Heart Bypass Surgery
or Stent:
An Old Argument Resurrected
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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)
Reported by Burt Cohen, March 1, 2007
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