23 March, 2024

Stent vs Bypass: Which is better?

Introduction:
Narrowing or blockages of the blood vessels of the heart (coronary arteries) are mostly due to cholesterol deposits and can lead to a heart attack if not managed on time. Such narrowing is referred to as Coronary Artery Disease (CAD) and is responsible for most lives lost across the globe. While prevention is always better than cure, we briefly touch upon treatment options, particularly on angioplasty (stent) vs bypass surgery.

Management options for CAD are a few:

Do nothing
Bad option. CAD is progressive in nature and often culminates in a major heart attack, heart failure, or death. Heart diseases are the most common reason for death and disability around the world, including in India. One should actively try to reduce its ill effects.

Medications alone
Medications are indicated for all patients who are diagnosed to have blockages. Many times, medications alone are sufficient for effective management.

Medications + stents (also known as angioplasty)
Stents can be placed to relieve the narrowing when medications fail to control symptoms or are highly likely to fail (based on the individual clinical situation), or if the blockages are thought to be high risk.

Medications + bypass  surgery (CABG)
Coronary Artery Bypass Grafting (CABG) is a surgical procedure in which bypass channels are created to “bypass” the site of blockages. Essentially, a blood vessel is taken out of the legs (or forearm) and attached to the heart arteries, bypassing the site of blockages. CABG is chosen when medications have failed (or are highly likely to fail) and stents are not a suitable option.

*The description below is generic and may not apply to individual cases. Please refer to your doctor for individualized case discussion and planning.

The general approach to managing coronary blockages:

1. All patients diagnosed or suspected of CAD should be started on evidence-based medicines regardless of whether angioplasty or CABG is chosen.
2. All patients with an acute heart attack (particularly ST elevation type) should undergo urgent angioplasty. An urgent CABG can be done in rare cases if angioplasty is not possible.
3. Patients with non-critical blockages and/or at non-critical locations are typically tried on medical therapy first. Stent or bypass surgery is opted for only if medical therapy fails. There are obvious exceptions based on individual case scenarios that need to be discussed with the treating cardiologist.
4. Patients with critical blockage at the critical location should be offered angioplasty.
5. Patients with too many critical blockages (typically more than 2) or blockages in areas that impose a higher risk for angioplasty should undergo CABG.

Most of the time, the decision to go with angioplasty vs CABG is straightforward for cardiologists. Simple 1-2 blockages can be easily handled by angioplasty, whereas multiple/complex blockages go for CABG. Occasionally though, blockages may seem suitable for either angioplasty or CABG. In such cases, a frank discussion should occur between the treating doctor and the patient/family. Below are a few additional aspects to consider:

1. CABG is a major surgical procedure, whereas angioplasty is minimally invasive.
2. Short-term risk is less with angioplasty.
3. CABG requires about 6 weeks of rehabilitation (longer in frail or older individuals), versus angioplasty for about one week.
4. Although medicines should be continued in both, angioplasty demands more disciplined medication management.
5. The future need for repeat angiography/angioplasty is higher with angioplasty than with CABG.
6. Patients with Diabetes and multiple blockages do better with CABG compared to angioplasty.

Other factors to be considered before making a decision include:
1. Heart pumping function
2. Associated heart valve dysfunction
3. Lung capacity
4. Age of the patient and baseline physical status
5. Any other major organ dysfunction, e.g. kidney failure
6. Cost of the procedure
7. Available surgical expertise
8. Patient’s ability to participate in physical rehabilitation after surgery, social support, etc.

Certains myths of Angioplasty or Bypass (CABG) surgery:
1. We can only put 1 or 2 stents at a time
False. From a pure procedure standpoint, there is no limit to the number of stents that can be placed. While it is true that most angioplasty procedures involve putting 1 or 2 stents, if more blockages need to be fixed, additional stents can be placed without any issues.

2. Stents lasts for a few years before they stop working
False. A stent is designed to last a lifetime. Once a stent is placed, the metallic scaffold maintains the same shape forever. As time passes, our body continues to form additional blockages, either in the stented or non-stented areas. A stent does not prevent future blockages; that’s the job of medicines and lifestyle. That is why medicines are continued even after successful stent placement.

3. Bypass surgery can not be performed in elderly individuals
False. There is no upper age limit for bypass surgery, although the risk for surgical complications increases as we age. For an elderly patient with multiple blockages who requires a CABG procedure, the risk of the procedure may be less than the risk of having heart-related issues if the blockages are not treated appropriately.

4. Procedural risk of angioplasty is always lower than CABG
False. While for most cases it is true, there are few complex cases where the risk of procedural death may be the same for either angioplasty or CABG.

5. A cardiologist can decide on angioplasty vs CABG by looking at the angiography report alone
False. For a cardiologist to get a clear idea about the blockages, he/she needs to see the angiography videos. Also, the decision to go with angioplasty vs CABG considers multiple factors, as discussed above. It is best to bring the patient, the angiography CD and all relevant medical records, for a professional and accurate medical opinion.

6. A patient is ‘cured’ of the disease after an angioplasty or a CABG
False. Stents or bypass surgery is meant to tackle the problem for that particular time. As we age, new blockages will continue to form and a patient may require further interventions for blockages as the situation arises. It is similar to cleaning a blocked drainage pipe. Once the pipe is cleaned, it can get clogged again if trash continues to fill it!

7. Once a stent is placed, bypass surgery can not be done in the future, and vice versa
False. For most cases, performing an angioplasty after a CABG or doing a CABG after an angioplasty is technically not an issue. Obviously, before we do any procedure, we need to confirm that there is a medical necessity to perform a procedure to begin with.

8. Angioplasty or CABG will make a weak heart become strong again
True and False. Angioplasty or bypass surgery restores normal blood flow to the weak heart, giving it a higher chance to recover. While the damaged portion of the heart muscle may recover, the cells which are dead are unlikely to recover even after a successful procedure. That is why it makes sense to treat the blockages before the heart muscle is permanently damaged.

9. Newer technology can remove blockages without the need for stent or bypass surgery
To date, no scientifically approved techniques are available to remove blockages from the heart arteries.

As you can see, a decision between angioplasty and CABG is based on multiple factors and is highly individualized based on the clinical parameters of the index patient. We should refrain from generalizing that one procedure is better than the other, as they both have their roles in patient management. The most important thing is to discuss with your treating doctor, understand the rationale of the decision taken, the pros and cons tailored to the individual patient, and finally, entertain the wishes of the patient as well.

I am sure I didn’t answer all your questions on this topic. Feel free to message me with your queries; I will happily answer them.

Medical disclaimer: The information on this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images and information, contained on or available through this website is for general information purposes only. You are encouraged to confirm any information obtained from or through this website with other sources and review all information regarding any medical condition or treatment with your physician. NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING YOU HAVE READ OR ACCESSED THROUGH THIS WEBSITE.