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Publications total: 16
  Mar 17th,2016

To Stent or not to Stent

Introduction:

One condition that is rapidly becoming one of the leading killers in the United States is coronary artery disease. Also termed as atherosclerosis, the condition is characterized by hardening of the coronary arteries due to deposition of fatty plaques on its interior walls. This decreases the size of the arterial lumen and lead to build-up of pressure on the heart and in extreme cases the plaques may completely stop the flow of blood leading to heart attacks (Michaels, 2002).

Different treatment options are available for coronary artery disease depending on the severity of the condition ranging from open bypass surgery to angioplasty. Angioplasty is a non-surgical treatment option that is significantly stress-free compared to open heart surgery (Webmed, 2016). According to Michaels (2002), nearly one third of the patients suffering from coronary artery disease can be benefitted from angioplasty.


Angioplasty:

During the angioplasty, a metal tube called stent is used to provide scaffolding support to the coronary artery from inside. The metal stent is inserted into the coronary artery using a catheter with a balloon at its tip. Once inside the air is blown into the balloon to increase the size of the artery and the accompanying stent ensures that the space created does not collapses back. Once the stent is firmly in its place air is blown out of the balloon and pulled back (Beckerman, 2016). Being non-surgical in nature, angioplasty and stenting is becoming a treatment of choice for patients suffering from coronary artery disease in the United States. Both the cardiac surgeons and the patients find the procedure appealing because the risks are significantly low compared to an open bypass surgery and the entire process can be completed in around 2 hours under local anaesthesia (Michaels, 2002).


Coronary bypass surgery procedure:

This is a major surgical procedure where a healthy blood vessel (artery or vein) is taken to create a bypass so that blocked coronary artery can be avoided and normal blood flow restored. This procedure is carried out in severe conditions such as in patients with more than 2 blocked coronary arteries. Coronary bypass surgery involves the use of a heart-lung machine to ensure normal blood circulation in the patient during the procedure and requires the use of general anaesthesia. Given the complicated nature of the surgery, the patient may require up to 3 months to completely recover from procedure (Michaels, 2002).


Stents or Bypass surgery:

The decision to select the best procedure for treating coronary artery disease varies significantly from one patient to another and the cardiac surgery will have to consider multiple aspects to make the best choice. Severity of the heart condition is a major factor that determines if a patient requires coronary bypass surgery or stenting. According to Pittman (2013) angioplasty and stenting is the best procedure for patients who have just one single clogged vessel but for patients with multiple artery blockage surgery may be the only option. Another aspect that is critical is making a selection between open heart surgery and stenting is the medical history of the patients. There are some scientific studies that indicate that coronary bypass surgery may be the best option for patients suffering from other conditions such as diabetes while stenting could be ideal for individuals suffering from different forms of lung conditions. The health of the patient is also a major determining factor that helps the surgeon in recommending the best option. Patients who are old or already suffer from other debilitating conditions such as heart valve defects may not be the right candidates for coronary bypass surgery (SCAI, 2015). Cohen et al carried out a randomized trial with a cohort of 1800 patients suffering from coronary artery disease where 897 patients underwent coronary-artery bypass grafting while 903 patients were treated with percutaneous coronary intervention using bare-metal stents. The results of this trial indicated that both the procedures brought significant relief to the patients suffering from coronary artery disease. During the follow up it was observed that patients who underwent coronary-artery bypass grafting showed greater reduction in the frequency of angina compared to patients who underwent stenting. However, the patients who were treated with percutaneous coronary intervention had a much better recovery rate from the procedure compared to the others who underwent open surgery. In essence, it can be clearly observed that both the procedures have their own benefits and shortcomings and their efficacy against coronary heart disease will strongly vary from one individual to another (Cohen et al., 2012). In the recent years massive progress has been made in the angioplasty and stenting procedure that can significantly reduce the chance of in-stent restenosis. During in-stent restenosis the lumen of the coronary artery becomes small again due to the formation of scar tissue within the stent. A modern procedure such as Intracoronary radiation that causes irradiation of the coronary tissue reduces the chances of restenosis. Another option is to use stents coated with special medication that inhibits the growth of scar tissues and thereby reduces the chance of in-stent restenosis substantially. Similarly, improvements have also been made in procedures such as coronary-artery bypass grafting. The minimally invasive direct coronary artery bypass technique is one such improvement that is significantly less invasive than coronary-artery bypass grafting. There is no need of any heart-lung machine and instead of a full open surgery the doctor just makes a small incision between the ribs to correct the blocked artery (Michaels, 2002). A recent study even reports that patients who received angioplasty and stenting as a treatment are 47% more likely to suffer from heart attacks or even die compared to patients who underwent bypass surgery but it can still be stated that the more invasive bypass surgical procedure should only be carried out in patients who have multiple blocked arteries and are under much greater risk compared to patients with single artery blockage (Park et al., 2015).


Conclusion:

As early as 2011 the American Medical Association published a report that indicated that there was a clear overuse of the angioplasty procedure in American hospitals. In over 30% of cases patients were suffering mild symptoms which could possibly be treated medically. It was suggested that in some cases financial incentive was the key driver that pushed doctors to perform this type of procedure rather a medical decision.

There seem to be in general a discrepancy between patient' beliefs and expectations-avoidance of a heart attack and that of the doctors-at odds with that belief. In fact patients pressure is also an important factor to consider when looking at the of angioplasty. As Dr. Crandall, head of the cardiac transplant program at the world-renowned Palm Beach Cardiovascular Clinic, “ Everybody wants an instant fix. No one wants to take the time to make lifestyle changes, or even take a nitroglycerin pill if they want to go out to play tennis. They want to play tennis and not have to think about it"

It can be clearly observed that there can't be a standard treatment procedure that can be recommended for all type of coronary artery disease patients. In some patients coronary bypass surgery may be the only option available while for others angioplasty and stenting could yield better results that surgery. With regards to expenses, an open heart bypass surgery can cost up to $64,000 while angioplasty and stenting could be carried out at a fraction of that amount (Nissen, 2010). If the blockage is seen in multiple arteries, surgery is the only option and could give excellent results if the bypass is created using the internal mammary artery because it is highly durable compared to other available choices. For doctors and surgeons the best option is to consider all aspects and obtain multiple opinions to ensure maximum benefit to the patients.

In the last few years, reimbursement cuts and increased number of patients that have to undergo open surgery after angioplasty has made the medical community alongside Medicare re-think the best way to treat patients in the future.


References

Angioplasty and Stents for Heart Disease Treatment. (2016). WebMD.
Retrieved 4 March 2016, from http://www.webmd.com/heart-disease/guide/treatment...

Beckerman, J. (2016). Angioplasty and Stents for Heart Disease Treatment . WebMD.
Retrieved 5 March 2016, from http://www.webmd.com/heart-disease/guide/treatment...

Cohen, D., Van Hout, B., Serruys, P., Mohr, F., Macaya, C., & Den Heijer, P. et al. (2012). Quality of Life After PCI With Drug-Eluting Stents in Coronary Artery Bypass Surgery. Survey Of Anesthesiology, 56(1), 6. http://dx.doi.org/10.1097/01.sa.0000410149.81655.3...

Michaels, A. (2002). Angioplasty Versus Bypass Surgery for Coronary Artery Disease. Circulation,106(23), 187e-190. http://dx.doi.org/10.1161/01.cir.0000044747.37349....

Nissen, S. (2010). Heart Bypass Surgery or Stenting—Which Is Best for Me? . US News & World Report.
Retrieved 5 March 2016, from http://health.usnews.com/health-news/blogs/health-...

Park, S., Ahn, J., Kim, Y., Park, D., Yun, S., & Lee, J. et al. (2015). Trial of Everolimus-Eluting Stents or Bypass Surgery for Coronary Disease. New England Journal Of Medicine , 372(13), 1204-1212. http://dx.doi.org/10.1056/nejmoa1415447

PITTMAN, G. (2013). Heart bypass surgery or stents? Depends on patient . Reuters.
Retrieved 5 March 2016, from http://www.reuters.com/article/us-heart-stents-idU...

Stents or Surgery? Which Is Right for You? Six Questions to Ask Your Doctor . (2015). Secondscount.org.
Retrieved 5 March 2016, from http://www.secondscount.org/treatments/treatments-...

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