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The High Tech Heart: Stents vs. Coronary Artery Bypass Operations

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In recent years, it's become common for many heart patients to receive stents during angioplasty procedures to prop open clogged arteries that lead to the heart than to have coronary artery bypass surgery, which is much more invasive and poses more initial risk. The number of bypass surgeries performed in the U.S. has decreased by a third in the past ten years, while the number of patients receiving stents has increased to nearly one million per year. The goal of both procedures is to help relieve the chest pain and shortness of breath caused by the buildup of plaque in the arteries. That buildup can eventually result in heart failure and heart attacks.

Stents are small mesh cylinders that surgeons place in arteries by threading extremely thin catheters up through the body via small incisions in the thigh. Patients are typically able to remain comfortable throughout the procedure, and they resume their normal activities quickly.

It's completely understandable for a patient to prefer stenting over bypass surgery. If you have a choice between having bypass surgery and having stents placed, you're going to choose the most comfortable procedure that will have the least impact on your ability to return to work and your daily routine.

Even though bypass surgery has become easier on patients in recent years, it still involves sawing through the breastbone in order to open the chest. But surgeons now are often able to make smaller incisions when they take blood vessels from the arms and legs to create the bypass around a blockage. And more and more, surgery can be performed using a robotic tool that allows surgeons to operate through small incisions between the ribs.

Recent research results—one more reason why stents not always appropriate

A very recent study surprised researchers by showing that for many patients, having stents placed may be no more effective than taking the proper medications. Participants in the study had severe artery blockages that were causing chest pain or shortness of breath, but that were not immediately life-threatening. The angioplasty and stents did provide temporary relief, but after five years, the patients who received stents and those who received medication had no significant difference in their symptoms.

It's important to note, however, that in emergency situations, when someone is having a heart attack, stenting is still the preferred choice.

The risk of stents: blood clots long after implantation

Research released in 2006 from clinical trials showed new evidence that patients who received drug-coated stents—the most common type, which reduces the likelihood that a blocked artery will close again—have a small risk that blood clots will form in the stents well after implantation.

This new evidence has confirmed for the experts that patients who have more than one blockage in two or more arteries should have coronary artery bypass surgery to treat their condition.

Trials underway to study stents vs. bypass

There are now two large clinical trials being conducted to compare bypass surgery and stents among patients who have more severe artery disease. In one trial, 1,500 patients are randomly assigned to have surgery or stenting. In another trial, stenting will be compared to bypass surgery for patients who have both diabetes and multiple blockages in their coronary arteries.

In the meantime, if your cardiologist determines that you have a buildup of plaque in your arteries, don't be surprised if you find out that surgery is the best option for you. For patients with more complex, more involved blockages, surgery really may be the best thing, even though having stents placed may seem more appealing.

If you have questions about your condition, be sure to ask your doctor until you're completely clear about what procedure you're going to have and why it's the right one for you.



Source:
The American Heart Association; The American College of Cardiology; The National Heart, Lung, and Blood Institute; the New York Time, "In the Stent Era, Heart Bypasses get a New Look," 25 February 2007; The New England Journal of Medicine, 12 April 2007



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