Different Procedures for Different Problems
Learning that the cause of your chest pain is a blockage in the arteries of the heart can be frightening! But the good news is that there are treatments available. And depending on your unique circumstances, you might not need open-heart surgery and instead might be a candidate for a less invasive heart procedure.
Cardiologist Ana C. Iribarren, MD, from the Barbra Streisand Women’s Heart Center at Cedars-Sinai Smidt Heart Institute, explains the differences among different heart surgeries—they are not all the same.
Diagnosing blockages in the coronary arteries can begin with functional testing, such as a stress test (either a nuclear stress test or a stress echocardiogram), to evaluate how well blood flows through the heart and identify ischemia—a temporary lack of blood flow to the heart muscle during the stress portion of the test. Functional testing can be followed by anatomic testing to directly visualize the coronary arteries. Anatomic testing may be conducted noninvasively using a coronary CT angiogram (CCTA) or invasively with a left heart catheterization. These tests reveal not only the number of blocked arteries but also the degree of blockage. Treatment for a blockage in the coronary arteries typically is required when the blockage poses significant health risks or causes symptoms. The need for treatment depends on several factors, including high-risk findings such as severe blockages (70% or more narrowing), left main coronary artery disease, evidence of ischemia in a functional test and the symptoms caused by the blockage.
Treatment includes lifestyle modifications, medications (such as statins, beta-blockers, nitrates, aspirin or other therapies) and heart revascularization procedures. Treatment decisions are typically made by a cardiologist based on diagnostic findings, symptoms and the patient’s overall risk profile. But not all revascularization procedures are the same.
Coronary artery bypass grafting (CABG), commonly called bypass surgery, is an open-heart procedure that bypasses the blocked arteries. During CABG, the heart surgeon takes a healthy blood vessel, called a graft, from another part of the body (usually the chest, leg or arm). Common grafts include the internal mammary artery, saphenous vein or radial artery. The graft is connected to the coronary artery below the blockage, creating a new pathway for blood to flow and bypassing the obstruction. This new route restores proper blood supply to the heart muscle, alleviating symptoms like chest pain (angina), and reduces risk for heart attacks or other complications. The terms “double bypass surgery,” “triple bypass surgery,” “quadruple bypass surgery” and “quintuple bypass surgery” refer to the number of blocked arteries being rerouted during the surgery.
There are different types of CABG…
Surgery time and recovery: The more bypasses done during the surgery, the longer the operation will take—typically from four to five hours. The average hospital stay after open-heart surgery is four or five days, longer if any complications develop.
Following CABG, complications can occur, though advances in surgical techniques and postoperative care have reduced their frequency. Common complications include…
Also, the more complicated the procedure, the longer the recovery period. The initial recovery period—before you can go back to work—typically is about six to eight weeks but expect to have to wait six months before engaging in sports such as golf and tennis.
Advances in CABG have significantly improved patient outcomes, recovery times and overall safety. Minimally invasive techniques, such as robotic-assisted and mini-thoracotomy, allow surgeons to perform bypasses through smaller incisions between the ribs in the patient’s chest, reducing pain, scarring and recovery time.
Another important advance: Until recently, traditional bypass surgery included stopping the heart by clamping the aorta and using a mechanical pump to circulate blood through the body. That by itself increased the risk for complications. Off-pump coronary artery bypass (OPCAB) surgery, performed on a beating heart without the use of a heart-lung machine, minimizes complications such as bleeding, stroke and inflammation.
Enhanced grafting techniques, including the use of arterial grafts like the internal mammary artery, have improved long-term outcomes by reducing the risk for graft failure.
Additionally, improvements in perioperative care, such as better anesthesia protocols, infection-control measures and postoperative rehabilitation programs, have enhanced recovery and reduced complication rates.
Percutaneous coronary intervention (PCI), also called angioplasty with stenting, is a minimally invasive procedure to open a blocked artery as opposed to bypassing it. The surgeon feeds a catheter through a blood vessel in the groin or arm up to the blockage where a balloon is inflated to open the blocked artery and position a stent to keep it open.
Given the less invasive nature of PCI, it is preferred over CABG when coronary artery disease is less complex, such as in single-vessel disease, or in cases of acute coronary syndrome, older patients or patients at high surgical risk (for example, those with severe pulmonary disease).
The likelihood of restenosis (the renarrowing of an artery after treatment with PCI), stent thrombosis (a blood clot that forms in a stent and reblocks the coronary artery) and the subsequent need for CABG after PCI depends on several factors, including the type of stent used, the patient’s underlying health conditions and the complexity of the coronary artery disease.
Although rarely used today, bare-metal stents (BMS) carry a higher risk for restenosis compared to drug-eluting stents (DES). Complex lesions, diabetes, smoking, poor medication adherence and incomplete revascularization (residual blockages in other arteries after PCI) are all associated with a higher risk for restenosis/thrombosis or CABG need after PCI. CABG may also be required if restenosis or stent thrombosis leads to recurrent symptoms or if progressive coronary artery disease develops in other vessels. Studies suggest that 5% to 10% of patients who undergo PCI may eventually require CABG within five to 10 years, depending on the severity of the disease and other risk factors.
Surgery time and recovery: In planned angioplasty, many people can go home on the same day as their PCI. You might be advised to rest for a day and avoid driving for 48 hours. But you can often resume all your activities after that time, depending on how you’re feeling.
Advances: Advances in PCI have significantly enhanced its safety, efficacy and long-term outcomes. The development of drug-eluting devices has reduced restenosis rates compared to earlier bare metal devices by releasing medication that inhibits tissue growth around the stent. Biodegradable stents, which dissolve over time, also are being explored to further minimize long-term complications. Intravascular imaging technologies, such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), allow for precise stent placement. Additionally, improved antiplatelet therapies have reduced the risk for stent thrombosis and enhanced post-PCI outcomes. Advances in procedural techniques, such as rotational atherectomy and intravascular lithotripsy, allow for the successful treatment of complex, calcified lesions that were previously challenging to address.
We now have better tests to diagnose blockages in early stages and treat people before those blockages multiply. And because of advances in PCI itself, many people who would have needed bypass surgery 15 years ago now are candidates for the less-invasive stenting procedure.
But there are many factors that go into the decision, including the severity of the blockage(s) and the person’s overall health. Example: If you have heart disease that has deposited plaque in multiple coronary arteries, it’s not likely that every one of them can be addressed with a stent, so bypass may be recommended. If you’re in good enough condition to handle bypass surgery, it often offers a better prognosis than having numerous stents put in.
Also: There may be technical issues based on the location of the obstruction—such as in the left main coronary artery—that require a discussion to determine whether open-heart surgery is preferable to the use of a stent.
Advanced age and numerous chronic conditions may make open-heart surgery, which requires general anesthesia, too risky. Stenting could be a safer option, with stents placed where they’re most needed.
Important: Prevention is still key. Many people who need open-heart surgery today didn’t control risk factors for heart disease such as high blood pressure and high cholesterol and were likely living with high levels for 10 or 20 years. Managing risk factors now can prevent or slow the progression of coronary atherosclerosis and make it more likely that any future blockages could be addressed with stenting or another minimally invasive procedure.
