When medication does not control chest pain (angina), or when the buildup of plaques in the coronary arteries is so severe that you are at high risk for a heart attack, your physician may recommend a revascularization procedure—angioplasty or bypass surgery.
These procedures do not cure atherosclerosis (the thickening and narrowing of arteries), so you will need to adopt or continue with the dietary and other preventive lifestyle measures. You will also need to take medications to improve your lipid levels, lower blood pressure, and prevent blood clots.
The angioplasty option
More than 1.3 million angioplasty procedures (also called percutaneous coronary intervention, or PCI) are performed in the United States each year. Angioplasty does not remove plaques from the coronary arteries. Instead, it widens the channel (lumen) through which blood flows.
About 90 percent of people notice an immediate improvement in symptoms when the lumen is at least 50 percent open after an angioplasty procedure.
In most cases, a small, metal, scaffold-like device called a stent is permanently placed in the artery during angioplasty to help keep the artery open over the long term. Without a stent, the rate of restenosis (narrowing of the artery after angioplasty) ranges from 30 to 40 percent. Stents reduce the restenosis rate to 10 to 20 percent.
Angioplasty has several advantages over bypass surgery. It is a relatively simple procedure, there’s no need for general anesthesia, and the risks of open-heart surgery are avoided. In addition, after only a one-night stay in the hospital, you can resume your normal activities almost immediately. Angioplasty is also less expensive.
However, restenosis is a possibility with angioplasty, and you may eventually need another angioplasty procedure or, ultimately, bypass surgery to treat the restenosis.
When bypass is best
Each year, more than 400,000 people in the United States undergo coronary artery bypass graft surgery (often called CABG) to improve blood flow to the heart. During the surgery, a blood vessel from elsewhere in the body (usually an artery from the chest or arm, or a vein from the leg) is used to reroute blood around a section of coronary artery narrowed by atherosclerosis.
Bypass surgery is usually favored over angioplasty for people with one or more of the following:
• Narrowing of the left main coronary artery. This blood vessel is the main artery supplying blood to the heart. Even a brief period of blockage of blood flow through this artery could severely damage heart muscle and be fatal.
• Narrowing of three or more vessels. Bypass surgery is a better option than angioplasty when plaque buildup has caused multiple obstructions in an artery or has narrowed several arteries.
• Diabetes. Research shows that people with diabetes tend to fare better with bypass surgery than with angioplasty.
Drawbacks of bypass surgery include longer hospital stays and longer rehabilitation times than with angioplasty. Additionally, some bypass surgery patients experience a decline in their mental abilities.
However, research suggests that the decline stems from the disease process itself rather than the surgery, as the likelihood of mental decline is no greater than that seen in people with coronary heart disease who undergo angioplasty or only take medication.
Compared to angioplasty, bypass surgery keeps coronary arteries open longer and may produce better blood flow through these arteries. Bypass surgery generally provides good relief of angina for at least five years.
Except in an emergency situation, you have time to get a second opinion when deciding between angioplasty and bypass surgery. An in-depth discussion with your physician and careful consideration of your health history will help lead you to the best treatment.