Surgery better option than stents?

Dr. Jeff Carstens knows the reaction he'll get when he mentions open heart surgery to a patient.

“They say, whoa, ‘I don't want to have that,'” said Carstens, an Omaha cardiologist.

Patients may balk, but a new study indicates that heart bypass surgery may be a better option than stents for many people with heart disease.

Researchers involved in the major European-American study say that tens or even hundreds of thousands of Americans are having coronary artery angioplasty and stenting every year when they should be having a bypass.

Patients and cardiologists frequently prefer angioplasty and the insertion of a stent to keep arteries open because it is quicker and easier. Patients also go home sooner and return to work more quickly.

But data from the study on more than 1,800 patients show that three years after the procedure, those who got stents were 28 percent more likely to suffer a major event, such as a heart attack or stroke, and 46 percent more likely to require a repeat procedure to reopen arteries. They were 22 percent more likely to die.

The research provides strong evidence that bypass can be the best option for patients with moderate or severe heart disease, said Dr. Tracy Dorheim, director of adult cardiac surgery at the Nebraska Medical Center.

Stents, on the other hand, can be effective for patients with mild heart disease, he said.

Patients and doctors need to keep their minds open to bypass surgery, said Carstens, executive medical director of the Alegent Health Heart and Vascular Institute.

Carstens said he's had patients refuse bypass surgery and opt for stents, even though he recommended bypass. Surgery can scare patients.

The study shows that it's essential for patients to talk with a heart surgeon, not just a cardiologist, before choosing stents or bypass, said Dr. James H. Wudel, cardiac surgeon at the Nebraska Heart Hospital in Lincoln. A surgeon can best explain the advantages and disadvantages of a bypass, Wudel said.

More than 1.3 million Americans now undergo angioplasty every year, compared with 448,000 who undergo bypass, according to the National Center for Health Statistics.

Dorheim said he and surgeons nationally are performing 20 to 30 percent fewer bypasses than they were 10 years ago.

Coronary-artery bypass grafts were the first treatment for blocked arteries. In the procedure, a blood vessel removed from elsewhere in the body, most often the chest or the leg, is used to bypass the blocked area, providing a new channel for blood to flow to the heart. Hospital stays generally last five or six days, and the patient can return to work after a few weeks.

In recent years, however, cardiologists have turned more and more to balloon angioplasty, in which a catheter is threaded through a blood vessel in the groin to reach the blockage and a balloon is inflated at the site to compress the plaque. Originally, that was all that was done. Then physicians began inserting bare-metal stents, springlike devices that hold the artery open. Hospital stays are typically overnight, and the patient can return to work after a couple of days.

The new research, unveiled Sunday at a Geneva meeting of the European Association for Cardio-Thoracic Surgery, is the first large trial to compare stenting and bypass grafts directly. The study involved patients at 85 centers in Europe and the United States.

Patients were randomized to receive either angioplasty with stenting or bypass.

Patients were considered to have mild disease if they had a single blocked artery.

Their disease was considered moderate or severe if they had a blockage in the left main artery — the primary artery supplying blood to the heart — plus blockage in one of the three other arteries, or if they had blockages in all three other arteries.

For patients with mild disease, the two procedures produced equivalent results, so angioplasty might be preferred because it is easier on the patient.

But the differences were much more dramatic for those with more severe disease, which is present in about half of all angioplasty patients in the U.S.