Both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are effective treatments of coronary artery disease (CAD).
The field of coronary revascularization (reestablishing blood flow to the heart) is complex and ever-changing. Clinical presentation, comorbidities (underlying health conditions), extent, and complexity of CAD and data from trials that reflect current practice must all be considered when determining the best revascularization strategy for an individual.
Although it is ultimately up to your doctor to determine the best treatment for you, it is important to understand and weigh your options.
CABG is usually considered when the most important artery has a disease.
- Three coronary arteries of the heart are not all created equal. The main artery is known as the left anterior descending artery (LAD) supplies blood to the entire front wall of the heart, which contains far more muscle than either of the other two coronary arteries.
- Narrowing or blockage of LAD is more serious than that of another artery. For blocked LAD, bypass surgery is usually the best option.
- Although both the other arteries are blocked, stents are more likely to be used if LAD is not blocked and if there are no other complicating factors.
- If you have two blocked vessels, one of which is LAD, particularly the upstream portion, data support bypass surgery.
- One important factor is that the graft for LAD bypass is placed in another artery, the mammary artery, which is located in the chest near the heart.
- Complications are uncommon, and CABG through the mammary artery can last for decades.
- Furthermore, for reasons that are still unknown, blockage rarely occurs in the mammary artery.
If you place a stent in LAD, you are only protecting the area of blockage and leaving the rest of the artery vulnerable, whereas a bypass will protect the downstream portion of that vessel for the rest of its life.
- CABG is best for people with diabetes.
- CABG may improve survival rates for people when more than one heart artery is blocked.
- CABG may be a better option for people who are 65 years and older.
PCI
- Stents are usually the first choice when LAD is not involved.
- Another situation in which stents are the best option is when bypass surgery is no longer an option.
- LAD repair with a mammary artery is usually permanent, whereas CABG in the other two arteries is not. PCI typically uses veins rather than arteries, and half of the time, the repurposed veins fail after 8 to 10 years.
- If this occurs and you require additional work, a second bypass can be performed, but most doctors prefer to use stents.
Coronary stents versus bypass surgery
- Despite their widespread use in the treatment of acute heart attacks and narrowed arteries, stents are used to keep the blood vessels open and can promote inflammation and scar tissue growth, causing vessels to constrict again.
- However, the technique for inserting a stent, known as PCI, requires a much shorter hospital stay than traditional open-heart bypass surgery, has faster recovery times, and is far less likely to cause strokes.
- Although stents are less risky for people in the first month or so after the procedure, they are riskier in the years that follow, with a higher risk of heart attack and death.
- Newer stents are made to be more compatible with living tissue and to be less likely to cause clots, inflammation, and tissue growth.
The standard of care for people with the three-vessel disease has been CABG, but long-term comparative results from randomized trials of CABG vs PCI using drug-eluting stents are limited.
What are the common heart procedures and surgeries?
The type of heart surgery or procedure performed may be determined by the person's symptoms, age, and comorbidities.
Angioplasty or percutaneous coronary intervention
- Special tubing with a deflated balloon attached is threaded up to the coronary arteries.
- The balloon is inflated to open up blocked areas in the heart muscle where blood flow has been reduced or cut off.
- It is often used in conjunction with the implantation of a stent to help prop the artery open and reduce the likelihood of another blockage.
- Because the body is not cut open, it is considered less invasive. The surgery can last anywhere from 30 minutes to several hours. You may need to spend the night in the hospital.
Benefits:
- Increases blood flow through the blocked artery significantly
- Reduces angina (chest pain)
- Increases physical activity (an ability that has been hampered by angina or ischemia)
- Used to open arteries in the neck and brain to help prevent strokes
Stent placement
A stent is a wire mesh tube that is used to prop an artery open during an angioplasty. The stent remains in the artery indefinitely. However, coronary narrowings can reoccur within stents and are known as restenosis.
Benefits:
- Keeps the artery open
- Increases blood flow to the heart muscle
- Relieves angina (chest pain)
Atherectomy
It is similar to an angioplasty, except the catheter has a rotating shaver on its tip to cut away plaque from the artery.
Benefits:
- By removing plaque buildup, it improves blood flow through the blocked artery.
- It may be used to remove plaque and reduce the risk of stroke in carotid arteries (major arteries of the neck that lead to the brain).
Bypass surgery or coronary artery bypass grafting
- It treats blocked heart arteries by using grafts, which are arteries or veins from other parts of your body, to reroute blood around the clogged artery and supply blood flow to your heart muscle.
- Depending on how many coronary arteries are narrowed, a person may require one, two, three, or more bypass grafts. Several days in the hospital are required.
Benefits:
- One of the most common and effective procedures for treating a blockage in the blood supply to the heart muscle
- Improves blood and oxygen supply to the heart
- Reduces angina (chest pain)
- Reduces the risk of a heart attack
- Improves physical activity that has been hampered by angina or ischemia
Heart transplant
When a heart is irreversibly damaged, it is removed and replaced with a healthy human heart obtained from a deceased organ donor.
Benefits:
- Recognized as a tried-and-true procedure for restoring heart health in carefully selected people.
Heart valve repair or replacement
- Surgeons either repair or replace the valve with an artificial or biological valve made from pig, cow, or human heart tissue.
- One repair method involves inserting a catheter through a large blood vessel, guiding it to the heart, and inflating and deflating a small balloon at the catheter's tip to widen a narrow valve.
Insertion of a pacemaker or an implantable cardioverter-defibrillator (ICD)
- Medicine is typically the first line of treatment for arrhythmia, a condition in which the heart beats too quickly, too slowly, or in an irregular rhythm.
- If medication is ineffective, a surgeon may implant a pacemaker beneath the skin of the chest or abdomen, with wires connecting it to the heart chambers.
- When a sensor detects an abnormal heart rhythm, the device uses electrical pulses to control it.
- When an ICD detects a dangerous arrhythmia, it sends electric signals to restore a normal rhythm.
What is the recovery period after a heart procedure?
The length of recovery depends on the type of surgery, but for most types of heart surgery, you will likely spend a day or more in the hospital's intensive care unit. You will then be transferred to an observation area of the hospital for several days until you are discharged.
According to research, the length of your recovery time at home will be determined by the type of surgery you had, your overall health before the surgery, and whether you experienced any complications from the surgery. The risk is higher if you have other diseases or conditions such as diabetes, peripheral artery disease, or kidney or lung disease.
Most heart surgeries necessitate a 3 to 12-week recovery period. The majority of heart surgeries are major operations.
Although they are frequently successful, they do involve risks such as:
- Bleeding
- Infection
- Reactions to anesthesia
- Damage to tissues in the heart, kidneys, liver, and lungs
- Stroke
- Death, especially for someone who is already very sick before surgery
Medical management or procedures such as stents or bypass surgery can be used to treat coronary artery disease (CAD). Choosing the best treatment option for you is a highly controversial issue because each approach has risks and benefits.
One of the major areas of CAD research is determining whether there is a clear difference in outcomes between medical treatment, stents, and bypass surgery and which conditions favor one option over the other. There are times when the answers are obvious, but there are times when one option is not superior to the others.
If you and your doctor are planning CAD treatment options, knowing where the current research stands can be beneficial.
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Coronary artery bypasses grafting (CABG) vs. percutaneous coronary intervention (PCI) in the treatment of multi vessel coronary disease: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082779/
Indications for Coronary Artery Bypass Surgery and Percutaneous Coronary Intervention in Chronic Stable Angina: https://www.ahajournals.org/doi/10.1161/01.cir.0000094405.21583.7c
CABG: When, why, and how? https://www.ccjm.org/content/88/5/295
Decision Making Between Percutaneous Coronary Intervention or Bypass Surgery in Multi-vessel Coronary Disease: https://www.revespcardiol.org/en-decision-making-between-percutaneous-coronary-articulo-S1885585713003198
PCI Versus CABG in Left Main and Multivessel Disease: Do We Still Have the Gordian Knot? https://journals.sagepub.com/doi/full/10.1177/0003319718772229
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