One of the very confusing issues for heart patients is to decide regarding bypass surgery or ballooning, as to which one to choose. Whenever coronary angiography is done many a times when a patient is offered ballooning he gets scared as to why not get surgery which he thinks is a more permanent solution to the problem. So lets us see what the truth behind this decision making is.
Let me first of all tell you little bit about the coronary heart disease natural history. As you know the coronary heart disease starts with the deposition of cholesterol in the coronary arteries (Plaques). This is a very slow process and takes years. Over years it increases and a time comes when it causes sufficient luminal narrowing as to cause ischemia/angina. In fact the deposition starts while in young age.In fact the preventive measures for coronary heart disease should start in the young age. Now the pattern of deposition of cholesterol in the arteries is very variable in different individuals. This deposition can be in a very short segment of the coronary artery or can be at multiple levels within a single coronary artery or it can be very diffuse throughout the vessel. Also sometimes a pattern of distal involvement is also seen in which only the farthest part of the vessel is involved and the proximal part is normal.
Now let us see how can we treat it
The best method to treat the existing blockage would be a medicine which dissolves the cholesterol which is deposited in the coronary arteries. Unfortunately no such medicine is available till now.Statins are one such drugs which lower cholesterol in the blood and have been claimed to reduce plaques in these coronary arteries. But this effect is very minimal and not predictable.We do give these drugs to most of the patients with the hope that even if it does not dissolve the existing blocks at least it will prevent the progression of the blockage to some extent and this is true also.
Now what are the options we have to treat these blockages?
We have three options. One is to continue the patient on various medicines which act by different mechanisms so as to suppress the symptoms and prevent the progression of the disease. Patients became symptoms free and feels much better. But this option we give only to patients in which the disease is minimal, does not involve the main arteries, or in patients in which it involves main arteries but in whom surgery or PTCA can not be done for technical reasons or if the assessment says that these procedures would not give benefit even if performed. Something like if the disease involves distal vessels as I discussed earlier.
Second method is to treat these blockages by ballooning. In medical terminology we call it PTCA (percutaneous coronary angioplasty). This is a technique which was started by Gruenig way back in 1977. Since then it has got enormous changes. The technique is at its near perfection. In this technique a catheter is inserted into the coronary artery from the groin after local anaesthesia.Through the catheter a very fine metallic wire is inserted into the coronary artery and is passed across the blockage.Over the wire a balloon is passed into the coronary artery across the blockage and is inflated.By this the deposited cholesterol is pressed into the vessel wall and blockage is opened. Now there is a tendency of the vessel again to close as this is a elastics structure .To prevent this a metallic mesh (Stent) compressed over a balloon is passed into the same segment and is inflated to leave the mesh there. Sometimes if the blockage is too much then a cutter (Rotablator or atherectomy device) is also used to debulk the lesion. Now the biggest problem with this technique is 20% chance of reblockage at the same site within six months which sometimes can be fatal also. Third Option is bypass surgery. Bypass surgery is a major surgery. In this surgery artery and veins taken from the body are anastomosed between aorta and beyond the blockage so as to bypass the blockages.
Now let us see which is better
As you know now, both the methods are same. As neither is permanent cure. Both are an attempt to take care of the existing blockages. New blockages can keep appearing at the same sites, other sites and in grafts and both do not treat the whole vessel or the very cause of blockage for which we have to depend on medicine and life modification methods any way.
That means we have to continue the medicines even after PTCA or CABG because the disease can still occur with the same probability at other points in the same or other coronary artery.
In a given patient we normally see the whole picture and take various parameters as to which method to choose.
- First is the no of vessels involved
- Second is the nature of blockages (Proximal, long segment, Bifurcation, trifurcation lesions tortuous vessels etc)
- Third is associated comorbid illnesses (Like Diabetes, CVA etc)
- Fourth is the age, body activeness and financial condition of the patient
If a patient has a single vessel involved then the best method is PTCA with stent. Sometimes in a single vessel if this vessel is LAID and the blockage is very proximal or right at the origin (Ostial) and especially if patient did not have any heart attack, that means the whole area is alive or the patient is diabetic then we do consider CABG as a good option.But even then lot of patients as well as doctors do consider PTCA as a good first option as now we have the technology available to tackle these lesions and even if reblockages occur surgery still can be done. Only thing is that patient suffers financially and requires another procedure if restenosis occurs. In fact now we have another stent (Cypher) which is launched recently which has restenosis rate of nearly 0 to 1%.
Patient with triple vessel disease should undergo CABG is a wrong statement. Patient with triple vessel disease should undergo revascularization is right statement. If the patient has double or triple vessel disease and all the lesions can be tackled by PTCA. Then this is the first option given to the patient. But the cost is more like for three vessels if three stents have to be placed then the expected cost of the procedure is around 2.25 lakhs rupees and also in 20-30% patients should be ready for CABG if restenosis occurs. With Cypher stent we are hoping that this figure of restenosis would drop to less than 2% but the cost of the procedure would increase tremendously. Surgery is a good option for triple vessel disease. It requires less money. But in surgery there is recovery time of minimum of 2 Months before patient really starts earning again. Also there is 2 to 4% chance of graft occlusion. So that means if the patient can afford, the lesions are amenable to PTCA and patient is willing to undergo surgery if required later (Becoming less and less day by day) the PTCA is a good first option as patient is discharged in 48 hours and patient starts working next day.This is the truth. Now comes the confusion in day to day practice when patient says that one doctor is asking for PTCA and another doctor is suggesting surgery. This is because most of the patients now can be managed by PTCA with stenting and some doctors by telling patients that surgery is permanent solution may misguide.
If the patient has double or triple vessel disease but the lesions can not be tackled by PTCA or the finances are limited or the willingness for another procedure is less then surgery is a good option.But even after surgery new blockages keep appearing and they again may have tobe tackled by PTCA or Re CABG again going by the same criteria as whether the new blockage is at one site, at multiple sites.At each stage we keep assessing the patient as a whole whether he can withstand which procedure more safely (Both physically and financially). At each stage the aim is to revascularize the maximum no of vessels. Sometimes in triple vessel disease patients doctors suggest that one vessel can be opened by PTCA and rest can be left if they are small and especially if they are difficult for the surgery also. As if you put a graft in very small vessel it does not last long If the patient has diabetes then the chances of restenosis after PTCA are more and there is a tendency to offer CABG especially in triple vessel disease.
If the patient is very old, with less mobility and if considered high risk for anaesthesia then PTCA, even if complete revascularization (That means you can't open all the blockages) is not possible, is a better option. At this time if some doctor says that incomplete work has been done is wrong.
Some doctors still misguide the patients by saying that since both are not the cure, and the new blockages keep appearing and they still can get heart attacks , so they should not undergo either PTCA or CABG and stick to medicines and other lifestyle modifications. This is wrong because both prolong life by avoiding major fatal heart attacks, both decrease morbidity. As the technology is improving, more and more patients even with complex anatomy can also be tackled with PTCA, which were previously managed by surgery only.
In the present era for a given patient mostly both the options of revascularization i.e. PTCA or CABG are available and a decision has to be made with mutual discussion of merits and demerits of both the procedures with the patient after studying the angiography report, heart pumping function and other comorbid illnesses. And importantly it is very important to understand that neither is permanent cure. Both are an attempt to take care of the existing blockages. New blockages can keep appearing at the same sites, other sites and in grafts. That means we have to continue the medicines and life modification methods even after PTCA or CABG.