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Bypass Surgery or Angioplasty?It’s a serious and highly individual decision. There are essential points to consider with your doctor
Diagnostic testing confirms that your arteries are narrowed by fatty deposits (plaque). Your doctor recommends revascularization: increasing blood flow to the heart muscle with balloon angioplasty or coronary artery bypass surgery. But which one is right for you?
The answer is more complex than you might think. Although some generalizations can be made about which patients are suited for one approach or the other, it’s nearly impossible to make hard and fast rules. Multiple factors must be considered, including the relative benefits and limitations of the procedures themselves. Understanding these factors can make your decision less mysterious and worrisome.
Angioplasty: Easier on the body
On first glance, angioplasty would seem the obvious choice for most patients. In this nonsurgical procedure, an interventional cardiologist threads a balloon-tipped catheter to the blockage. Inflating the balloon compresses the plaque against the artery wall, opening the vessel and allowing blood to flow more freely to the heart. Angioplasty typically requires only an overnight stay in the hospital; avoids general anesthesia and a surgical incision; eliminates the need to use a heart-lung bypass machine; and allows patients to resume their normal activities in less than a week.
The downside of angioplasty is that the artery may re-narrow, a process known as restenosis. Within six months of angioplasty, 20 to 40 percent of patients experience restenosis. Nevertheless, restenosis rates have improved substantially in recent years, explains Richard Grimm, DO, a staff cardiologist and program director of the cardiovascular imaging fellowship at The Cleveland Clinic.
The improvements are attributable to doctors having acquired more skill and experience in performing the procedures; the use of better combinations of blood-thinning and platelet-blocking medications after angioplasty; and the increasing use of stents. A stent is a wire mesh tube that is carried on the angioplasty balloon. As the balloon inflates, the stent becomes permanently embedded in the vessel wall and helps to hold the artery open.
Coronary artery bypass: more risky
Coronary artery bypass surgery is a more complex procedure. It’s a three-to-six-hour surgery in which the breast bone must be split and spread apart to gain access to the heart. A section of a vein or artery from another area of the body is then sewn in place to divert blood flow around the blockage. In traditional bypass surgery, doctors stop the heart and route the blood flow through a heart-lung bypass machine. Recovery entails a four-to-five-day hospital stay and six to eight weeks at home.
The advantage of bypass surgery is the greater durability and more complete restoration of blood flow. On average, 90 percent of bypass grafts are open and functioning well within 10 years after surgery. The drawbacks are the rigors and risks of open-heart surgery and the lengthy recovery time. Extended time on a heart-lung bypass machine carries a small risk of stroke and is associated in some patients with memory impairment, difficulty concentrating, and other neurological changes. (Fortunately, these impairments are usually temporary.) The risk of dying during bypass surgery is 1 to 3 percent—depending on age and other medical conditions—compared to 1 percent or less for angioplasty. It’s also possible to perform bypass surgery on certain patients without stopping the heart, a procedure known as off-pump bypass.
General guidelines
Multiple factors go into the angioplasty-or-bypass decision, but here are some general considerations:
Number of diseased arteries: Angioplasty is often recommended when one or two arteries are blocked. Having more than two diseased arteries makes bypass a potentially more suitable procedure.
Location of blockage: A severe blockage in the left main coronary artery, the proximal left anterior descending and circumflex coronary artery, or one at an artery branching point usually requires bypass.
Length of the blockage: Angioplasty is more successful when performed on relatively short blockages.
Degree of calcification: The more stiff, calcified plaque in the blocked artery, the harder it is to get a good result from angioplasty.
Condition of the heart muscle: A person with less advanced coronary artery disease is usually a better candidate for angioplasty. On the other hand, angioplasty may also be the preferred treatment for someone with advanced heart disease and other medical conditions, for whom bypass would be too risky.
Condition of the aorta: If a patient's aorta is calcified (lined with stiff plaque), angioplasty may be safer.
Presence of diabetes: Some studies suggest that patients with diabetes may have better outcomes with bypass surgery rather than angioplasty. This article originally appeared in the January 2002 issue of Men's Health Advisor.
