Bypass Surgery is More Effective than Stent for Coronary Artery Blockage/ Chronic Unstable Angina
The arteries that bring blood to the heart muscle (coronary arteries) can become clogged by plaque (a buildup of fat, cholesterol and other substances). Disease develops when a combination of fatty material, calcium, and scar tissue (plaque) builds up in the arteries that supply the heart with blood. Through these arteries, called the coronary arteries, the heart muscle (myocardium) gets the oxygen and other nutrients it needs to pump blood.
This can slow or stop blood flow through the heart's blood vessels, leading to chest pain or a heart attack. Increasing blood flow to the heart muscle can relieve chest pain and reduce the risk of heart attack.If plaque completely blocks blood flow, it may cause a heart attack (myocardial infarction) or a fatal rhythm disturbance (sudden cardiac arrest).
Although both angioplasty and bypass surgery can improve blood flow to patients’ hearts, the principal limitation of angioplasty is a ‘reclogging’ or ‘restenosis’ after the procedure. The main limitation of bypass surgery is the invasiveness and recovery time after the operation.
Coronary bypass surgery is a common procedure used to divert blood around blocked arteries in the heart. Coronary bypass surgery remains one of the gold standard surgical treatments for coronary artery disease.Coronary bypass surgery uses a healthy blood vessel harvested from your leg, arm, chest or abdomen and connects it to the other arteries in your heart so that blood is bypassed around the diseased or blocked area.
In some patients, alternative treatment of coronary artery disease includes medical therapy with specific medication or non-surgical treatment such as balloon angioplasty, laser angioplasty, stents or atherectomy (plaque removal). Your physician (cardiologist) will help decide which treatment is best for you.
Angioplasty is a procedure in which your health care provider inserts a balloon catheter into a blocked artery to unblock the artery. The blocked artery may be an artery in your arm, leg, or neck. If the blocked artery is a blood vessel that supplies blood to the heart, the procedure is called coronary angioplasty, or percutaneous transluminal coronary angioplasty (PTCA).
The recent recognition that coronary-artery stenting has improved the short- and long-term outcomes of patients treated with angioplasty has made it necessary to reevaluate the relative benefits of bypass surgery and percutaneous interventions in patients with multivessel disease. Stenting (the implantation of a stent) for the treatment of coronary artery disease is a common procedure. A stent is a tiny metal or plastic tube. A stent is placed into an artery, blood vessel, or other duct (such as one that carries urine) to hold the structure open.
One year after the procedure, coronary stenting for multivessel disease is less expensive than bypass surgery and offers the same degree of protection against death, stroke, and myocardial infarction. However, stenting is associated with a greater need for repeated revascularization.
Bypass surgery is better than stent-assisted angioplasty at relieving chest pain and improving quality of life in the year after the procedure, reported the researchers from Journal of the American Heart Association .They said further “If patients want to know which one will make them feel better, the answer is coronary artery bypass surgery.”
Minimally invasive heart bypass surgery results in longer and better quality of life than the use of artery-opening stents for patients who have a single blocked coronary artery, according to the results of three British studies.
Two of the studies found that the minimally invasive bypass procedure was more cost-effective than stenting, and the third found that minimally invasive heart bypass surgery resulted in fewer complications than stenting.
"In this day and age, many patients, when they see a cardiologist, are told, or it is implied, that the same result can be achieved through a stent as it can with surgery, and that's not the case," said Dr. David Taggart, a professor of cardiovascular surgery at the University of Oxford and author of an accompanying editorial of the British Medical Journal.
Stents are tiny mesh tubes placed into arteries to increase blood flow. But, according to Taggart, many patients don't understand that within a few years after stenting, they have a sevenfold higher risk of needing new treatment compared with patients who had a bypass. "Even more important, they are at a higher risk of dying than if they had a bypass operation," he said.
In two of the studies, a team led by Dr. Thanos Athanasiou from the department of biosurgery and surgical technology, Imperial College London and St. Mary's Hospital, London, reviewed published studies that compared minimally invasive bypass surgery with stenting.
In one report, they found that a procedure called "minimally invasive left internal thoracic artery bypass" may be a more cost-effective medium- and long-term alternative to coronary artery stenting. In the other study, they concluded that this surgery "resulted in fewer complications in the mid-term" compared with stenting.
In the third study, Dr. Harry Hemingway, a professor of clinical epidemiology in the department of epidemiology and public health at University College London Medical School, and colleagues studied randomly selected patients who underwent either cardiac procedure.
Hemingway's team found that coronary bypass surgery was cost-effective, but stenting wasn't. In fact, they concluded that, "cost-effectiveness analysis based on observational data suggests that the clinical benefit of percutaneous coronary intervention [angioplasty plus stenting] may not be sufficient to justify its cost."
Taggart noted that despite these reports, choosing which procedure is best needs to be determined on a patient-by-patient basis.
"Patients with this type of complex disease should be treated by a multidisciplinary team, including a cardiac surgeon, rather than just a cardiologist," Taggart said. "If you are not treated by a team, you will not always be given the appropriate information to choose which treatment is best for you," he said.
Taggart believes that patients often opt for stents, because they fear the bypass operation. "If someone said to you, 'You can either have your chest cracked open or I can fix you with a couple of little stents,' the vast majority of patients would say, 'Of course, I don't want my chest cracked open.' "
One expert said there are risks and drawbacks with each procedure.
"There is no surprise here," said Dr. William Maisel, a cardiologist at Beth Israel Deaconess Medical Center, Boston. "It's been known for a long time that bypass surgery, for people with significant coronary blockage, is more likely to offer long-term symptom relief and, because of the likelihood that you won't need further treatment for many years, it is more cost-effective in the long run."
But risks on the operating table remain higher with bypass, he stressed. "What these reports gloss over is that your chance of dying [during surgery] is twice as high with bypass surgery than it is with stenting," Maisel said.
The reality is that bypass and stenting are both viable treatment options for patients, Maisel said. "If you survive your surgery, you are probably better off with a bypass," he said. "But many patients are scared by the up-front mortality. But, both procedures remain reasonable," he said.
Coronary bypass surgery doesn't cure the underlying disease process called atherosclerosis or coronary artery disease. Even if you have bypass surgery, lifestyle changes are still necessary and an integral part of treatment after surgery. Lifestyle changes — especially smoking cessation — are crucial to reduce the chance of future blockages and heart attacks, even after successful bypass surgery.