Skip navigation

People who develop blocks in the coronary arteries are often advised to undergo bypass surgery. During last quarter of 20th century coronary angioplasty saw dramatic improvements leading to a sea change in the kind treatment offered to patients with coronary artery disease (CAD). In the west, there has been a sharp decline in the number of coronary artery bypass grafting (CABG) surgeries and a phenomenal increase in the number of angioplasties.

 

Is that because angioplasty is better than surgery?

 

More importantly, is this situation applicable to India?

 

There are patients of CAD where CABG is the only solution. Angioplasty will simply not do. Similarly, there are patients where angioplasty and not surgery is the appropriate treatment. For the sake of this discussion, we leave out these unambiguous cases. The argument as to whether surgery or stenting is superior is relevant in cases where both treatments are equally feasible and a choice requires to be made.

 

The recently published Stenting versus Internal Mammary (SIMA) trial (conducted at multiple hospitals in Europe, Chief Investigator Dr Jean-Jacques Goy, MD, University Hospital, Lausanne, Switzerland) should serve as an ideal backdrop to this comparison between surgery and stenting.

 

Coronary block occurring at the beginning (proximal part) of the major blood vessel called Left anterior descending (LAD) artery of the heart are often fatal. This proximal LAD block is so feared that the artery is euphemistically known as the ‘widow maker’. Traditionally CABG surgery has been the main treatment of blocks in this location. There has been no direct comparison of long term results of surgery and stenting for treating blocks of this kind.

 

This new study has shown that patients who undergo stenting for proximal LAD blocks fare as well as those who undergo surgery, as far as protection against heart attacks and loss of life. The study also showed that in some patients whose blocks were treated by stenting, the blocks recurred. Such patients then required to undergo repeat angioplasty or CABG surgery.

 

In essence this means that:

 

1.         Patients with critical blocks in the widow-maker artery now have two options: Bypass surgery or stenting. Either way the risk of such a patient getting a heart attack or actually dying are quite low

 

2.         Stenting offers a convenience unbeatable by surgery. Patient is up and about in two or three days.

 

3.         In nearly 80% of patients, there is no recurrence of the block and patient will not need another procedure in his/her entire life for this block.

 

 

This study was begun over a decade ago and in those days the heart specialists used ‘Bare Metal’ stents (BMS). These BMS carried a risk of recurrence of the block in nearly 20% patients who were treated. On the other hand, bypass surgery is far superior in the long term if the internal mammary artery (IMA, the artery behind the breast bone) was used for grafting. Over 95% of patients with IMA graft to the LAD were free from problems even after 15 years of surgery! Because of this difference in risk of recurrence, surgery was always considered superior to stenting.

 

Cut to 2002: Johnson & Johnson released a new stent, CYPHER, known as Drug Eluting Stent (DES) essentially a BMS which was coated by a special medicine, which was intended to prevent the recurrence of the blocks treated. After several million of these DES having been implanted, we know that there is no recurrence in 90 – 95% of patients: as good as surgery with IMA graft. Soon after other DES have appeared in the market and look to be as good as CYPHER if not better.

 

Through SIMA study we know that stenting is safe even with BMS. Cardiologists are certain that with the use of DES even the recurrence rates are comparable to surgery, so stenting seems to be an effective alternative to surgery.

 

Caveats for the Indian patients:

 

1.         Several cardiac surgery centres in India especially in the tier 2 cities lack the expertise to offer IMA graft for the widow maker artery in bypass surgeries. Veins from the leg are used instead. Venous grafts are not as durable as IMA grafts and in fact nearly 20% of them occlude in the first 5 to 6 years. While venous grafts are acceptable in grafting of other arteries, in most cases IMA grafts must be preferred for the LAD. So before a patient decides on surgery it should be confirmed whether an IMA graft will be used.

 

2.         Many makes of DES are available in India manufactured in India, Europe, China and so on. Though none of these stents have been specifically compared in tests against bypass surgery, only few can claim really low recurrence rates. In other words all DES are not equal. So a patient offered stenting with a DES should not automatically assume that he will have a surgery-equivalent procedure unless he knows what DES is being used

 

3.         In the west, the leaning towards stenting is because stenting is cheaper than bypass surgery. Insurance companies prefer to go along cardiologists who advise stenting. Hospitals are happy because number of hospital days are less and so patient turnover can be more.

 

4.         In India, however, CABG is far cheaper than stenting with DES. So the western preference of stenting over surgery need not be automatically applied to India.

 

So what seems to be the right thing for the Indian patients with block in the widow maker artery?

 

1.         Stenting with a standard DES is as good as CABG with IMA grafting

 

2.         In case the stents fail, a second procedure would most likely be required.

 

3.         So, if you are short on cash (selling off a couple of cows or an acre of land to raise the money), perhaps surgery is a better choice because it is likely to be a once-in-a-lifetime procedure.

 

4.         If you have loads of cash and prefer to avoid surgery, stenting with a standard DES is fine: because there is a 95% chance that you actually get away!

 

5.         All this applies to the average patient: there are special circumstances in which these rules do not apply and the treating doctor is the best person to take the decision

Advertisements

8 Comments

  1. I had gone through stenting 3 weeks back.Doctor advised me for stenting and really it was a very amazing experience.I simply was admitted for 3 days only.
    Now I am slowly back to normalcy.
    How far I am safe from further blockage.
    Please advice me, whether I can go back to previous diet ?

      • mindovermedicine
      • Posted November 13, 2011 at 9:02 am
      • Permalink
      • Reply

      Hi, I’m glad you are recovering well from your procedure. In general, with state of the art technology there is a 95% chance that you will not need a second procedure for the block that was treated by stenting. Assuming that your current, careful diet is dramatically different from your previous diet, the advise is: stick to strict diet precaution for the rest of your life. If you don’t make appropriate life style changes now, you may end up with another block. Remember, all blocks can’t be treated by stents. You won’t be this excited if you end up with CABG!

  2. Very useful information. My mum is on her way for an angio as I am writing this and this was really valuable information as it is most likely that she has an LAD block.

    • @Millia
      All the best for mum’s angio. We will hope that everyone concerned will take the best decision, in the event there is actually a block 🙂

  3. Thanks for your wishes. Much appreciated. I do have a question for my own interest. If a drug coated stent is placed on a person with history of GI bleeds (gastric and duodenal ulcers- although might have healed over the years being on Omeprazole), would drug coated stents where aspirin and clopidogrel need to be given life-long be an contra-indication? I would assume that there would be a risk of GI bleed or even perhaps a stent closure? How can a stent closure happen? Is that fatal? or is it a matter of risk versus benefit? Even a general comment would be most welcome.

    • @Millia
      Very interesting….
      Anyway, a number of thoughts/ideas come through. In actual practice, I would discuss all these with the patient and perhaps the decision as to what is to be done would be related to both that interaction as well as my judgment of the patient’s condition. Nevertheless, here goes:
      1. If the GI bleed is years ago, then most cardiologists would place medicated stents and would ccover the entire period of aspirin/clopidogrel therapy with anti-ulcer drugs. Omeprazole itself is in some controversy, with suggestions that it reduces the efficacy of clopidogrel, but excellent alternatives exist.
      2. WIth current generation of medicated stents, we are seeing far less problems and so most cardiologists would discontinue aspirin after one year in a case like this and continue clopidogrel for the rest of patient’s life, after placing a DES.
      3. A current and an extremely attractive option is to placce a stent with a biodegradable polymer. LEADERS trial has shown that the BIOMATRIX stent is a terrific stent even after 4 years of placing it. I have personally stopped dual antiplatelet therapy in patients after 3 months after placing this stent. The current recommendation is that you could stop atleast one drug after 6 months. In the hypothetical patient we are discussing, aspirin could be stopped after 6 months after placing BIOMATRIX.
      4. Finally, one would specifically look at the angiogram iteself. Some blocks, for example, very short blocks in large caliber arteries, or blocks in non-critical areas do not necessitate placement of medicated stents in the first place. One would implant a bare metal stent and do away with dual antiplatelet therapy after 6 weeks.
      Hope that clears it up a bit!
      Venkatesh

  4. Thank you very much Venkatesh. Much appreciated.

  5. hmmmm.okkk..


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: