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Coronary artery disease - Surgery

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of coronary artery disease (CAD).

Alternative Names

Angina; Atherosclerosis; Heart disease

Surgery:

Angioplasty and Stents

Angioplasty, also called percutaneous coronary intervention (PCI), involves procedures such as percutaneous transluminal coronary angioplasty (PTCA) that help open the blocked artery.

Angioplasty can help reduce the frequency of angina attacks. It is commonly recommended for patients who have critically blocked arteries or have already had a recent, acute heart attack. Angioplasty can also help improve survival and prevent heart attacks in patients with acute coronary syndrome (ACS). However, doctors have been uncertain about angioplasty's benefits for survival and heart attack prevention in lower-risk patients with stable coronary artery disease.

Angioplasty works no better than standard heart medication (drugs to control blood pressure, lower cholesterol, and prevent blood clots) in preventing heart attack, stroke, and hospitalization in patients with stable coronary artery disease. Doctors are now recommending angioplasty only for patients who have severe heart disease. For patients with stable heart disease, drug therapy may be sufficient enough treatment and allow them to safely defer having surgery.

PCTA
Click the icon to see an animation about percutaneous transluminal coronary angioplasty.

Procedure. A typical angioplasty procedure follows these steps:

The cardiologist threads a narrow catheter (a tube) containing a catheter from the groin area into the blocked vessel.
The doctor opens the blocked vessel using balloon angioplasty, in which the surgeon passes a tiny deflated balloon through the catheter to the vessel.
The balloon is inflated to compress the plaque against the walls of the artery, flattening it out so that blood can once again flow through the blood vessel freely.
To keep the artery open afterwards, doctors use a device called a coronary stent, an expandable metal mesh tube that is implanted during angioplasty at the site of the blockage. (In some cases, a stent may be used as the initial opening device instead of balloon angioplasty.) The stent may be bare metal or it may be coated with a drug that slowly releases medication.
Once in place, the stent pushes against the wall of the artery to keep it open.

Balloon angioplasty
Click the icon to see an animation about percutaneous transluminal coronary angioplasty.

Complications occur in about 10% of patients (about 80% of them happening within the first day). Success rates are better in hospital settings with experienced teams and backup.

Coronary artery balloon angioplasty - series
Click the icon to see an illustrated series detailing coronary artery balloon angioplasty surgery.

Recuperation and Complications. Angioplasty is less invasive than bypass surgery, requiring only one night in the hospital. Recuperation takes about a week. Chest pain after the procedure is very common and usually due to problems other than ischemia. Mild chest pain is even more common when a stent is used, possibly because the artery is stretched.

The most important short- and long-term complication of angioplasty is narrowing or reclosure (restenosis) of the artery, which can lead to heart attack if not treated with a repeat procedure. Stenting, anti-clotting drugs, and other advances have significantly helped prevent reclosure and reduce heart attack rates. Nevertheless, a repeat procedure is still needed to restore the opening in 10 - 15% of patients who have stents.

Drug-Coated Stents. Stents coated with the drugs sirolimus (Rapamune) or paclitaxel (Taxol) have been increasingly used in the last several years. Drug-eluting stents (as they are also called) can help prevent restenosis. However, because drug-eluting stents reduce arterial tissue growth, they can increase the risks of blood clots.

Recent studies indicate that drug-eluting stents are safe and effective for patients with coronary artery disease when they are used for FDA-approved indications. Some studies have indicated that problems may arise when these stents are used for “off-label” purposes in patients with more complicated health problems, although other studies have found no increased risks. There is still some concern that all stents (both bare metal and drug eluting) may be used too frequently for patients who may be better served by drugs or bypass surgery.

It is very important that all patients who have drug-eluting stents take aspirin and clopidogrel (or, rarely, ticlopidine) for at least 1 year after the stent is inserted to reduce the risk of blood clots. Clopidogrel and ticlopidine are thienopyridine drugs that, like aspirin, help prevent blood platelets from clumping together. It is important that patients who have drug-eluting stents take both aspirin and a thienopyridine drug. If for some reason patients cannot take a thienopyridine drug, they should receive a bare metal stent instead of a drug-eluting stent

Coronary Artery Bypass Graft Surgery

Coronary artery bypass graft surgery (CABG) is an alternative to angioplasty for many patients with severe coronary artery disease, but it is a very invasive open-heart surgical procedure:

Coronary artery bypass graft (CABG)
Click the icon to see an animation about CABG.

Click the icon to see an image about bypass grafting.

The chest is opened, and the blood is rerouted through a lung-heart machine.
The heart is stopped during the procedure.
Blood vessel grafts are taken from arteries or veins in the chest wall or other areas of the body. The grafts are transplanted in front of and beyond the blocked arteries, so the blood flows through the new vessels around the blockage. Patients may require one, two, or three grafts depending on the number of coronary arteries that are blocked.
In general, patients with triple bypass procedures stay in the hospital for 5 or 6 days. Those with one-vessel bypass may be able to go home in 3 days.

Heart bypass surgery - series
Click the icon to see an illustrated series detailing a heart bypass surgery.

Complications. Complications are generally rare but can include bleeding, infections, heart attack, and stroke. Finding a surgeon who performs at least 100 of the procedures a year helps reduce the risk for complications.

Blood clots may form in the new graft, closing it up or narrowing the treated vessel over time. Therapy with aspirin and other anti-clotting drugs help keep the graft open and working properly.

Recuperation and Rehabilitation. After leaving the hospital, patients have cardiac rehabilitation. Rehabilitation includes education about healthy diet and lifestyle choices, as well as exercise training to rebuild strength and stamina.

Resources

www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
www.americanheart.org -- American Heart Association
www.acc.org -- American College of Cardiology

References

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Reviewed last on: 5/15/2009
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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