Balloon Angioplasty and Stents
Using a small balloon to dilate a blocked coronary artery is referred to as a balloon angioplasty, which is referred to by doctors as PTCA (percutaneous transluminal coronary angioplasty). The procedure involves inserting a catheter (a hollow flexible tube) into a leg or arm artery, then guiding it into the blocked coronary artery while viewing an x-ray image. Another catheter with a balloon on the end is then inserted inside the first catheter, and inflated in the narrowed area to dilate the artery. It is not technically "surgery," and is performed by cardiologists, not cardiac surgeons. This procedure has transformed the way heart disease is being treated, and each year over 600,000 balloon angioplasties are performed. In recent years, stents have been used to improve the results of angioplasties. A stent is a small piece of inflatable wire mesh tubing that is placed in the artery where it was blocked following balloon angioplasty to keep the artery from narrowing again. More recently, radiation has been incorporated into the stent and the angioplasty equipment to help prevent recurrence of narrowing. The use of radiation is new and still under investigation. Angioplasty and stent placement are likely to evolve during the next several years as new technology is being developed.
Frequently Asked Questions
What types of blockages are best treated with balloon angioplasty?
The best results are achieved in a patient with a short blockage in a single artery. However, many cardiologists are using angioplasty in individuals with blockages in several vessels. This is called multivessel angioplasty. A patient who has blockages that are best treated with surgery but who is at very high risk for bypass surgery due to other medical problems or age may undergo angioplasty instead.
What are the results usually expected of angioplasty?
Angioplasty is a very safe procedure when performed by a trained cardiologist who does the procedure on a regular basis. A blocked artery can be dilated over 95% of the time with excellent relief of symptoms. Death from the procedure, the need of emergency surgery during the procedure, and other major complications are infrequent, occurring less than 2% to 3% of the time. The disadvantage of angioplasty is the likelihood that the blockage will happen again. In about 20% to 30% of patients, the blockage will return within 6 months. Many patients will need repeat angioplasties in the future or require bypass surgery.
How does angioplasty compare with bypass surgery?
Bypass surgery is a major operation. It comes with pain, discomfort, and the usual risks of major surgery. However, the risks of surgery in general are low these days. A successful bypass operation provides a far better long-term outcome for the patient than angioplasty. (Outcome here means freedom from the symptoms of coronary artery disease and from the need for a second procedure.) In contrast, angioplasty is a less invasive procedure and the patient is home quickly, frequently the next day, but the downside of angioplasty is the likely need for more procedures in the future. For those individuals with single-vessel blockage, the long-term survival rate is the same for bypass surgery as it is for angioplasty. There are several exceptions however, the major one being blockage in the left main coronary artery. Therefore, the current recommendation for single-vessel disease is angioplasty. For those individuals with multivessel disease, surgery appears to be the best option although this recommendation is not unanimous among physicians.
What role does a stent play?
A stent - a small piece of inflatable wire mesh tubing - is used to reduce the recurrence of a blockage after angioplasty. Stents are usually placed at the time of an angioplasty procedure. After an artery has been dilated and the blockage cleared, the stent is placed at the site of the blockage. Even though the success with stents has been modest, the use of stents with angioplasty has increased exponentially.
Coronary Artery Bypass Surgery
Doctors refer to coronary artery bypass surgery as CABG (pronounced "cabbage"), which is an abbreviation for coronary artery bypass grafting. It is one of the most common operations in the United States. According to the Society of Thoracic Surgeons, more than 500,000 CABG operations are performed yearly. Most of these patients are men and over the age of 60 years.
I tell my patients that CABG is an operation used to bypass blocked arteries with new plumbing, similar to a detour during road construction. There are six major steps to the operation:
1. opening the chest and getting to the heart
2. taking the veins and arteries needed for the operation from different areas ("harvesting")
3. putting the patient on the heart-lung machine and stopping the heart
4. attaching the harvested arteries and veins to the heart ("bypass grafting")
5. restarting the heart and taking the patient off the heart-lung machine
6. checking and cleaning the area and closing
Each operation requires a surgeon-in-charge and several assistants who are assigned to different tasks.
Most CABG operations are elective; in other words, the surgery is scheduled in advance and the patient comes to the hospital either on the day of the operation or the day before. The operation takes approximately 4 to 5 hours. After surgery, the patient will go to the intensive care unit and stay from several hours to 1 or 2 days before moving to a regular hospital floor. Most patients can go home 5 to 7 days after their operation.
Frequently Asked Questions
What types of blockages should be bypassed with surgery rather than dilated with angioplasty?
There is considerable variability among cardiologists and the field is changing very quickly. In general, bypass surgery is better when several vessels are blocked and the blockages are more extensive. In some patients, the location of a blockage in a critical artery such as the left main coronary artery makes angioplasty unsuitable. An artery that is 100% blocked (as opposed to partially blocked) can make angioplasty nearly impossible.
Are there other options beside coronary artery bypass surgery?
If bypass surgery has been recommended for you, the likelihood is that your cardiologist has already explored other options such as drug therapy, balloon angioplasty, and stents. These are usually the initial treatment methods and bypass surgery is the best treatment when the other treatments are no longer appropriate. Some physicians have advocated coronary artery disease reversing strategies that include diet and lifestyle changes instead of CABG. These approaches may be difficult to adhere to for many individuals, their outcomes are uncertain, and they are probably not appropriate for someone who requires immediate surgical intervention for coronary artery disease.
When bypass surgery is recommended, how important is a second opinion?
You should obtain a second opinion whenever feasible, although surgery should not be delayed for a significant period of time while searching for a second opinion. The cardiologist who recommended bypass surgery can usually provide the name of another cardiologist for a second opinion.
What are the risks of coronary artery bypass surgery?
Coronary artery bypass surgery is a major operation. As such, this surgery is associated with potentially serious complications and death, even if you are the ideal patient and you have chosen the best surgeon. The list of complications can be quite long and may include internal bleeding, heart attack, heart failure, heart rhythm disturbances, the need for insertion of a permanent pacemaker, stroke, wound infection, pneumonia, respiratory failure, kidney failure, and others. If you are to have bypass surgery, the surgeon or one of the surgical assistants will discuss these complications with you when the surgery consent form is given to you to sign. You should not be distressed by the long list of potential complications. The likelihood of a complication after surgery is small, and most of the complications are treatable; however, they may extend your stay in the hospital. It is important for the surgeon or one of the team to discuss these matters with you in a clear and realistic manner.
What is the risk of death associated with coronary artery bypass surgery?
For most individuals, the risk of dying from bypass surgery ranges from 1% to 2%. In some patients, the risk can be considerably higher. The risk of death is dependent on several factors—the most important ones being heart function, age, severity of other medical problems, and history of a recent heart attack. There are a number of methods to measure heart function. A left ventricular ejection fraction (LVEF) test is one of the more common methods and measures the percentage of blood ejected from the left ventricle during each heart contraction. As the heart fails, less blood will be ejected with each contraction. The risk of surgery increases significantly when the ejection fraction falls below 30% and thus bypass surgery must be reviewed on a case-by-case basis. When the ejection fraction falls below 25%, the risk is probably too high to justify surgery, and heart transplantation may be considered.
Is there an upper age limit for bypass surgery?
If you are in your late 70s or 80s, the risks of surgery are higher. However, if you lead an active life and don't have any other major medical problem, bypass surgery can be undertaken and is becoming quite common for people in this age range. On rare occasions, surgery has been performed for patients in their 90s. All these cases are reviewed carefully on an individual basis, balancing risks against benefits.
Is there anything that can be done to decrease the risk of bypass surgery?
Yes, there is. If you still smoke, stop immediately. If you take aspirin or aspirin-containing medications, they should be stopped 7 days before surgery (but consult with the surgeon first). If you have other significant medical problems, you should undergo a preoperative evaluation by your family physician to ensure you receive optimal treatment and care before, during, and after your surgery. If you have a history of respiratory problems, your lung function should be in maintained in the most optimal condition using a combination of breathing exercises and/or drug therapy, supervised by a lung specialist. And although I am unable to provide a scientific explanation, I believe that being in a state of optimism is very important.
Are there preparations that I should undertake before surgery?
Although the operation will most likely go smoothly, it is a major procedure associated with serious complications and death. Accordingly, personal matters should be in order and a will should be in place prior to the scheduled surgery date. A living will that expresses your wishes regarding issues such as prolonged life support is highly recommended. You can usually obtain information on this through the hospital's chaplain's office, social services, or the surgeon's office.
Can I have visitors while I am in the hospital following surgery?
Visitation should be limited to the immediate family. You will probably feel very tired after surgery and should not be imposed upon to entertain excessive number of visitors. For most patients, hospitalization is no more than 7 days, and many important healthcare activities are compressed into this brief period. The presence of numerous visitors may interfere with these activities. The situation changes when prolonged hospitalization is required due to an unexpected complication. Visits from friends and work associates can be a source of hope and inspiration in this case.
How can my family help when I need coronary artery bypass surgery?
Your immediate family should provide you with companionship, support, and assistance. Prior to surgery, encouragement and optimism on their part can provide a sense of security and hope. You and your family should avoid excessive anxiety. Most surgery is uncomplicated, and the presence of someone from your family round the clock is unnecessary. Setting up a visiting schedule is a good idea such that no one family member is under too much pressure. When appropriate, family members can assist you when you need to walk. They can also provide quiet company and read to you, both of which can help you relax and thus aid your recovery.
What can be done to speed up my recovery?
Recuperation from surgery is not a race. Healing takes time and I question the wisdom of speeding up the recovery. It is remarkable how the body heals on its own. Our job is to stay out of the way and allow the body to heal, but the process can benefit from plenty of rest, a healthy diet, daily walks at least once or twice a day, and following your surgeon's instructions.
When can I return to work after coronary artery bypass surgery?
It depends primarily on the recovery course, the type of work you do, and your age. Once again, remember that coronary artery bypass surgery is a major operation. I usually suggest 3 months as the necessary time for recuperation. Some patients are able to return to work sooner, while a few have used the operation as the beginning of their retirement.
What is a heart-lung machine?
The heart-lung machine takes over the functions of the heart and lung organs during surgery. The surgeons call the process cardiopulmonary bypass or extracorporeal circulation. The machine is required because it is necessary to stop the heart during bypass surgery so that the beating of the heart does not interfere with the delicate suturing of the coronary arteries.
How is the heart stopped during surgery?
The heart is stopped with a solution called cardioplegia, which contains a large amount of potassium.
How does the heart start beating after surgery?
Sometimes, the heart will start beating on its own and at other times, it will require an electrical shock to restore its regular rhythm.
What is used to bypass the blocked heart arteries?
The standard choices are the veins in the legs and the mammary arteries in the chest. Studies have shown that the mammary artery lasts considerably longer than the best leg (saphenous) veins. Overall, the veins used as bypass arteries will last approximately 5 to 10 years; the mammary arteries, 10 years or more. The success of the mammary artery has led to the use of other arteries, such as the radial artery in the forearm, the right gastroepiploic artery near the stomach, and the inferior epigastric artery on the abdominal wall, for bypass surgery.
How frequent is blood transfusion required during surgery?
The answer depends on your baseline blood count, how well the surgery goes, and numerous others factors. Overall, more than 50% of patients will receive some blood products during surgery.
What is the my chance of infection with the HIV or hepatitis virus following blood transfusion?
The probability of HIV or hepatitis infection from blood transfusion is very low but never zero. For HIV, the risk of infection is approximately 1 in 650,000 units of blood. If you are concerned, you can save your own blood before surgery for use if needed; this is called autologous blood donation. Storing one's own blood This program is not suitable in every case, and the urgency of surgery can preclude its use. Your family and friends can donate blood and should be encouraged to do so. However, studies have shown that blood from the blood bank is just as safe as their blood.
What is minimally invasive coronary artery bypass surgery?
With minimally invasive coronary artery bypass surgery, the bypass operation is performed through a smaller incision; you are not placed on the heart-lung machine; and your heart is not stopped during surgery. Usually, only one vessel can be bypassed with this technique, although there are some surgeons doing multiple-vessel bypass with it. The advantages of minimally invasive coronary artery bypass surgery are less pain, possibly a reduced complication rate, shortened hospital stay, and a faster recovery. It needs to be pointed out that no studies have so far shown that the procedure is superior to conventional coronary bypass surgery.
Will I need another coronary artery bypass surgery in the future?
Most patients will get by with only one operation, but a few will require a second one and on rare occasions a third one. The mammary artery will usually last more than 10 years, while veins will last 5 to 10 years. Remember that surgery does not cure atherosclerosis; it is purely a mechanical process that bypasses one or more blocked arteries.
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