Angioplasty vs Coronary Artery Bypass: Choose Wisely

Angioplasty vs Coronary Artery Bypass: Choose Wisely

Data released from an important European-American study may change the face of severe heart disease treatment; or maybe it is better described as 'turning back the clock' to a time when Coronary Artery Bypass Grafts (CABG), were the first treatment for blocked arteries.

During the CABG procedure, a blood vessel is transplanted from elsewhere in the body, most often the chest or the leg, and is used to bypass the blocked area, providing a new channel for blood to flow to the heart.

Brief angioplasty history:

First performed in 1977, popularity of this procedure has grown over the years and  cardiologists are choosing more often to use balloon angioplasty, wherein  a catheter is threaded through a blood vessel in the groin to reach the arterial blockage and a balloon is inflated at the site to compress the plaque.

in 1994 the first stent was approved by the FDA driven by the need to improve the effiacy of Plain Old Balloon Angioplasty (POBA) procedures in effort to eliminate the two main problems with angioplasty, elastic recoil and neointimal hyperplasia. 

Elastic recoil occured in 5-10% of patients within the first few hours, or even minutes, of surgery leading to severe complications such as myocardial infarction and the need for emergency CABG.

Neointimal hyperplasia is the immune system's reaction to the intrusion of angioplasty which causes damage on the endothelial barrier at the site of balloon inflation exposing the extracellular matrix.  In short, the tissue becomes thickened and scarred, redeveloping arterial blockage, obstructing blood flow, leading to restenosis.

Within 3-6 months of POBA, 40-50% of patients experienced restenosis which was most commonly treated with a repeat of the procedure. 

Physicians began inserting bare-metal vascular stents without coating (as used in drug-eluting stents); spring-like devices that hold the artery open.

Several trials in the 1990s showed the superiority of stent placement over balloon angioplasty. Restenosis was reduced because the stent acted as a scaffold to hold open the dilated segment of artery; acute closure of the coronary artery (and the requirement for emergency CABG) was reduced, because the stent repaired dissections of the arterial wall. By 1999, stents were used in 84% of percutaneous coronary interventions (i.e., those done via a catheter, and not by open-chest surgery).

Approved by the Food and Drug Administration (FDA) in 2004, paclitaxel-eluding stents, metal stents which release a drug designed to limit the growth of neointimal scar tissue reducing the risk of restenosis, became the treatment of choice for arterial blockage.

The much less invasive angioplasty procedure and placement of stents, shorter hospitalization time and quicker recovery time have catapulted angiography stent placement to the forefront of preferred heart disease treatment.  According to the National Center for Health Statistics (NCHS), more than 1.3 million Americans undergo angioplasty every year.

New Study and Results:

The most recent study reported at a Geneva meeting of the European Association for Cardio-Thoracic Surgery, called Synergy between Percutaneous Coronary Intervention with Tzxus and Cardiac Surgery (SYNTAX), enlisted 1,800 patients at 85 centers in Europe and the United States  in the largest trial ever comparing stenting and CABG directly.

Data revealed that three years after the procedure, patients receiving stents were 28% more likely to suffere a major heart event such as heart attack or stroke, and 46% more likely to require a repeat procedure due to restenosis and 22% more likely to die.

For purposes of the study, mild heart disease was described as a single blocked artery; moderate or severe heart disease if a blockage was located in the left main artery and blockage in one of the other three arteries, or blockages in all three other arteries.  The presence of totally blocked arteries, very long blockages within the artery or "very tortuous, curvy ateries" that make angioplasty difficult. 

Mild heart disease patients can often be treated successfully with medical therapy alone; CABG and angioplasty revealed equivalent results, suggesting angioplasty to be the more preferred procedure because it is easier on the patient.

However, patients with moderate or severe heart disease, accounting for about 50% of all angioplasty patients, revealed much higher risk for stroke, heart attack, additional angioplasty, CABG or even death.

Medical Professional Comments:

Co-author of the report, Michael J. Mack, MD, Medical Director Cardiovascular Services, Director of Transplatation, Medical City Dallas Hospital believes the current practice of performing angioplasty when blockages are discovered because  the patient is 'already on the table', "takes away the opportunity for informed consent.  The patient is lying on the table, recommendations are being made, and there is no real opportunity to gather all the facts.  There is now a trend toward stopping, having an objective conversation with the patient, the cardiologist and a surgeon."

Dr. Stephen Lahey,  Cardiac Surgeon, Maimonides Medical Center in Brooklyn, and Professor of Medicine at SUNY Downstate comments, ""The natural tendency is to opt for something that is [more convenient], far less invasive and doesn't hurt as much.  But is that the right thing, or good for the patient? Sometimes, we have to say I know you want [angioplasty], but that really isn't the right thing for you."

In regard to  physicians ensuring patients have all the facts prior to undergoing any procedure, Dr. John Conte, Associate Director of Cardiac Surgery, John Hopkins Hospital Baltimore says, "It's absolutely amazing that the federal government and private insurers don't insist on it. Wouldn't it make sense to do the right procedure the first time, rather than do it over and over and drive up the cost of healthcare? To me, it's a no-brainer."