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Bypass Better Than Stent Use for Blocked Artery

Studies favor bypass, but experts say decision must be made on case-by-case basis

FRIDAY, March 23, 2007 (HealthDay News) -- Minimally invasive heart bypass surgery results in longer and better quality of life than the use of artery-opening stents for patients who have a single blocked coronary artery, according to the results of three British studies.

Two of the studies found that the minimally invasive bypass procedure was more cost-effective than stenting, and the third found that minimally invasive heart bypass surgery resulted in fewer complications than stenting.

"In this day and age, many patients, when they see a cardiologist, are told, or it is implied, that the same result can be achieved through a stent as it can with surgery, and that's not the case," said Dr. David Taggart, a professor of cardiovascular surgery at the University of Oxford and author of an accompanying editorial in the March 24 issue of the British Medical Journal.

Stents are tiny mesh tubes placed into arteries to increase blood flow. But, according to Taggart, many patients don't understand that within a few years after stenting, they have a sevenfold higher risk of needing new treatment compared with patients who had a bypass. "Even more important, they are at a higher risk of dying than if they had a bypass operation," he said.

In two of the studies, a team led by Dr. Thanos Athanasiou from the department of biosurgery and surgical technology, Imperial College London and St. Mary's Hospital, London, reviewed published studies that compared minimally invasive bypass surgery with stenting.

In one report, they found that a procedure called "minimally invasive left internal thoracic artery bypass" may be a more cost-effective medium- and long-term alternative to coronary artery stenting. In the other study, they concluded that this surgery "resulted in fewer complications in the mid-term" compared with stenting.

In the third study, Dr. Harry Hemingway, a professor of clinical epidemiology in the department of epidemiology and public health at University College London Medical School, and colleagues studied randomly selected patients who underwent either cardiac procedure.

Hemingway's team found that coronary bypass surgery was cost-effective, but stenting wasn't. In fact, they concluded that, "cost-effectiveness analysis based on observational data suggests that the clinical benefit of percutaneous coronary intervention [angioplasty plus stenting] may not be sufficient to justify its cost."

Taggart noted that despite these reports, choosing which procedure is best needs to be determined on a patient-by-patient basis.

"Patients with this type of complex disease should be treated by a multidisciplinary team, including a cardiac surgeon, rather than just a cardiologist," Taggart said. "If you are not treated by a team, you will not always be given the appropriate information to choose which treatment is best for you," he said.

Taggart believes that patients often opt for stents, because they fear the bypass operation. "If someone said to you, 'You can either have your chest cracked open or I can fix you with a couple of little stents,' the vast majority of patients would say, 'Of course, I don't want my chest cracked open.' "

One expert said there are risks and drawbacks with each procedure.

"There is no surprise here," said Dr. William Maisel, a cardiologist at Beth Israel Deaconess Medical Center, Boston. "It's been known for a long time that bypass surgery, for people with significant coronary blockage, is more likely to offer long-term symptom relief and, because of the likelihood that you won't need further treatment for many years, it is more cost-effective in the long run."

But risks on the operating table remain higher with bypass, he stressed. "What these reports gloss over is that your chance of dying [during surgery] is twice as high with bypass surgery than it is with stenting," Maisel said.

The reality is that bypass and stenting are both viable treatment options for patients, Maisel said. "If you survive your surgery, you are probably better off with a bypass," he said. "But many patients are scared by the up-front mortality. But, both procedures remain reasonable," he said.

More information

For more information on heart bypass surgery and stents, visit the American Heart Association.

SOURCES: David Taggart, M.D., professor, cardiovascular surgery, University of Oxford, U.K.; William Maisel, M.D., cardiologist, Beth Israel Deaconess Medical Center, Boston; March 24, 2007, British Medical Journal
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