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Post Info TOPIC: Stents or Bypass Surgery for Coronary Disease?
ed11563


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Stents or Bypass Surgery for Coronary Disease?
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Some background:

For patients with blocked arteries to their hearts, standard practice for many years was to bypass those blocked (or mostly blocked) arteries by sewing (grafting) a piece of vein onto the heart to bypass the blockages. (Coronary Artery Bypass Graft, or CABG).

 

I've observed hundreds of these procedures.

 

Then another procedure came into use, feeding a tube with a balloon on the end through an artery in the leg or groin, up to the heart and into the blocked coronary artery, expanding the balloon to press the fatty material causing the blockage outward to create a wider channel. Then a wire mesh tube is inserted and expanded by the balloon, to keep the walls from closing down.

 

A problem showed up pretty quickly: Plaque was forming on the wire mesh, and re-blocking the arteries.

 

The next step was to coat the metal with a drug to prevent plaque formation.

 

That seems to work pretty well. But the question remains, are the patients better off having the open chest CABG procedure, or having stents inserted?

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Trial of Everolimus-Eluting Stents or Bypass Surgery for Coronary Disease

Seung-Jung Park, M.D., Ph.D., Jung-Min Ahn, M.D., Young-Hak Kim, M.D., Duk-Woo Park, M.D., Sung-Cheol Yun, Ph.D., Jong-Young Lee, M.D., Soo-Jin Kang, M.D., Seung-Whan Lee, M.D., Cheol Whan Lee, M.D., Seong-Wook Park, M.D., Suk Jung Choo, M.D., Cheol Hyun Chung, M.D., Jae Won Lee, M.D., David J. Cohen, M.D., Alan C. Yeung, M.D., Seung Ho Hur, M.D., Ki Bae Seung, M.D., Tae Hoon Ahn, M.D., Hyuck Moon Kwon, M.D., Do-Sun Lim, M.D., Seung-Woon Rha, M.D., Myung-Ho Jeong, M.D., Bong-Ki Lee, M.D., Damras Tresukosol, M.D., Guo Sheng Fu, M.D., and Tiong Kiam Ong, M.D. for the BEST Trial Investigators

N Engl J Med 2015; 372:1204-1212March 26, 2015DOI: 10.1056/NEJMoa1415447

Background

Most trials comparing percutaneous coronary intervention (PCI) with coronary-artery bypass grafting (CABG) have not made use of second-generation drug-eluting stents.

Full Text of Background...

Methods

We conducted a randomized noninferiority trial at 27 centers in East Asia. We planned to randomly assign 1776 patients with multivessel coronary artery disease to PCI with everolimus-eluting stents or to CABG. The primary end point was a composite of death, myocardial infarction, or target-vessel revascularization at 2 years after randomization. Event rates during longer-term follow-up were also compared between groups.

Full Text of Methods...

Results

After the enrollment of 880 patients (438 patients randomly assigned to the PCI group and 442 randomly assigned to the CABG group), the study was terminated early owing to slow enrollment. At 2 years, the primary end point had occurred in 11.0% of the patients in the PCI group and in 7.9% of those in the CABG group (absolute risk difference, 3.1 percentage points; 95% confidence interval [CI], −0.8 to 6.9; P=0.32 for noninferiority). At longer-term follow-up (median, 4.6 years), the primary end point had occurred in 15.3% of the patients in the PCI group and in 10.6% of those in the CABG group (hazard ratio, 1.47; 95% CI, 1.01 to 2.13; P=0.04). No significant differences were seen between the two groups in the occurrence of a composite safety end point of death, myocardial infarction, or stroke. However, the rates of any repeat revascularization and spontaneous myocardial infarction were significantly higher after PCI than after CABG.

Full Text of Results...

Conclusions

Among patients with multivessel coronary artery disease, the rate of major adverse cardiovascular events was higher among those who had undergone PCI with the use of everolimus-eluting stents than among those who had undergone CABG. (Funded by CardioVascular Research Foundation and others; BEST ClinicalTrials.gov number,

 

 



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lilyofcourse


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I would not have been a candidate for anything more than the stent. And my coverage probably would not have covered anything more.

But I do still have pain in my goin every now and then. Been years since my last heart cath.

Another thing that I would like to see is counseling after any of those procedures. I know I needed it.



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I don't see how open heart surgery can be considered a better option than a stent. Putting a stent in doesn't require cutting your chest open and breaking your rib cage. Both necessary things done when grafting a vein.

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Fort Worth Mom


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My sister Trudy had triple bypass about 10 or 12 years ago. She didn't have her chest cracked. Her doctor used this method.

Totally Endoscopic Coronary Artery Bypass

 

Another Form of Minimally Invasive Coronary Bypass Surgery

What is TECAB?

 

 

Totally endoscopic coronary artery bypass (TECAB) is the least invasive coronary artery bypass grafting operation. The bypass graft is placed through tiny holes without any opening of the chest. In comparison to coronary artery bypass grafting procedures, which are carried out through very small openings in the chest (MIDCAB), the operation is performed only through these small portholes. As a result, the surgical trauma and scarring for the patient are very minimal.

What happens during the operation?

The surgeon uses a surgical robot for the procedure, which enables the surgeon to perform complex surgical maneuvers inside the chest. The surgeon inserts a video camera, which is mounted on the operation robot, into the chest and uses two or three additional instruments on the robotic arms.

Robot-assisted minimally invasive surgery provides the benefits of traditional minimally invasive or laparoscopic surgery, but with important technological improvements, including:

 

  • Advanced optics that provide 10-times magnified, three-dimensional images of the surgical area.
  • Robotic arms that eliminate even the slightest human hand tremors, which allow for very precise surgical work.
  • Instruments with "wrists" that pivot 540 degrees, for greater maneuverability than is possible with human hands or laparoscopic instruments.

A very small incision is made in the groin for connection of the heart-lung machine. A sophisticated special heart-lung machine system is used for these operations. This system serves as a safety net for the patient and takes over the blood circulation while the heart is stopped for the bypass graft connection. The surgeon is working on vessels that are approximately 2 to 3 millimeters in diameter. A stopped heart and the robotic system ensure very accurate suturing of tiny bypass grafts.

After the bypass grafts have been placed and the heart-lung machine is removed, the surgeon and his team check the quality of the grafts by an angiographic exam, which is done while the patient is still under general anesthesia.

After the Operation

 

 

After the operation, the patient is transported to an intensive care unit for postoperative observation. The patient will be on a ventilator for several hours. The doctors watch carefully for adequate heart function. This requires monitors and lines connected to the body for several hours. Patients can drink, eat and walk around very quickly and are discharged home usually within four to five days after the operation.

Advantages

 

 

The minimally invasive TECAB procedure eliminates the need for a large (6-10 inch) incision made down the sternum (breastbone) to access the heart, which reduces a patient's surgical trauma. Other potential patient benefits include:

 

 

  • Less pain (and need for pain medication)
  • Less scarring
  • Shorter hospital stay
  • Quicker recovery and return to normal activities, and even light sports, within two to three weeks after the intervention
  • Less bleeding and need for blood transfusions
  • Lower risk of infection
  • The bypass grafts that are used can stay open and supply the heart with blood for a very long time. These so-called internal mammary arteries show durabiltiy rates in the 20- to 30-year range and are the best option for a patient with coronary artery disease.
  • No foreign material is implanted
  • Except for aspirin, which the patient with coronary artery disease has to take anyway, no blood-thinning medication is necessary



Source: Totally Endoscopic, Minimally Invasive Coronary Bypass Surgery | University of Maryland Medical Center http://umm.edu/programs/heart/services/services/cardiac-surgery/cabg/endoscopic#ixzz3VW32fZ4R
University of Maryland Medical Center
Follow us: @UMMC on Twitter | MedCenter on Facebook



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Tinydancer


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I still think I'd choose the stent. No intensive care was needed and I never needed to go on the ventilator. I think a graft would have put me out of commission a lot longer than the stent did.

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lilyofcourse


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Me too, Tiny.



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Don't get me wrong. I'm sure stents are just fine, for some people.smile

My point is, the robot surgery for bypass, has been around a long time. If a doctor told me I needed bypass, and he/she was going to crack my chest to do it?

Hell no. I'd be finding a new doctor. Quick!



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My doctor never even brought it up. He's a firm believer in using stents as opposed to grafting. I'm glad I didn't have to go that route because I believe my recovery was much quicker with the stent.

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lilyofcourse


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I like starting with the most minimally evasive option first.



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It isn't necessarily a choice. It is going to be based on a lot of different whichever one your doctor decides to recommend for you.

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ed11563


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Tinydancer wrote:

My doctor never even brought it up. He's a firm believer in using stents as opposed to grafting. I'm glad I didn't have to go that route because I believe my recovery was much quicker with the stent.

There's no question that stenting is MUCH easier on the patient and recovery is much faster and easier.

The other questions is, which procedure is more likely to leave you healthier longer term .

A patient once told me, "If I have the stents put in now, and it doesn't work, I can always get the open heart procedure done later."

Okay, but no if you have a stroke or a fatal heart attack because clots form on and can break free from the stents.

But that won't happen to most patients.

 



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Southern_Belle


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Stents aren't always the best choice. It just depends on the patient and the amount of blockage, and a million other factors.

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