Is Coronary Artery Bypass Surgery Is Coronary Artery Bypass Surgery Really Better than Coronary Really Better than Coronary

Stents?Stents?A look at the risks and benefitsA look at the risks and benefits

Sarah SmithSarah SmithAdvisor: Dr. GrimesAdvisor: Dr. Grimes

Why is this important?Why is this important?

The leading cause of death in the United The leading cause of death in the United States is coronary heart diseaseStates is coronary heart disease

It accounts for about 1 million deaths per It accounts for about 1 million deaths per yearyear

About 43% of heart disease deaths are About 43% of heart disease deaths are related to coronary artery diseaserelated to coronary artery disease

Heart disease is the leading cause of death Heart disease is the leading cause of death of American women, accounting for 32% of of American women, accounting for 32% of all deaths per year.all deaths per year. One in three women will die from heart disease, One in three women will die from heart disease,

while one in 25 will die from breast cancerwhile one in 25 will die from breast cancer Trends in the United States suggest that half Trends in the United States suggest that half

of healthy 40-year-old males will develop of healthy 40-year-old males will develop CAD in the future, and one in three healthy CAD in the future, and one in three healthy 40-year-old women40-year-old women

PathophysiologyPathophysiology

CAD is a chronic CAD is a chronic disease in which the disease in which the coronary arteries coronary arteries gradually harden and gradually harden and narrownarrow

Limitation of blood flow Limitation of blood flow to the heart causes to the heart causes ischemia of the ischemia of the myocardial cells, myocardial cells, leading to a myocardial leading to a myocardial infarctioninfarction

This leads to heart This leads to heart muscle damage, heart muscle damage, heart muscle death and later muscle death and later scarring without heart scarring without heart muscle regrowthmuscle regrowth

Pathophysiology Cont.Pathophysiology Cont.

CAD can be thought of as a wide spectrum of CAD can be thought of as a wide spectrum of disease of the heartdisease of the heart

At one end is the asymptomatic individual with At one end is the asymptomatic individual with fatty streaks within the walls of the coronary fatty streaks within the walls of the coronary arteriesarteries Over time these streaks will increase in thickness and Over time these streaks will increase in thickness and

may affect the flow of blood through the arteriesmay affect the flow of blood through the arteries As the plaque continues to grow and obstruct the As the plaque continues to grow and obstruct the

vessel to more than 70% the patient typically vessel to more than 70% the patient typically develops symptoms of obstructive coronary artery develops symptoms of obstructive coronary artery diseasedisease

At this stage the patient is said to have At this stage the patient is said to have ischemic heart disease, meaning the patient’s ischemic heart disease, meaning the patient’s heart is experiencing an increased workload, heart is experiencing an increased workload, thus reduced blood supply to the heart wallsthus reduced blood supply to the heart walls

PathophysiologyPathophysiology

As CAD progresses, there may be As CAD progresses, there may be nearly complete obstruction of the nearly complete obstruction of the lumen of the coronary arterylumen of the coronary artery

Patients at this level have typically Patients at this level have typically suffered from 1 or more myocardial suffered from 1 or more myocardial infarctions, and may have angina at infarctions, and may have angina at rest and pulmonary edemarest and pulmonary edema

An individual may develop a rupture An individual may develop a rupture of a plaque at any stage of the of a plaque at any stage of the spectrum.spectrum. The acute rupture a plaque may lead to The acute rupture a plaque may lead to

an acute MIan acute MI

Risk FactorsRisk Factors

Family history of premature CADFamily history of premature CAD SmokingSmoking Diabetes mellitusDiabetes mellitus HTNHTN HyperlipidemiaHyperlipidemia obesityobesity

Presentation/DiagnosisPresentation/Diagnosis

Generally patients present with stable Generally patients present with stable angina, unstable angina, or a angina, unstable angina, or a myocardial infarctionmyocardial infarction

Coronary angiogram is currently golden Coronary angiogram is currently golden standard for determining the presence standard for determining the presence of obstructive coronary artery diseaseof obstructive coronary artery disease Yields a 2D picture of coronary arteriesYields a 2D picture of coronary arteries A catheter is inserted into the coronary A catheter is inserted into the coronary

arteries and injected with dyearteries and injected with dye The dye allows the physician to pinpoint The dye allows the physician to pinpoint

the number and location of blockages in the number and location of blockages in the coronary arteriesthe coronary arteries

Treatment OptionsTreatment Options

There are many different treatment There are many different treatment options availableoptions available

A physician will look into the patients’ A physician will look into the patients’ individual risk factors, severity of the individual risk factors, severity of the blocked artery, and analyze the blocked artery, and analyze the benefits and risks for possible benefits and risks for possible proceduresprocedures

Two popular procedures are PCTA/stent Two popular procedures are PCTA/stent implantation and CABG surgeryimplantation and CABG surgery

Medical therapy is also available for a Medical therapy is also available for a more conservative treatmentmore conservative treatment

Overview of StentsOverview of Stents

1/3 of patients with CAD will undergo coronary 1/3 of patients with CAD will undergo coronary angioplasty with stents or Percutaneous Transluminal angioplasty with stents or Percutaneous Transluminal Coronary Angioplasty (PCTA)Coronary Angioplasty (PCTA)

Angioplasty involves temporarily inserting and Angioplasty involves temporarily inserting and expanding a tiny balloon at the site of blockage to expanding a tiny balloon at the site of blockage to help widen the narrowed arteryhelp widen the narrowed artery

Usually combined with stent implantation in the Usually combined with stent implantation in the artery to help prop it open and decrease the chance artery to help prop it open and decrease the chance of it narrowing again or restenosisof it narrowing again or restenosis

Performed in cardiac catheterization lab and are non-Performed in cardiac catheterization lab and are non-surgical treatmentsurgical treatment

Usually last about 1-2 hours and most patients are Usually last about 1-2 hours and most patients are usually discharged in 1-2 days after a procedureusually discharged in 1-2 days after a procedure

Stents are a stainless or nytinol mesh like deviceStents are a stainless or nytinol mesh like device Angioplasty and StentsAngioplasty and Stents YouTubeYouTube Stent Stent

StentsStents

A stent is a stainless tube with A stent is a stainless tube with slots. It is mounted on a balloon slots. It is mounted on a balloon catheter in a collapsed state. catheter in a collapsed state. When the balloon is imflated, the When the balloon is imflated, the stent expands and pushes itself stent expands and pushes itself against the inner wall of the against the inner wall of the coronary artery.coronary artery.

The risk of emergency referral for The risk of emergency referral for CABG and need for subsequent CABG and need for subsequent revascularization procedures has revascularization procedures has reduced by more than 50% reduced by more than 50% because of coronary stentsbecause of coronary stents

Stent implantation has shown to Stent implantation has shown to reduce restenosis in vessels with reduce restenosis in vessels with reference diameter >3mm, reference diameter >3mm, however in-stent restenosis still however in-stent restenosis still occurs in about 10-40% of patientsoccurs in about 10-40% of patients

According to the American Heart According to the American Heart Association stents can be Association stents can be considered for use in patients who considered for use in patients who have significant disease of left have significant disease of left main and left anterior descending main and left anterior descending coronary artery. Also patients with coronary artery. Also patients with 2 or 3-vessel disease should be 2 or 3-vessel disease should be consideredconsidered

In previous years these In previous years these patients were only candidates patients were only candidates for bypass surgeryfor bypass surgery

Risks/Benefits of StentsRisks/Benefits of Stents

Benefits:Benefits: Shorter procedural Shorter procedural

and recovery time and recovery time than CABGthan CABG

Angina relief about Angina relief about 75% of the time75% of the time

Decreases the risk Decreases the risk for heart attackfor heart attack

Increases blood flow Increases blood flow to the heartto the heart

Risks and Risks and Limitations:Limitations: Risk of death <1%Risk of death <1% Risk of heart attack, Risk of heart attack,

thrombosis and thrombosis and bleeding <4%bleeding <4%

Major limitation of Major limitation of procedure is a high procedure is a high rate of restenosis and rate of restenosis and need for need for revascularizationrevascularization

Scar tissue formationScar tissue formation Not a cure to the Not a cure to the

disease, still need to disease, still need to reduce risk factors reduce risk factors and make lifestyle and make lifestyle changes to prevent changes to prevent future disease future disease progressionprogression

Research…Research…

Patients receiving stents had lower incidence Patients receiving stents had lower incidence of death, MI, and stroke at 30-day follow-up of death, MI, and stroke at 30-day follow-up compared to CABG.compared to CABG.

However, patients receiving stents had a However, patients receiving stents had a higher incidence of repeat revascularization higher incidence of repeat revascularization proceduresprocedures 25% of patients at 1 year and 47% at 5 years25% of patients at 1 year and 47% at 5 years

This high risk of restenosis is one of the This high risk of restenosis is one of the major reasons for patients refusing major reasons for patients refusing angioplasty and opting for other treatment angioplasty and opting for other treatment modalities like surgerymodalities like surgery

The introduction of drug-eluting stents may The introduction of drug-eluting stents may shift patients from surgical procedures back shift patients from surgical procedures back to angioplasty and stent use.to angioplasty and stent use.

Drug-eluting StentsDrug-eluting Stents

These are stents that are coated with These are stents that are coated with a drug that is known to interfere with a drug that is known to interfere with the process of restenosisthe process of restenosis

As of December 2007, the FDA has As of December 2007, the FDA has approved of 2 DES: sirolimus-eluting approved of 2 DES: sirolimus-eluting stents and paclitaxel-eluting stentsstents and paclitaxel-eluting stents

Studies show that there is a 70-90% Studies show that there is a 70-90% reduced rate of restenosis when reduced rate of restenosis when compared with bare-metal stentscompared with bare-metal stents

DES were first introduced in April DES were first introduced in April 2003, and just 9 months later made 2003, and just 9 months later made up 35% of all stent implantations in up 35% of all stent implantations in the United Statesthe United States

Problem with DES?Problem with DES?

1. They are expensive1. They are expensive It costs about $2200 for a DES, when compared to bare-It costs about $2200 for a DES, when compared to bare-

metal stents which costs about $600.metal stents which costs about $600. In one study they looked at the cost-effectiveness of In one study they looked at the cost-effectiveness of

DES. They took into account the fact that there will be DES. They took into account the fact that there will be reduced repeat revascularization procedures, and reduced repeat revascularization procedures, and discovered that there was still an increase in $600 per discovered that there was still an increase in $600 per patient, and with an estimated 1 million procedures patient, and with an estimated 1 million procedures done a year, about $600 million increased in annual done a year, about $600 million increased in annual healthcare spendinghealthcare spending

2. The drug agents can interfere with the healing 2. The drug agents can interfere with the healing process and found to hamper natural vascular healing process and found to hamper natural vascular healing processprocess In 2007, the FDA has cautioned the use of DES, because In 2007, the FDA has cautioned the use of DES, because

they are associated with increased risks of both early they are associated with increased risks of both early and late stent thrombosis, as well as death, and and late stent thrombosis, as well as death, and myocardial infarctionmyocardial infarction

DES are still a novel idea; it will be interesting to see DES are still a novel idea; it will be interesting to see the research that comes out in the next couple years the research that comes out in the next couple years looking at their effectiveness and future indicationslooking at their effectiveness and future indications

Overview of CABGOverview of CABG

CABG is still the best therapy for CABG is still the best therapy for reintervation for most patients reintervation for most patients with proximal left anterior with proximal left anterior descending, multivessel, and left descending, multivessel, and left main-stem coronary artery main-stem coronary artery diseasedisease

Of the patients with CAD, about Of the patients with CAD, about 10% will undergo CABG surgery10% will undergo CABG surgery

CABG is a surgery that increases CABG is a surgery that increases blood flow to the heart by blood flow to the heart by creating a detour and re-routing creating a detour and re-routing the blood flow around the blocked the blood flow around the blocked portion of the artery. portion of the artery.

A section of a blood vessel from A section of a blood vessel from another part of the body is another part of the body is removed and grafted above and removed and grafted above and below the damaged portion of the below the damaged portion of the coronary artery to form an un-coronary artery to form an un-blocked arteryblocked artery

Most commonly used are the Most commonly used are the saphenous vein and internal saphenous vein and internal thoracic arterythoracic artery

This procedure is performed with This procedure is performed with assistance of a heart-lung assistance of a heart-lung machine, which supports the machine, which supports the patient’s blood during surgerypatient’s blood during surgery

CABG SurgeryCABG Surgery

Risks/Benefits CABG Risks/Benefits CABG surgerysurgery

CABG was introduced about 50 years ago CABG was introduced about 50 years ago and is now performed in 1 million patients and is now performed in 1 million patients at a cost exceeding $20 billion annuallyat a cost exceeding $20 billion annually

Many benefits such as decrease in angina, Many benefits such as decrease in angina, improved life-span, and providing an improved life-span, and providing an effective route for blood with prevention of effective route for blood with prevention of new plaques to formnew plaques to form

Surgery is however a much more serious Surgery is however a much more serious operation that lasts a long time, with a long operation that lasts a long time, with a long recovery timerecovery time

Some complications seen after surgery are Some complications seen after surgery are atrial fibrillation, increased risk of stroke, atrial fibrillation, increased risk of stroke, and cognitive dysfunctionand cognitive dysfunction

Research…Research…

Less than 5% chance of heart damage and less than Less than 5% chance of heart damage and less than 2% chance of death2% chance of death

Stroke or other neurological injury occurs in 5% Stroke or other neurological injury occurs in 5% patientspatients

Atrial fibrillation occurs in 20-40% of patients after Atrial fibrillation occurs in 20-40% of patients after CABGCABG

2 reasons as to why CABG offers survival advantages 2 reasons as to why CABG offers survival advantages for multivessel and left main-stem coronary artery for multivessel and left main-stem coronary artery diseasedisease 1. Bypass grafts are placed on the midcoronary vessel, 1. Bypass grafts are placed on the midcoronary vessel,

CABG not only protects the culprit lesion, but also offers CABG not only protects the culprit lesion, but also offers prophylaxis against new lesions in diseased prophylaxis against new lesions in diseased endotheliumendothelium

Where stents only treat immediate culprit lesion, with no Where stents only treat immediate culprit lesion, with no protective effect against the development of new diseaseprotective effect against the development of new disease

2. failure of stents to achieve complete 2. failure of stents to achieve complete revascularization in most patients with multivessel revascularization in most patients with multivessel disease reduces survival proportional to the degree of disease reduces survival proportional to the degree of incomplete revascularizationincomplete revascularization

Isolated LAD and Left-main Isolated LAD and Left-main stem CADstem CAD

CAD in LAD has been reported as high as CAD in LAD has been reported as high as 50% among patients who undergo CABG50% among patients who undergo CABG

CABG is regarded as an accepted golden CABG is regarded as an accepted golden standard for left main coronary artery standard for left main coronary artery diseasedisease

CABG has generally been considered the CABG has generally been considered the golden standard of therapy for left-main stem golden standard of therapy for left-main stem stenosis for the last decade.stenosis for the last decade. However, there are recent studies out that show However, there are recent studies out that show

patients underwent PCI more than CABG for this patients underwent PCI more than CABG for this type of disease. This artery has a relatively large type of disease. This artery has a relatively large diameter, making it an attractive site for PCIdiameter, making it an attractive site for PCI

Restenosis rates in a study were 30.3% in bare-Restenosis rates in a study were 30.3% in bare-metal stents, 7.4% in DES group, and 3.7% in CABG metal stents, 7.4% in DES group, and 3.7% in CABG groupgroup

Multivessel CADMultivessel CAD

MVD accounts for approximately 60% of the MVD accounts for approximately 60% of the CAD patientsCAD patients

The use of stents in these patients has The use of stents in these patients has resulted in higher restenosis and repeat resulted in higher restenosis and repeat vascularization rates than in patients treated vascularization rates than in patients treated with surgerywith surgery Stents group had 16.8% restenosis rate as Stents group had 16.8% restenosis rate as

compared with 3.5% who underwent surgerycompared with 3.5% who underwent surgery CABG patients also experience fewer MI and CABG patients also experience fewer MI and

major adverse cardiovascular eventsmajor adverse cardiovascular events DES have decreased the difference between DES have decreased the difference between

CABG and bare-metal stentsCABG and bare-metal stents In order for PCI to replace CABG as the In order for PCI to replace CABG as the

preferred therapy in MVD, clinical trials must preferred therapy in MVD, clinical trials must demonstrate long-term outcomes that are demonstrate long-term outcomes that are equivalentequivalent

What about the Diabetic What about the Diabetic Patient?Patient?

The diabetic patient is a high risk for coronary artery The diabetic patient is a high risk for coronary artery disease, the incidence and severity of the disease disease, the incidence and severity of the disease are higher as compared to nondiabetic patientare higher as compared to nondiabetic patient

Revascularization of diabetic patients has been a Revascularization of diabetic patients has been a huge dilemma and a great challengehuge dilemma and a great challenge

A study confirmed that even a low-risk diabetic A study confirmed that even a low-risk diabetic patient there is a survival advantage at 10 years for patient there is a survival advantage at 10 years for CABG in comparision with PCI of 58% vs. 46%CABG in comparision with PCI of 58% vs. 46% Also found that there is a huge difference in the need Also found that there is a huge difference in the need

for revascularization in both; 18% of CABG patients and for revascularization in both; 18% of CABG patients and 80% of PCI80% of PCI

Studies state that the preferred revascularization Studies state that the preferred revascularization strategy in the diabetic patient with MVD is CABG strategy in the diabetic patient with MVD is CABG surgerysurgery Lower mortality in CABG patients vs. PCI patients (1.4% Lower mortality in CABG patients vs. PCI patients (1.4%

vs. 12.8%)vs. 12.8%) Lower major adverse cardiovascular events (8.6% vs. Lower major adverse cardiovascular events (8.6% vs.

26.6%)26.6%)

The FutureThe Future

Minimally invasive direct coronary artery bypass Minimally invasive direct coronary artery bypass (MIDCAB) is on the rise(MIDCAB) is on the rise

It is performed on a beating heart with use of stabilizing It is performed on a beating heart with use of stabilizing devices or using minimal access bypass system with devices or using minimal access bypass system with endo-aortic clamping and cardioplegic arrestendo-aortic clamping and cardioplegic arrest

Yields shorter hospital stay with lower postoperative Yields shorter hospital stay with lower postoperative complications and better quality of life with similar complications and better quality of life with similar safety and long-term efficacy as conventional CABGsafety and long-term efficacy as conventional CABG

Robotic instrumentation is also developingRobotic instrumentation is also developing Surgery does not have a single chest incision of any kind, Surgery does not have a single chest incision of any kind,

this surgery requires 3 pencil-sizes holes made between this surgery requires 3 pencil-sizes holes made between the ribsthe ribs

2 robotic arms and an endoscope gain access to the heart, 2 robotic arms and an endoscope gain access to the heart, making surgery possible without opening the chestmaking surgery possible without opening the chest

Has been proven that these patients get out of the Has been proven that these patients get out of the hospital 1-2 days earlierhospital 1-2 days earlier

This technique may develop into new technology that This technique may develop into new technology that might be used more often in the future and may replace might be used more often in the future and may replace open heart surgeryopen heart surgery

ConclusionConclusion

CABG still remains that best therapy in CABG still remains that best therapy in terms of superior survival and decreased terms of superior survival and decreased need for reintervention for most patients need for reintervention for most patients with proximal LAD, multivessel, and left with proximal LAD, multivessel, and left main-stem CAD.main-stem CAD.

These affects are magnified in the diabetic These affects are magnified in the diabetic patientpatient

PCI with stent is still chosen as treatment PCI with stent is still chosen as treatment option for single-vessel disease, and now option for single-vessel disease, and now considered for 2 or 3-vessel diseaseconsidered for 2 or 3-vessel disease

Each patient is evaluated for the best Each patient is evaluated for the best treatment option based on their own risk treatment option based on their own risk factors and progression of diseasefactors and progression of disease

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