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					Is Coronary Artery Bypass Surgery
Really Better than Coronary Stents?
  A look at the risks and benefits
           Sarah Smith
        Advisor: Dr. Grimes
        Why is this important?
   The leading cause of death in the United States is
    coronary heart disease
   It accounts for about 1 million deaths per year
   About 43% of heart disease deaths are related to
    coronary artery disease
   Heart disease is the leading cause of death of
    American women, accounting for 32% of all
    deaths per year.
       One in three women will die from heart disease, while
        one in 25 will die from breast cancer
   Trends in the United States suggest that half of
    healthy 40-year-old males will develop CAD in the
    future, and one in three healthy 40-year-old
    women
               Pathophysiology
   CAD is a chronic disease in
    which the coronary arteries
    gradually harden and
    narrow
   Limitation of blood flow to
    the heart causes ischemia
    of the myocardial cells,
    leading to a myocardial
    infarction
   This leads to heart muscle
    damage, heart muscle
    death and later scarring
    without heart muscle
    regrowth
         Pathophysiology Cont.
   CAD can be thought of as a wide spectrum of
    disease of the heart
   At one end is the asymptomatic individual with
    fatty streaks within the walls of the coronary
    arteries
       Over time these streaks will increase in thickness and
        may affect the flow of blood through the arteries
       As the plaque continues to grow and obstruct the vessel
        to more than 70% the patient typically develops
        symptoms of obstructive coronary artery disease
   At this stage the patient is said to have ischemic
    heart disease, meaning the patient’s heart is
    experiencing an increased workload, thus reduced
    blood supply to the heart walls
              Pathophysiology

   As CAD progresses, there may be nearly
    complete obstruction of the lumen of the
    coronary artery
   Patients at this level have typically suffered
    from 1 or more myocardial infarctions, and
    may have angina at rest and pulmonary
    edema
   An individual may develop a rupture of a
    plaque at any stage of the spectrum.
       The acute rupture a plaque may lead to an
        acute MI
           Risk Factors

 Family history of premature CAD
 Smoking
 Diabetes mellitus
 HTN
 Hyperlipidemia
 obesity
        Presentation/Diagnosis

   Generally patients present with stable
    angina, unstable angina, or a myocardial
    infarction
   Coronary angiogram is currently golden
    standard for determining the presence of
    obstructive coronary artery disease
       Yields a 2D picture of coronary arteries
       A catheter is inserted into the coronary arteries
        and injected with dye
       The dye allows the physician to pinpoint the
        number and location of blockages in the
        coronary arteries
          Treatment Options

   There are many different treatment options
    available
   A physician will look into the patients’
    individual risk factors, severity of the
    blocked artery, and analyze the benefits
    and risks for possible procedures
   Two popular procedures are PCTA/stent
    implantation and CABG surgery
   Medical therapy is also available for a more
    conservative treatment
            Overview of Stents
   1/3 of patients with CAD will undergo coronary angioplasty
    with stents or Percutaneous Transluminal Coronary
    Angioplasty (PCTA)
   Angioplasty involves temporarily inserting and expanding a
    tiny balloon at the site of blockage to help widen the
    narrowed artery
   Usually combined with stent implantation in the artery to
    help prop it open and decrease the chance of it narrowing
    again or restenosis
   Performed in cardiac catheterization lab and are non-surgical
    treatment
   Usually last about 1-2 hours and most patients are usually
    discharged in 1-2 days after a procedure
   Stents are a stainless or nytinol mesh like device
   Angioplasty and Stents
   YouTube Stent
                                     Stents
   A stent is a stainless tube with slots. It
    is mounted on a balloon catheter in a
    collapsed state. When the balloon is
    imflated, the stent expands and pushes
    itself against the inner wall of the
    coronary artery.
   The risk of emergency referral for
    CABG and need for subsequent
    revascularization procedures has
    reduced by more than 50% because of
    coronary stents
   Stent implantation has shown to
    reduce restenosis in vessels with
    reference diameter >3mm, however
    in-stent restenosis still occurs in about
    10-40% of patients
   According to the American Heart
    Association stents can be considered
    for use in patients who have significant
    disease of left main and left anterior
    descending coronary artery. Also
    patients with 2 or 3-vessel disease
    should be considered
       In previous years these patients
           were only candidates for bypass
           surgery
        Risks/Benefits of Stents
   Benefits:                        Risks and Limitations:
       Shorter procedural and           Risk of death <1%
        recovery time than               Risk of heart attack,
        CABG                              thrombosis and
       Angina relief about               bleeding <4%
        75% of the time                  Major limitation of
       Decreases the risk for            procedure is a high rate
        heart attack                      of restenosis and need
       Increases blood flow to           for revascularization
        the heart                        Scar tissue formation
                                         Not a cure to the
                                          disease, still need to
                                          reduce risk factors and
                                          make lifestyle changes
                                          to prevent future
                                          disease progression
                    Research…
   Patients receiving stents had lower incidence of
    death, MI, and stroke at 30-day follow-up
    compared to CABG.
   However, patients receiving stents had a higher
    incidence of repeat revascularization procedures
       25% of patients at 1 year and 47% at 5 years
   This high risk of restenosis is one of the major
    reasons for patients refusing angioplasty and
    opting for other treatment modalities like surgery
   The introduction of drug-eluting stents may shift
    patients from surgical procedures back to
    angioplasty and stent use.
         Drug-eluting Stents
   These are stents that are coated with a
    drug that is known to interfere with the
    process of restenosis
   As of December 2007, the FDA has
    approved of 2 DES: sirolimus-eluting stents
    and paclitaxel-eluting stents
   Studies show that there is a 70-90%
    reduced rate of restenosis when compared
    with bare-metal stents
   DES were first introduced in April 2003,
    and just 9 months later made up 35% of
    all stent implantations in the United States
              Problem with DES?
   1. They are expensive
        It costs about $2200 for a DES, when compared to bare-metal
         stents which costs about $600.
        In one study they looked at the cost-effectiveness of DES.
         They took into account the fact that there will be reduced
         repeat revascularization procedures, and discovered that there
         was still an increase in $600 per patient, and with an estimated
         1 million procedures done a year, about $600 million increased
         in annual healthcare spending
   2. The drug agents can interfere with the healing process
    and found to hamper natural vascular healing process
        In 2007, the FDA has cautioned the use of DES, because they
         are associated with increased risks of both early and late stent
         thrombosis, as well as death, and myocardial infarction
   DES are still a novel idea; it will be interesting to see the
    research that comes out in the next couple years looking at
    their effectiveness and future indications
                  Overview of CABG
   CABG is still the best therapy for
    reintervation for most patients with
    proximal left anterior descending,
    multivessel, and left main-stem
    coronary artery disease
   Of the patients with CAD, about 10%
    will undergo CABG surgery
   CABG is a surgery that increases blood
    flow to the heart by creating a detour
    and re-routing the blood flow around
    the blocked portion of the artery.
   A section of a blood vessel from
    another part of the body is removed
    and grafted above and below the
    damaged portion of the coronary
    artery to form an un-blocked artery
        Most commonly used are the
         saphenous vein and internal thoracic
         artery
   This procedure is performed with
    assistance of a heart-lung machine,
    which supports the patient’s blood
    during surgery
   CABG Surgery
Risks/Benefits CABG surgery
   CABG was introduced about 50 years ago and is
    now performed in 1 million patients at a cost
    exceeding $20 billion annually
   Many benefits such as decrease in angina,
    improved life-span, and providing an effective
    route for blood with prevention of new plaques to
    form
   Surgery is however a much more serious operation
    that lasts a long time, with a long recovery time
   Some complications seen after surgery are atrial
    fibrillation, increased risk of stroke, and cognitive
    dysfunction
                          Research…
   Less than 5% chance of heart damage and less than 2%
    chance of death
   Stroke or other neurological injury occurs in 5% patients
   Atrial fibrillation occurs in 20-40% of patients after CABG
   2 reasons as to why CABG offers survival advantages for
    multivessel and left main-stem coronary artery disease
        1. Bypass grafts are placed on the midcoronary vessel, CABG
         not only protects the culprit lesion, but also offers prophylaxis
         against new lesions in diseased endothelium
             Where stents only treat immediate culprit lesion, with no protective
              effect against the development of new disease
        2. failure of stents to achieve complete revascularization in
         most patients with multivessel disease reduces survival
         proportional to the degree of incomplete revascularization
     Isolated LAD and Left-main
              stem CAD
   CAD in LAD has been reported as high as 50%
    among patients who undergo CABG
   CABG is regarded as an accepted golden standard
    for left main coronary artery disease
   CABG has generally been considered the golden
    standard of therapy for left-main stem stenosis for
    the last decade.
       However, there are recent studies out that show patients
        underwent PCI more than CABG for this type of disease.
        This artery has a relatively large diameter, making it an
        attractive site for PCI
       Restenosis rates in a study were 30.3% in bare-metal
        stents, 7.4% in DES group, and 3.7% in CABG group
               Multivessel CAD
   MVD accounts for approximately 60% of the CAD
    patients
   The use of stents in these patients has resulted in
    higher restenosis and repeat vascularization rates
    than in patients treated with surgery
       Stents group had 16.8% restenosis rate as compared
        with 3.5% who underwent surgery
   CABG patients also experience fewer MI and major
    adverse cardiovascular events
   DES have decreased the difference between CABG
    and bare-metal stents
   In order for PCI to replace CABG as the preferred
    therapy in MVD, clinical trials must demonstrate
    long-term outcomes that are equivalent
          What about the Diabetic
                 Patient?
   The diabetic patient is a high risk for coronary artery
    disease, the incidence and severity of the disease are higher
    as compared to nondiabetic patient
   Revascularization of diabetic patients has been a huge
    dilemma and a great challenge
   A study confirmed that even a low-risk diabetic patient there
    is a survival advantage at 10 years for CABG in comparision
    with PCI of 58% vs. 46%
        Also found that there is a huge difference in the need for
         revascularization in both; 18% of CABG patients and 80% of
         PCI
   Studies state that the preferred revascularization strategy in
    the diabetic patient with MVD is CABG surgery
        Lower mortality in CABG patients vs. PCI patients (1.4% vs.
         12.8%)
        Lower major adverse cardiovascular events (8.6% vs. 26.6%)
                       The Future
   Minimally invasive direct coronary artery bypass (MIDCAB) is
    on the rise
   It is performed on a beating heart with use of stabilizing
    devices or using minimal access bypass system with endo-
    aortic clamping and cardioplegic arrest
   Yields shorter hospital stay with lower postoperative
    complications and better quality of life with similar safety
    and long-term efficacy as conventional CABG
   Robotic instrumentation is also developing
        Surgery does not have a single chest incision of any kind, this
         surgery requires 3 pencil-sizes holes made between the ribs
        2 robotic arms and an endoscope gain access to the heart,
         making surgery possible without opening the chest
        Has been proven that these patients get out of the hospital 1-2
         days earlier
        This technique may develop into new technology that might be
         used more often in the future and may replace open heart
         surgery
                  Conclusion
   CABG still remains that best therapy in terms of
    superior survival and decreased need for
    reintervention for most patients with proximal
    LAD, multivessel, and left main-stem CAD.
   These affects are magnified in the diabetic patient
   PCI with stent is still chosen as treatment option
    for single-vessel disease, and now considered for
    2 or 3-vessel disease
   Each patient is evaluated for the best treatment
    option based on their own risk factors and
    progression of disease
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

				
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