March 1, 2007 -- For 30 years surgeons and interventional cardiologists have been debating the issue of open heart bypass surgery vs. angioplasty and stents. Now a front page story In the Sunday New York Times reports that, given the recent concerns over drug-eluting stent problems, in some patients bypass surgery may be a better solution than stents for treating the problem of coronary artery disease.

Downsides of Surgery
What the New York Times article doesn't discuss is that surgery, like angioplasty, is not perfect. In the article, surgery is characterized as certainly more invasive, but probably more durable and longer-lasting than stenting. But surgical bypasses sometimes fail, and close up again. When a bypass graft closes up, especially a saphenous vein graft (SVG) taken from the leg, angioplasty and/or stenting is what's used to open up the bypass.

For example, the patient who testified at the recent FDA stent safety panel about the fears he was experiencing about drug-eluting stents, was in fact a surgical triple bypass patient whose grafts had all closed up. He had a drug-eluting stent implanted in his main LIMA bypass graft. He was speaking to the panel only because that stent was doing its job, keeping the artery open, and him alive.

There also was no mention of the cognitive decline that has been measured in 50% of low-risk patients who had bypass surgery (recently published 5-year follow up of the Octopus Study showed that this decline was the same for off or on-pump surgery -- the cause is not clear, but may have to do with anesthesia, inflammatory response, etc.). Dr. Harlan Krumholz of Yale Medical School concluded that: "Informed consent for CABG should incorporate information about cognitive risk."

Moreover mistakes can be made no matter what the procedure. Sure interventional cardiologists may err in placing a stent, but just ask comedian Dana Carvey about getting the wrong artery bypassed. That's what happened to him and it was angioplasty that fixed the surgical error.

An Old Argument
There's nothing new here. When coronary angioplasty was first performed in Zurich in 1977 (see the video) there was suddenly an alternative to coronary artery bypass grafting (CABG) -- a new, less invasive procedure to open a blocked artery, one that didn't involve cracking open the chest.

Surgeons in the early 80's pooh-poohed angioplasty as being a minor procedure that might work for a few per cent of the population at best. The rest is history, but not really news. Over three decades, cardiac surgeons have seen their patient numbers shrink, along with their incomes, as the number of interventional procedures (angioplasty and stenting) increased -- now more than two-thirds of all "blocked arteries" are opened up via angioplasty.

Lack of Good Data
There have been many articles in the wake of the "drug-eluting stent is not perfect" era (i.e. the past 6 months) and many hark back to "the good ol' days" of bare metal stents and, now, surgery.

Actually surgeons made a bit of a splash at the December FDA stent safety hearings -- several presented data showing the superiority of surgery, specifically in patients with complex multivessel disease. Much of the data the surgeons presented tracked patients starting in the 1990's -- the basic flaw here being that they were comparing surgery with the very beginning days of stenting, an era well before the availability of drug-eluting stents.

The problem is that there is no good long-term data comparing the two procedures because by the time any randomized clinical trial can present its follow up results, the practice of medicine has changed with new devices, new surgical techniques and new drugs.

Which is Best?
There is no question that some patients, who have diffuse disease in multiple vessels, are better served through surgery. The important question is not which procedure is best, because both work when used appropriately -- the important question is what is best for each individual patient?

Dr. Robert Guyton, a cardiac surgeon quoted in the Times article, worked and published papers with Andreas Gruentzig, the inventor of angioplasty, back in the 80's at Emory Hospital in Atlanta. Dr. Guyton told Angioplasty.Org that Gruentzig was a very special doctor (something anyone who met him knew) and always carefully explained to the patient what he planned to do and what the patient's options were. Gruentzig worked with surgeons and spoke at many surgical meetings. Guyton's concerns are that in today's healthcare environment, patients aren't being given the choice of stent vs. surgery.

Patient Choice
Certainly more enlightened hospitals and medical practices give patients the plus and minus of both options. Also, new pharmaceuticals and devices are being introduced to manage heart disease more effectively. On the horizon, solutions coming from microbiology, angiogenesis and nanotechnology may revolutionize treatment completely.

The Times article reports that patients, given the choice, will opt for stents -- will try to avoid surgery -- even if surgery is recommended. But this puts patients in line with all the forward movement in medicine toward less invasive treatment. And, like the debate over stents vs. surgery, it is an old story. Over 200 years old. As John Hunter, the father of scientific surgery, wrote in 1777:

This last part...namely operations...is a tacit acknowledgement of the insufficiency of surgery. It is like an armed savage who attempts to get that by force which a civilized man would get by stratagem. (from "The True Principles of Surgery" -- 1777)

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