A tough call for doctors, patients
When 68-year-old Mike Gavin began to develop chest pain last December, he wasted little time before seeing his doctor. A coronary angiogram revealed that several of the arteries supplying blood to his heart were partially blocked. The doctors with whom Gavin consulted agreed that something had to be done quickly to restore healthy blood flow. They disagreed, however, on how that should be accomplished.
Two cardiologists recommended a bypass. In that surgery, healthy blood vessels from the leg, chest or arm are transplanted to the heart to detour blood around the blocked portions of the coronary arteries.
The treatment requires that the chest be opened and -- in most cases -- that the heart be temporarily stopped. (A heart-lung machine is used to oxygenate the blood and circulate it throughout the body during the procedure.) The risk of complications, including strokes, is relatively high. Patients typically spend about four days in the hospital and may not fully recuperate for weeks or months.
A third cardiologist, however, thought surgery could be avoided. “He suggested he could do it with angioplasty and a stent,” recalls Gavin, who lives in Encino.
In this approach, a balloon-tipped catheter is inserted into a large blood vessel in the arm or leg and gently guided toward the heart, where it can be threaded into a coronary artery. Once in place, the balloon is inflated, stretching the artery from the inside. The plaque that is causing the blockage is compressed to create a wider passage for the blood. To reduce the likelihood that the vessel will close up again, a wire mesh tube, or stent, is then placed inside the vessel.
Angioplasty is less invasive than bypass surgery, complications are less common, and recovery is much quicker. Many people leave the hospital the day after they have the procedure and are able to resume normal activities -- including work -- within several days.
Both angioplasty and bypass surgery are currently in wide use for the treatment of coronary artery disease, and deciding which procedure is more appropriate can be challenging for patients and physicians alike.
Although bypass surgery is clearly riskier than angioplasty, it appears to offer some long-term advantages. In people with extensive coronary disease, surgery does a more complete job of restoring blood flow to the heart. Reclogging of the vessels, or restenosis, is also less likely after bypass surgery than angioplasty.
Last year the American College of Cardiology and the American Heart Assn. concluded that for people with disease involving only one artery, angioplasty probably offers some advantage; for those with multivessel disease, there appears to be no difference in survival between the techniques.
But a study published in May in the New England Journal of Medicine contradicted part of this conclusion. Researchers compared the outcomes of more than 37,000 patients with multivessel coronary disease who underwent bypass surgery with those of more than 22,000 patients who received stents. Contrary to what other studies had shown, they found that, for patients with two or more diseased coronary arteries, surgery resulted in significantly better long-term survival.
“The study can’t be disregarded,” said Gerald Pohost, chief of cardiovascular medicine at USC’s Keck School of Medicine. But he believes the results must be interpreted cautiously; he points out that the study is already outdated owing to recent advances in stent technology.
In 2003, the Food and Drug Administration approved drug-eluting stents; these stents release a medication that helps reduce scar formation during the healing process and helps prevent the vessels from closing up again. “Restenosis rates have dropped from about 20% to about 5%,” says Jonathan Tobis, a cardiologist at UCLA’s David Geffen School of Medicine.
Although there are still no definitive answers for many patients, cardiac specialists typically agree on general guidelines. “People who have less severe disease should have angioplasty,” says Tobis. This includes individuals with disease affecting only one or two vessels, provided the areas of narrowing are easy to get to with angioplasty.
Bypass surgery is generally more appropriate for people with extensive disease. “If it’s more than two vessels, I think surgery is the way to go,” says Pohost. It may also be a better choice for people with diabetes, since they experience higher rates of restenosis with stents.
Gavin ultimately opted for angioplasty. “I knew that a bypass would incapacitate me,” he says. And as primary caregiver to his wife, Paula, who is seriously ill, he felt he could not afford that. “I could take off a day or two, but not a month or two.”
It’s been six months since he had the procedure, and he’s comfortable with his decision. “Everything looks good,” he says. “I haven’t had any chest pain since.”
