WASHINGTON -- Since reimbursement has improved for coronary revascularization at ambulatory surgery centers (ASCs), outpatients going this route have been few but fairly well selected.

Medicare claims records showed a modest increase in the share of percutaneous coronary intervention (PCI) procedures done at freestanding ASCs from 2018 to 2022, rising from 0.01 to 0.87 per 10,000 Medicare beneficiaries.

Since CMS started reimbursing for PCI in ASCs in 2020, just 1.8% of outpatient PCIs nationwide took place in them up through 2022, according to Katerina Dangas, BMBCh, research fellow at Beth Israel Deaconess Medical Center in Boston, reporting here at the Society for Cardiovascular Angiography & Interventions opens in a new tab or window (SCAI) annual meeting.

Dangas noted that ASCs seemed to reach underserved populations, as patients getting PCI at these settings were more typically those in the South (66.1% vs 44.5% at hospital outpatient departments [HOPDs]) and those scoring in the most vulnerable quintile of the Social Vulnerability Index (36.6% vs 21.9%).

The ASC PCI cohort also underwent some degree of patient selection, as judged by their lower likelihood of an acute MI in the year preceding the procedure (2.7% vs 6.0%). Their procedures showed a lower use of atherectomy (2.4% vs 6.8%), intravascular ultrasound (IVUS) or fractional flow reserve guidance (12.8% vs 35.4%), and multivessel PCI (3.0% vs 5.9%).

A Regional, Low-Volume Niche?

ASCs thus met expectations that they would address the niche of straightforward PCI cases, considered appropriate for same-day discharge, in a setting lacking the advanced mechanical circulatory support and surgical backup available at HOPDs.

"Much thought has been directed to the question of how and when to do cardiac procedures safely in ASCs," commented James Blankenship, MD, of the University of New Mexico in Albuquerque, who cited SCAI's position statement opens in a new tab or window on coronary intervention in ASCs and an upcoming guidance paper on electrophysiology ablations at ASCs from the American College of Cardiology/Heart Rhythm Society.

Despite all the attention, he estimated that fewer than 1% of all PCIs (inpatient and outpatient) are being done in ASCs based on the present report.

"That low uptake presumably reflects several factors: hospital outpatient departments historically and currently dominate the market for outpatient coronary procedures and are certainly going to use their influence on physicians to maintain that dominance," Blankenship told MedPage Today .

"Most PCIs are done on patients admitted with unstable coronary syndromes, so cardiologists perform the majority of PCIs in-hospital, and generally will be most familiar with the hospital environment and with working there," he added. "Only a minority of patients have stable coronary disease and could be considered candidates for ASC procedures."

Finally, an ASC would need a relatively large number of PCI patients to justify the large costs of operating the facility, according to Blankenship.

During a press conference, SCAI past president David Cox, MD, of Brookwood Baptist Hospital in Birmingham, Alabama, highlighted the "intriguing" observation that ASCs appear to be a regional phenomenon.

Regulatory differences are an important factor to this, responded Dangas, who noted that the states with the most ASC PCIs were the ones without any state restrictions on them.

Notably, the repeat PCI data include both staged revascularization procedures and treatment failures. The finding of more repeat PCIs at ASCs "could reflect more conservative initial approaches, lower thresholds for repeat procedures, or potential quality issues," suggested Arasi Maran, MD, of Medical University of South Carolina in Charleston. She urged further investigation of this trend.

In any case, the lower hospital readmissions and lower acute MIs do suggest appropriate patient selection for ASCs, Maran said.

After all, the most controversial aspect of ASC PCI is the concept of complex, higher-risk PCIs moving to this setting opens in a new tab or window .

"Interventional cardiologists have become very proficient at estimating the risk of complications, and this data shows they are being appropriately cautious about performing high-risk procedures in ASCs," said Blankenship. "Also, cardiologists have become experts at troubleshooting procedural complications so most problems that arise can be safely handled with successful completion of the procedure."

Dangas acknowledged that her group's "reassuring" findings need to be validated in other datasets, as the Medicare claims data lacked important variables such as procedural medications, symptom severity, and medication adherence after PCI.

At face value, some improvement seems to have been made since 30-day bleeding rates opens in a new tab or window reportedly reached double-digits in people undergoing PCI at ASCs from 2007 to 2016.

"Physicians in ASCs know that they will be watched carefully which adds to their caution," according to Blankenship.

"I think this current study is reassuring that PCI in the ASC setting appears safe, however, it highlights potential areas for improvement in quality, such as increased utilization of coronary physiology and/or intravascular imaging," said William Fearon, MD, of Stanford University in California, who was not involved with the present study.

Dangas noted the study period preceded 2023, the year Medicare started reimbursing for IVUS at ASCs.

Another form of guidance to consider would be cardiac CT angiography (CCTA), according to Maran.

"CCTA can be a promising pre-procedure screening tool that could enhance ASC patient selection by providing detailed plaque characterization, predicting procedural complexity, and identifying patients who would benefit from hospital-based procedures due to calcification or complex anatomy. Implementing routine CCTA screening could potentially address the higher repeat PCI rates by ensuring only appropriate cases are directed to the ambulatory setting," she suggested.

Blankenship urged "extreme caution" against any indication creep for ASCs taking on higher-risk procedures like atherectomy and chronic total occlusion PCI. "It would be prudent for all ASCs to enter their data into the American College of Cardiology National Cardiovascular Data Registry Cardiovascular Ambulatory Surgical Center Registry and benchmark outcomes against peer institutions," he added.

"As this care model expands, developing ASC-specific quality metrics and standardized protocols for patient selection and post-procedure care will be essential to optimize outcomes while maintaining the cost and efficiency benefits of the ambulatory setting," Maran said.

Dangas, Blankenship, Cox, and Maran reported no disclosures.

Fearon disclosed research support from Abbott, CathWorks, and Medtronic; consulting with Shockwave and Edwards; and stock options with CathWorks.

Source Reference: opens in a new tab or window Dangas K, et al "Percutaneous coronary intervention in ambulatory surgery centers: a contemporary analysis of Medicare claims" SCAI 2025.