Should You Have a Stent or a Bypass Operation?

Overview

By Steve W. Guyton, MD, MHA, FACS

Article

You’ve had a coronary angiogram that shows you have coronary artery disease (blockages or narrowing in the blood vessels that feed your heart muscle). Should you have a stent or a bypass operation? Well, it depends.

If your coronary artery disease is not severe, and you have symptoms that can be controlled with medications, then you may be able to manage your coronary artery disease through lifestyle changes and without a stent or bypass. Your doctor can help you decide if you need a procedure. In any case, if you’re a smoker, you should quit smoking. You also should be on maximal medical therapy with aspirin, a cholesterol-lowering drug, and a beta-blocker, as well as any drugs needed to control high blood pressure or diabetes.

In recent years, stenting of coronary arteries has increased dramatically. Stenting is a form of percutaneous coronary intervention (PCI), not heart surgery. PCI is a nonsurgical procedure that uses a thin, flexible catheter placed through your skin into an artery in the groin or arm. A balloon on the end of the catheter is positioned in the narrowed coronary artery and inflated to open up the blockage in your artery. A stent is a metal mesh tube (like microscopic chicken wire) which is left behind to help keep your artery from collapsing. Drugs attached to the stent help prevent your body from reacting to the stent and shutting down the artery again. The greatest risks of PCI relate to problems within the coronary artery itself, which can lead to blockage and a heart attack or, in rare cases, death. Also, kidney problems can result if a large amount of x-ray dye is needed during the procedure.     

Stenting is done without having to open your chest with an incision, so recovery afterward is generally quick. It does require being on a type of blood-thinning medication called antiplatelet drugs, usually for a year after the procedure. Stenting is usually done on patients with less severe coronary artery disease than patients treated with coronary bypass operations. Coronary bypass operations have been shown to give better long-term results if you have more severe coronary blockages. Needing repeat procedures for coronary blockages is more common after PCI than after coronary bypass operations.

A scoring system has been developed to help determine if PCI is appropriate therapy for your coronary artery disease. If the “SYNTAX Score” is low, then this generally indicates that PCI is appropriate. A bypass operation is more appropriate if the score is high, indicating more severe disease. For intermediate scores, careful consideration by a “Heart Team,” consisting of both cardiologists and cardiac surgeons, is appropriate to determine the best treatment. 

Coronary artery bypass grafting (CABG, often pronounced “cabbage”) is the most commonly performed heart operation; though PCI is now being done more often than CABG. An artery or vein from another area of your body is used to take blood around the diseased portion of the coronary artery and provide more normal blood flow to your heart (that’s why it is called a “bypass” operation). The operation was originally developed to treat angina, or chest pain. Studies over the years have shown that there are situations in which CABG actually helps you live longer (also with less angina). CABG is generally used to treat more severe degrees of coronary artery disease, having a better track record of good results in these patients than does PCI. This is particularly true in patients with diabetes or with significant prior heart attacks.

CABG usually requires opening the chest through the middle of the breastbone (called a “median sternotomy”), so recovery takes longer after CABG than after PCI. In my experience, after surgery, patients are usually in intensive care 1 night, up walking the day after, and home 3 to 5 days later. Full activity should wait until your breastbone heals, 6 to 8 weeks post-op. 

A heart-lung machine allows the surgeon to stop your heart to attach bypass grafts to your coronary arteries. The surgery can also be done “off-pump” without the use of the heart-lung machine, holding the coronary artery still while sewing the graft to it. Off-pump CABG was developed to decrease the chances of complications after surgery, including bleeding, strokes, lung problems, and kidney problems.  

CABG has been proven to be safe and effective overall, but like all procedures, it can result in serious complications. The risks increase with age and with conditions such as a prior stroke, heart attack, kidney disease, lung problems, or conditions that weaken the body or affect your ability to recover. The overall death rate after CABG is less than 3% , and there is a small but real risk of stroke, heart attack, bleeding, kidney failure, pneumonia, and wound infection. Some patients require blood transfusions during or after their operations.

The Society of Thoracic Surgeons Risk Calculator, available online, can help determine your approximate risk of death or other complications from heart surgery. The results can help you and your doctor when discussing what’s best for you. 

Both CABG and PCI must be accompanied by maximal medical treatment to prevent disease progression and provide greater long-term success. A Heart Team approach, reviewing all patients requiring procedures for coronary disease, can help ensure that patients get the best available treatment.

 

The opinions expressed in this article are those of the author and do not necessarily reflect the views of The Society of Thoracic Surgeons.