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December 4, 2002
Bypass
Surgery Favored Over Stents for Some Patients in Long-Term
Comparison
Three-year follow-up shows high rate
of repeat treatment among coronary patients with blockages
who received stents. Effectiveness of newer stents not addressed.
(BETHESDA,
MD)—For patients with a single blockage in a coronary
artery, angioplasty using a stent to restore blood flow may
be the popular choice. However, surgery to bypass the blockage
produced better long-term results among certain patients with
high-grade artery lesions, according to a new
study in the Dec. 4, 2002, issue of the Journal of
the American College of Cardiology.
The
Dutch and Italian researchers previously reported short-term
follow-up results showing that patients with a single type
B2 or C lesion in a coronary artery fared better if they were
treated with bypass surgery.
"Now
three years later, this benefit is sustained; and we also
found that the patients who were treated by a surgeon were
less likely to have a return of angina, used significantly
less medication and were in better condition that the patients
who were treated by a cardiologist with a stent," said
Dr. Piet Boonstra of the University Hospital Groningen, the
Netherlands. The study focused on patients who fall between
those with simple lesions that are routinely treated with
stents and patients with more severe cases of multiple lesions
who are usually offered bypass surgery.
The
study involved 102 patients with a high-grade stenosis of
the proximal left anterior descending coronary artery who
agreed to be randomly assigned to either angioplasty or surgery.
For the angioplasty patients, a cardiologist threaded a catheter
into the narrowed artery to restore blood flow and then left
a wire mesh stent in place to keep the vessel open. The surgery
patients underwent a "keyhole" type operation in
which the surgeon worked through a small incision in the chest
to graft a bypass vessel around the artery blockage. The surgery
was performed on a beating heart without using a heart-lung
machine. Two patients assigned to the surgery group opted
for angioplasty instead. A third patient was deemed unfit
for surgical anesthesia and switched to angioplasty due to
chronic obstructive pulmonary disease. During an average 3-year
follow-up period, the researchers counted the number of patients
who died, suffered a heart attack or stroke, or needed a second
procedure because the same coronary artery clogged up again.
Using
an analysis based on the original randomization (intention-to-treat),
23.5 percent of the angioplasty patients suffered a major
adverse event compared to 9.8 percent of the surgery patients.
However, while the angioplasty patients were more likely to
suffer a heart attack, stroke or need a repeat procedure,
the only two deaths occurred in the surgery group. Dr. Boonstra
says he does not believe the surgical procedure caused the
deaths. All of the adverse events took place within the first
year following treatment.
Dr.
Boonstra said that while it is understandable that patients
prefer less-invasive angioplasty over surgery, the experience
in this study indicates concerns about the hazards of surgery
are not as great as many people believe, and that angioplasty,
at least for the specific type of patients included in this
study treated with the stents available at the time, carried
a greater risk of problems over the long run, including a
greater likelihood to need medication for chest pain or repeat
treatment because the blood vessel became blocked again.
Dr.
Stuart Jamieson of the University of California San Diego
Medical Center, who was not involved in this research, agreed
that the study highlights the temporary benefit provided by
angioplasty, in contrast to the long term effectiveness of
bypass surgery for these patients. He noted that the results
should help counteract some of the reluctance among patients
to opt for surgery. "The point has long been made that
patients prefer angioplasty over surgery. But this choice
is made because of convenience, comfort and cost. If one takes
into account the convenience, comfort and cost involved in
gaining relatively temporary benefit only, with the possibility
of later repeat interventions, these advantages are lost,
and surgery provides a better choice in the long term,"
Dr. Jamieson said.
Dr.
Boonstra noted, "It is important to recognize that this
is not true for all patients. It is true for the patients
we studied with one-vessel disease and a lesion in a difficult
part of the coronary artery that is difficult for cardiologists
to treat." Most patients with multiple vessel blockages
are treated with surgery, while patients with smaller, easier-to-reach
narrowing can be effectively dealt with by angioplasty, he
said. He said this study provides guidance for the treatment
of patients who fall in-between those two groups.
The
researchers noted that advances in stents have taken place
since they began their study, including the development of
stents that contain a drug that can reduce the likelihood
an artery will narrow again, although drug-eluting stent studies
on patients similar to those included in this report have
not yet been published.
The
American College of Cardiology, a 28,000-member nonprofit
professional medical society and teaching institution, is
dedicated to fostering optimal cardiovascular care and disease
prevention through professional education, promotion of research,
leadership in the development of standards and guidelines,
and the formulation of health care policy.
The
American College of Cardiology (ACC) provides
these new reports of clinical studies published
in the Journal
of the American College of Cardiology as a
service to physicians, the media, the public,
and other interested parties. However, statements
or opinions expressed in these reports reflect
the view of the author(s) and do not represent
official policy of the ACC unless stated so.
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