safety of everyone who participates in the procedure.The article by Bernardi utilizes fluoroscopy time andrelated parameters to develop a model to compare thedifficulty of interventional procedures. This article dem-onstrates that such a comparative quantification is possi-ble and can be done with reproducibility.

It is not surprising that the clinical characteristics ofpatients played no part in predicting the difficulty of theprocedure or the fluoroscopy time. Total procedural timeitself was not used and therefore the length of procedurein a markedly obese patient with a difficult-to-cannulatefemoral artery would not be apparent in this series ofpatients. It is likewise not surprising that the more diffi-cult or complex the lesion, as defined by the modifiedAmerican Heart Association/American College of Car-diology grading system classifications, the longer thefluoroscopy time. Experienced interventional cardiolo-gists know that all right coronary arteries are not createdequal in terms of interventional ease and that a stentplacement in the mid left anterior descending coronaryartery can be influenced by a number of anatomic factors.

The findings of this study, while interesting, are hardlystartling, but they are intriguing in terms of their potentialusefulness in a number of aspects of interventional car-diology. It is possible that the authors have developed avalid method to compare interventional cases that couldhave far reaching positive implications for the field ofinterventional procedures. Such as the following.

One, third-party payers. Might it be possible that insur-ance companies would recognize that there are differencesin procedures in spite of what they are called and actuallyreimburse for the procedure based on the time and difficultyinvolved rather than blanketing all single-vessel angioplas-ties as the same? It would be amazing if a third-party payercould include the CI (complexity index) to recognize that asingle lesion in a tortuous coronary artery that takes an hourto wire and place a stent should be reimbursed at a higher

level than a single lesion in a smooth C-shaped right coro-nary artery that requires a small fraction of that time for theentire procedure. It is also possible that someday pigs mayfly but perhaps a scoring system such as the CI will strike achord with a progressive insurance carrier at some time inthe future.

Two, hospital credentialling. In reviewing an individualpractitioner’s ability in the interventional laboratory, hospi-tal credentials committees have a difficult time assessingtechnical capabilities. Concepts in this article could give thecatheterization laboratory committee and credentials com-mittee numerical parameters to ascertain that the skills ofpractitioners in the laboratory are appropriate. By a reversalof the process developed by Bernardi, the predicted CI ofcases could be established and acceptable fluoroscopy timespredicted. The actual results could then be compared to thepredicted acceptable times. If these goals are not consis-tently achieved by a practitioner, proctorship could be in-stituted to be certain that patients are being treated withappropriate skill.

Three, low-volume operators. The Society for CardiacAngiography and Interventions and the American Collegeof Cardiology continue to wrestle with the concept of thelow-volume operator in interventional procedures andwhether patients treated by low-volume operators receivesafe and appropriate care. One way to handle this situationmight be to restrict low-volume operators (less than 75cases/year) to the performance of procedures with a CI with twoor less. This type of restriction has been discussed as havingmerit but difficult to quantify. The precepts in this articlemay give the basis of a potential quantification scheme thatcould prove valuable in solving this conundrum.

Four, interventional programs in hospital without operat-ing room backup. Another thorny issue that is before thevarious societies and colleges as well as state licensingboards is whether or not it is safe to perform angioplastiesin hospitals without operating room backup. With properalliances with medical centers that have full cardiovascularprograms in place, perhaps procedures with a low CI couldbe safely performed in such an institution, targeting the highCI procedures to the hospital with surgical backup.

The possibilities are numerous, and the advantagesmany, to be able to quantify the difficulty of a proposedinterventional procedure. This article demonstrates anexample of how this can be done with reproducibility. Itprovides another parameter that, combined with accepteddefinitions of complexity, could be a very valuable toolin many aspects of interventional practice.

Catheterization and Cardiovascular Interventions 51:10 (2000)

© 2000 Wiley-Liss, Inc.