For Multiple Heart Blockages, Bypass Surgery or Stents?

March 16, 2011 -- For patients who have several blocked arteries around their heart, the gold standard treatment has long been coronary artery bypass surgery.

Now a large clinical trial suggests that drug-coated stents, springy lattice tubes used to prop open clogged arteries, may also work well in patients with multiple blockages. And in some patients, the stents produce equally good results with faster recovery times.

The caveats, experts say, are that people with daily or weekly chest pain from advanced coronary artery disease will probably experience slightly better relief from bypass surgery compared to stenting; but they can also count on waiting to get the full benefit of that procedure weeks to months longer than people who get stents.

Experts say the study, which is published in The New England Journal of Medicine, brings to light important trade-offs that people with complex coronary artery disease need to weigh before making a decision between the two procedures.

“I think the message here, therefore, is not a simple one -- that there’s a clear winner -- but that patients will need to choose based on their own priorities and values,” says study researcher David J. Cohen, MD, a cardiologist at St. Luke’s Mid America Heart Institute in Kansas City, Mo.

Independent experts agree.

“If you take the 50,000-mile view, it looks like these procedures got about the same results,” says A. Marc Gillinov, MD, cardiac surgeon at the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic, in Ohio. “But if you really dig down and look at the clinical circumstances going in, you’ll see there are important differences. So the real value in this study is that it can help patients and doctors make informed decisions on an individual basis.”

Comparing the Effectiveness of Stents vs. Bypass

For the study, researchers at 85 medical centers around the world randomly assigned 1,800 patients with at least three clogged arteries around their hearts, or alternatively, a clogged left main coronary artery -- the vessel that carries the lion’s share of blood to the heart’s primary pumping chamber -- to one of two treatments: coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI).

In CABG, surgeons typically saw through the breast bone and open the rib cage, a procedure that, in and of itself, requires significant downtime for recovery. Doctors usually also need to make incisions in other parts of the body, often the legs, to harvest healthy vessels that can be used to bypass blockages.

In PCI, a catheter is threaded through an artery in the groin up to the heart, where a doctor uses a video monitor and radioactive dye to locate the blockages within arteries. The doctor then inflates a balloon to compress the buildup against the artery walls and places a stent to hold the spot open.

The stents in this trial were coated with the drug paclitaxel, which is thought to help prevent the formation of scar tissue around the site of stent implantation, a problem called restenosis.