The Coronary Artery Bypass (CABG) operation is one of the commonest operations performed worldwide. Coronary artery disease, its complications and its management is the single most studied, researched, documented and published subject in medical literature. And coronary artery disease is by far the commonest cause of death worldwide.
There are two main arteries supplying the heart. The Left and the Right coronary arteries. The Left coronary artery divides quickly into two major branches soon after its origin, the Left Anterior Descending (LAD) artery, and the Circumflex artery. That is why we generally say the heart has three major vessels supplying it. But the Left Anterior Descending artery typically supplies 45-55 percent of the blood to the heart, and is the most critical and important vessel supplying the heart. When these arteries get blocked due to the build up of plaques, we say the patient has coronary artery disease. Blockage often leads to a heart attack.
The operation is just a simple plumbing procedure – using a conduit to bypass a block or blocks in the coronary arteries. Various conduits are in use, including arterial conduits like the internal mammary artery (taken from the chest), radial artery (from the hand), gastroepiploic artery (from the upper abdomen) or the reversed saphenous vein (taken from the leg).
It is our duty as doctors to read, intensively study, judiciously assess, comprehensively review, and critically evaluate evidence relating to treatment for diseases, so that the patient gets the optimum treatment and the best outcomes, at the most affordable cost. Issues of patient preference that influence treatment are only secondary. In my opinion, patients are woefully ill-informed and incompetent to make a decision on treatment for themselves. Doctors base their advice on treatment of an individual patient based on years of clinical experience. Unlike what patients assume, this cannot be replaced by information downloaded from the Internet. Unfortunately, the trust deficit between doctors and patients has reached such a level, that patients look for other opinions, including those on the Internet.
It is also our moral responsibility to tell patients what the best treatment is for them as individuals, based on existing available evidence.
And most importantly, ethically and without conflict of interest on our part as doctors.
CABG vs Stents
The “Heart Team” approach - the combined decisions of the interventional cardiologists and the cardiac surgeons together - in patients with coronary artery disease, especially in patients with more than one block – is the ideal and optimum revascularization strategy for the patient. Unfortunately this does not happen in most centres treating heart disease.
One option is to do what is called a Percutaneous Coronary Intervention (PCI). It basically involves threading a catheter into the coronary artery via the groin or hand, dilating the coronary artery, and then putting in a stent, which acts as a scaffolding to keep the coronary artery open.
The problem today, is that many cardiologists put in multiple stents in patients who clearly will do better with surgery.
Putting in stents is often done without the knowledge or consent of the cardiac surgeon, and without the patient being told of the benefits of surgery over stents in patients with multiple vessel blocks. Cardiologists often say that patients are afraid of undergoing surgery or that they do not want surgery, and hence they are putting in stents.
However, the crux of the issue is not addressed when this happens.
Putting multiple stents is not the recommended or ideal treatment for a patient with multiple blocks, especially if the blocks also involve the initial segment of the Left Anterior Descending artery. Patients should be clearly told that bypass surgery has much better short-term and long-term outcomes compared to stents. And diabetics with multiple blocks should never be offered stents, as these stents tend to block very quickly in diabetics.
It is not that in the above situations, stents are an inferior option. It is the wrong option.
Patients must be clearly told that putting stents in such cases is clearly a poorer, less satisfactory, often flawed, and sometimes a detrimental option.
Unfortunately, stents are being put in indiscriminately, without any rationale, justification or evidence. And significantly, often without a “Heart Team” approach. And it has everything to do with the profits involved in putting in stents.
So my advice?
Based on current evidence, if you have two or more blocks of the coronary artery, and if one of them involves the early part of the Left Anterior Descending artery, you should choose surgery over having stents put in.
If you are diabetic, with multiple vessel disease, having stents put in is a poor choice for yourself. The only option? Have a coronary bypass operation. Patients should never be offered another option, except if there is some other unrelated medical condition which precludes surgery.
The subsequent need for a second procedure/surgery for a recurrence of the blocks is much less with a bypass operation as compared to stents.
And the long-term survival is significantly more with a bypass operation.
(The author is a former head of the department of cardiothoracic surgery at Christian Medical College and Hospital, Vellore. He is currently the chief administrative officer, and head of the cardiothoracic surgery department at Pushpagiri Heart Institute, Tiruvalla.)