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KMID : 1234820170180020163
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Korean Society of Law and Medicine
2017 Volume.18 No. 2 p.163 ~ p.194
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Cardiac Intracoronary Stenting vs CABG: Prevention of Medical Accident
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Kim Kyoung-Reay
Park Kook-Yang
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Abstract
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Coronary artery disease will be more increased in Korea in 2017 as the country enters the aged society. It is well known that the incidence of coronary artery disease is related to aging, hypertension, diabetes, hyperlipedemia, and dietary habit. For effective treatment of significant coronary stenosis, close coordination between cardiac surgerical and cardiology team is essentail. Especially cardiologists' decision whether to go to stent placement or CABG is very important in the clinical field where the cardiologists usually start consultation of the patients choice for their treatment. Recently, non-surgical interventions(that is stent placement) in cardiology field have been dramatically increased as the national insurance system set no limitation of the number of stents deployed. However, accidents are often caused by inappropriate use of stents, especially in patients with triple coronary disease or left main disease. Heavy coronary calcifications can also be a problem and cause complications. Another aspect of stent placement is to cope with an emergency case in the event of coronary rupture or pericardial tamponade during coronary interventions without cardiac surgeons. In the past two years, the Korea Consumer Agency (Consumer Dispute Coordination Committee) analyzed eight cases of medical dispute settlement. Only two hospitals were manned with both cardiologists and cardiac surgeons. Seven patients died of procedures of stenting and five patients died on the day of the procedure. Among the 8 cases, 5 cases showed 3 vessel disease and the rest of the cases had either severe calcification, complete occlusion or poor coronary antomies for stenting.According to a 2017 national data registry of coronary stenting, less than 3 drug-eluting stents were implanted in 98% of all patients. In 2015, the number of stent procedures was 38,922, and approximately in 800 (2%) cases, more than four stents were used per patient. We emphasize that it is necessary to seriously consider the cost-benefit analysis between stent and CABG. It is the patient who has the right to choose the right procedure by asking the liability of 'instruction explanation obligation'. He should be well informed of the pros and cons of both procedures to avoid overuse of stent procedures. It can be solved by intimate discussion of individual cases with the cardiac surgeon and the patient. Unilateral dialogue with the patient, forceful restriction on the number of stenting, lack of surgeon's backup in difficult cases should all be avoided. It is also necessary to solve the problem not only at the hospital level, such as multidisciplinary integrated medical care, but also a nationwide solution such as expanding cardiac surgeons as essential personnel to public officials.
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KEYWORD
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Coronary artery disease, Percutaneous Coronary Interventions(PCI), Coronary Artery Bypass Graft(CABG), triple blood vessels and calcification vessel, instruction explanation obligation
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