Bypass Surgery is the Better Option

According to an analysis by the Duke University Medical Center, patients with severe coronary disease fare better with bypass surgery of the coronary artery instead of artery-opening angioplasty or heart medications. The bypass surgery gives them a better chance of survival.

Despite this the researchers estimate up to 40% of patients of severe coronary disease do not get the option of receiving bypass surgery as their first treatment. They are generally treated with angioplasty or medications. While bypass surgery is more expensive and invasive, it also gives additional benefit of increasing the life expectancy as compared to other options.

In bypass surgery, the patient’s chest is opened up and the blocked arteries are surgically bypassed with healthy arteries taken from other parts of the body. In angioplasty an expandable balloon is snaked through a tube inserted through the blocked coronary artery and then expanded to push the blockage against the walls of the artery, thereby opening it.

“It may sound very appealing to patients with severe coronary artery disease to get a treatment that is less expensive or less invasive, but they may not be getting the same survival benefit as those patients receiving bypass surgery,” said Dr. Peter Smith, Chief of Cardiothoracic Surgery and lead investigator for the study.

“The 40-year history of bypass surgery has shown it to be a durable and reliable treatment for coronary artery disease,” Dr. Smith said. “It may seem counterintuitive to start a patient on the most invasive treatment option, but our analysis shows surgery provides significant improvement in longevity for patients with severe disease.”

18,481 patients of Duke between 1986 and 2000 were covered under the study. All of these patients had at least one coronary artery blocked more than 75% and had received either bypass surgery, angioplasty or heart medications. Patients with at least three coronary arteries more than 75% blocked were considered as having severe coronary artery disease.

Patients were divided into three groups on the basis of the period in which they received treatment – 1986-1990, 1991-1995 and 1996-2000. Researchers paid special attention to the last period because insertion of stents during angioplasty procedures came into use from 1996.

Stents are a significant advance over angioplasty alone because they cut the chances of the treated artery becoming blocked again by half. Stents are inserted for more than one-third of patients undergoing angioplasty today. The researchers ended their study period in 2000 because “drug-eluting stents,” the new generation, drug-releasing stents were introduced in that year.

“We believe our findings have a particular relevance to practice today, since recent studies are suggesting there may be problems with the long-term durability of drug-eluting stents,” Dr. Smith said. “Because of these new questions, many physicians are going back to the traditional stents.”

Patients from the period 1996-2000 who received bypass surgery lived an average of 5.3 months longer than those treated by angioplasty. Statistically this is a significant difference. “These findings should change practice,” Dr. Smith said. “We’ve clearly needed the long-term survival data, and this study provides it. Patients receiving bypass surgery get a durable fix for their disease. Patients undergoing angioplasty with a stent not only have a foreign object in their body, but they also must take drugs to keep clots from forming in the stent.”

Researchers also found both bypass surgery and angioplasty to be beneficial in comparison to medicines alone. Most severe patients of the disease had 23.6 months added to their lives over the 15 year period of the study. This addition was 10.6 months for patients with medium severity and 8.1 months for those with low severity.

According to Dr. Smith, the patients analyzed under the study are fairly representative of the general population of heart patients and so his team’s findings showing long-term benefits of bypass surgery are widely applicable. The findings of the analysis appear in the October 2006 issue of the journal Annals of Thoracic Surgery.

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