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Is Coronary Artery Bypass Surgery Really Better than Coronary Stents A look at the risks and benefit


The leading cause of death in the United States is coronary heart disease ... About 43% of heart disease deaths are related to coronary artery disease ... – PowerPoint PPT presentation

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Title: Is Coronary Artery Bypass Surgery Really Better than Coronary Stents A look at the risks and benefit

Is Coronary Artery Bypass Surgery Really Better
than Coronary Stents?A look at the risks and
  • Sarah Smith
  • Advisor Dr. Grimes

Why is this important?
  • The leading cause of death in the United States
    is coronary heart disease
  • It accounts for about 1 million deaths per year
  • About 43 of heart disease deaths are related to
    coronary artery disease
  • Heart disease is the leading cause of death of
    American women, accounting for 32 of all deaths
    per year.
  • One in three women will die from heart disease,
    while one in 25 will die from breast cancer
  • Trends in the United States suggest that half of
    healthy 40-year-old males will develop CAD in the
    future, and one in three healthy 40-year-old

  • CAD is a chronic disease in which the coronary
    arteries gradually harden and narrow
  • Limitation of blood flow to the heart causes
    ischemia of the myocardial cells, leading to a
    myocardial infarction
  • This leads to heart muscle damage, heart muscle
    death and later scarring without heart muscle

Pathophysiology Cont.
  • CAD can be thought of as a wide spectrum of
    disease of the heart
  • At one end is the asymptomatic individual with
    fatty streaks within the walls of the coronary
  • Over time these streaks will increase in
    thickness and may affect the flow of blood
    through the arteries
  • As the plaque continues to grow and obstruct the
    vessel to more than 70 the patient typically
    develops symptoms of obstructive coronary artery
  • At this stage the patient is said to have
    ischemic heart disease, meaning the patients
    heart is experiencing an increased workload, thus
    reduced blood supply to the heart walls

  • As CAD progresses, there may be nearly complete
    obstruction of the lumen of the coronary artery
  • Patients at this level have typically suffered
    from 1 or more myocardial infarctions, and may
    have angina at rest and pulmonary edema
  • An individual may develop a rupture of a plaque
    at any stage of the spectrum.
  • The acute rupture a plaque may lead to an acute MI

Risk Factors
  • Family history of premature CAD
  • Smoking
  • Diabetes mellitus
  • HTN
  • Hyperlipidemia
  • obesity

  • Generally patients present with stable angina,
    unstable angina, or a myocardial infarction
  • Coronary angiogram is currently golden standard
    for determining the presence of obstructive
    coronary artery disease
  • Yields a 2D picture of coronary arteries
  • A catheter is inserted into the coronary arteries
    and injected with dye
  • The dye allows the physician to pinpoint the
    number and location of blockages in the coronary

Treatment Options
  • There are many different treatment options
  • A physician will look into the patients
    individual risk factors, severity of the blocked
    artery, and analyze the benefits and risks for
    possible procedures
  • Two popular procedures are PCTA/stent
    implantation and CABG surgery
  • Medical therapy is also available for a more
    conservative treatment

Overview of Stents
  • 1/3 of patients with CAD will undergo coronary
    angioplasty with stents or Percutaneous
    Transluminal Coronary Angioplasty (PCTA)
  • Angioplasty involves temporarily inserting and
    expanding a tiny balloon at the site of blockage
    to help widen the narrowed artery
  • Usually combined with stent implantation in the
    artery to help prop it open and decrease the
    chance of it narrowing again or restenosis
  • Performed in cardiac catheterization lab and are
    non-surgical treatment
  • Usually last about 1-2 hours and most patients
    are usually discharged in 1-2 days after a
  • Stents are a stainless or nytinol mesh like
  • Angioplasty and Stents
  • YouTube Stent

  • A stent is a stainless tube with slots. It is
    mounted on a balloon catheter in a collapsed
    state. When the balloon is imflated, the stent
    expands and pushes itself against the inner wall
    of the coronary artery.
  • The risk of emergency referral for CABG and need
    for subsequent revascularization procedures has
    reduced by more than 50 because of coronary
  • Stent implantation has shown to reduce restenosis
    in vessels with reference diameter 3mm, however
    in-stent restenosis still occurs in about 10-40
    of patients
  • According to the American Heart Association
    stents can be considered for use in patients who
    have significant disease of left main and left
    anterior descending coronary artery. Also
    patients with 2 or 3-vessel disease should be
  • In previous years these patients were only
    candidates for bypass surgery

Risks/Benefits of Stents
  • Benefits
  • Shorter procedural and recovery time than CABG
  • Angina relief about 75 of the time
  • Decreases the risk for heart attack
  • Increases blood flow to the heart
  • Risks and Limitations
  • Risk of death
  • Risk of heart attack, thrombosis and bleeding
  • Major limitation of procedure is a high rate of
    restenosis and need for revascularization
  • Scar tissue formation
  • Not a cure to the disease, still need to reduce
    risk factors and make lifestyle changes to
    prevent future disease progression

  • Patients receiving stents had lower incidence of
    death, MI, and stroke at 30-day follow-up
    compared to CABG.
  • However, patients receiving stents had a higher
    incidence of repeat revascularization procedures
  • 25 of patients at 1 year and 47 at 5 years
  • This high risk of restenosis is one of the major
    reasons for patients refusing angioplasty and
    opting for other treatment modalities like
  • The introduction of drug-eluting stents may shift
    patients from surgical procedures back to
    angioplasty and stent use.

Drug-eluting Stents
  • These are stents that are coated with a drug that
    is known to interfere with the process of
  • As of December 2007, the FDA has approved of 2
    DES sirolimus-eluting stents and
    paclitaxel-eluting stents
  • Studies show that there is a 70-90 reduced rate
    of restenosis when compared with bare-metal
  • DES were first introduced in April 2003, and just
    9 months later made up 35 of all stent
    implantations in the United States

Problem with DES?
  • 1. They are expensive
  • It costs about 2200 for a DES, when compared to
    bare-metal stents which costs about 600.
  • In one study they looked at the
    cost-effectiveness of DES. They took into
    account the fact that there will be reduced
    repeat revascularization procedures, and
    discovered that there was still an increase in
    600 per patient, and with an estimated 1 million
    procedures done a year, about 600 million
    increased in annual healthcare spending
  • 2. The drug agents can interfere with the healing
    process and found to hamper natural vascular
    healing process
  • In 2007, the FDA has cautioned the use of DES,
    because they are associated with increased risks
    of both early and late stent thrombosis, as well
    as death, and myocardial infarction
  • DES are still a novel idea it will be
    interesting to see the research that comes out in
    the next couple years looking at their
    effectiveness and future indications

Overview of CABG
  • CABG is still the best therapy for reintervation
    for most patients with proximal left anterior
    descending, multivessel, and left main-stem
    coronary artery disease
  • Of the patients with CAD, about 10 will undergo
    CABG surgery
  • CABG is a surgery that increases blood flow to
    the heart by creating a detour and re-routing the
    blood flow around the blocked portion of the
  • A section of a blood vessel from another part of
    the body is removed and grafted above and below
    the damaged portion of the coronary artery to
    form an un-blocked artery
  • Most commonly used are the saphenous vein and
    internal thoracic artery
  • This procedure is performed with assistance of a
    heart-lung machine, which supports the patients
    blood during surgery
  • CABG Surgery

Risks/Benefits CABG surgery
  • CABG was introduced about 50 years ago and is now
    performed in 1 million patients at a cost
    exceeding 20 billion annually
  • Many benefits such as decrease in angina,
    improved life-span, and providing an effective
    route for blood with prevention of new plaques to
  • Surgery is however a much more serious operation
    that lasts a long time, with a long recovery time
  • Some complications seen after surgery are atrial
    fibrillation, increased risk of stroke, and
    cognitive dysfunction

  • Less than 5 chance of heart damage and less than
    2 chance of death
  • Stroke or other neurological injury occurs in 5
  • Atrial fibrillation occurs in 20-40 of patients
    after CABG
  • 2 reasons as to why CABG offers survival
    advantages for multivessel and left main-stem
    coronary artery disease
  • 1. Bypass grafts are placed on the midcoronary
    vessel, CABG not only protects the culprit
    lesion, but also offers prophylaxis against new
    lesions in diseased endothelium
  • Where stents only treat immediate culprit lesion,
    with no protective effect against the development
    of new disease
  • 2. failure of stents to achieve complete
    revascularization in most patients with
    multivessel disease reduces survival proportional
    to the degree of incomplete revascularization

Isolated LAD and Left-main stem CAD
  • CAD in LAD has been reported as high as 50 among
    patients who undergo CABG
  • CABG is regarded as an accepted golden standard
    for left main coronary artery disease
  • CABG has generally been considered the golden
    standard of therapy for left-main stem stenosis
    for the last decade.
  • However, there are recent studies out that show
    patients underwent PCI more than CABG for this
    type of disease. This artery has a relatively
    large diameter, making it an attractive site for
  • Restenosis rates in a study were 30.3 in
    bare-metal stents, 7.4 in DES group, and 3.7 in
    CABG group

Multivessel CAD
  • MVD accounts for approximately 60 of the CAD
  • The use of stents in these patients has resulted
    in higher restenosis and repeat vascularization
    rates than in patients treated with surgery
  • Stents group had 16.8 restenosis rate as
    compared with 3.5 who underwent surgery
  • CABG patients also experience fewer MI and major
    adverse cardiovascular events
  • DES have decreased the difference between CABG
    and bare-metal stents
  • In order for PCI to replace CABG as the preferred
    therapy in MVD, clinical trials must demonstrate
    long-term outcomes that are equivalent

What about the Diabetic Patient?
  • The diabetic patient is a high risk for coronary
    artery disease, the incidence and severity of the
    disease are higher as compared to nondiabetic
  • Revascularization of diabetic patients has been a
    huge dilemma and a great challenge
  • A study confirmed that even a low-risk diabetic
    patient there is a survival advantage at 10 years
    for CABG in comparision with PCI of 58 vs. 46
  • Also found that there is a huge difference in the
    need for revascularization in both 18 of CABG
    patients and 80 of PCI
  • Studies state that the preferred
    revascularization strategy in the diabetic
    patient with MVD is CABG surgery
  • Lower mortality in CABG patients vs. PCI patients
    (1.4 vs. 12.8)
  • Lower major adverse cardiovascular events (8.6
    vs. 26.6)

The Future
  • Minimally invasive direct coronary artery bypass
    (MIDCAB) is on the rise
  • It is performed on a beating heart with use of
    stabilizing devices or using minimal access
    bypass system with endo-aortic clamping and
    cardioplegic arrest
  • Yields shorter hospital stay with lower
    postoperative complications and better quality of
    life with similar safety and long-term efficacy
    as conventional CABG
  • Robotic instrumentation is also developing
  • Surgery does not have a single chest incision of
    any kind, this surgery requires 3 pencil-sizes
    holes made between the ribs
  • 2 robotic arms and an endoscope gain access to
    the heart, making surgery possible without
    opening the chest
  • Has been proven that these patients get out of
    the hospital 1-2 days earlier
  • This technique may develop into new technology
    that might be used more often in the future and
    may replace open heart surgery

  • CABG still remains that best therapy in terms of
    superior survival and decreased need for
    reintervention for most patients with proximal
    LAD, multivessel, and left main-stem CAD.
  • These affects are magnified in the diabetic
  • PCI with stent is still chosen as treatment
    option for single-vessel disease, and now
    considered for 2 or 3-vessel disease
  • Each patient is evaluated for the best treatment
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