Risks and benefits of coronary stenting vs. CABG

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Risks and benefits of coronary stenting vs. CABG

  1. 1. Is Coronary Artery Bypass Surgery Really Better than Coronary Stents? A look at the risks and benefits Sarah Smith Advisor: Dr. Grimes
  2. 2. Why is this important? <ul><li>The leading cause of death in the United States is coronary heart disease </li></ul><ul><li>It accounts for about 1 million deaths per year </li></ul><ul><li>About 43% of heart disease deaths are related to coronary artery disease </li></ul><ul><li>Heart disease is the leading cause of death of American women, accounting for 32% of all deaths per year. </li></ul><ul><ul><li>One in three women will die from heart disease, while one in 25 will die from breast cancer </li></ul></ul><ul><li>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 </li></ul>
  3. 3. Pathophysiology <ul><li>CAD is a chronic disease in which the coronary arteries gradually harden and narrow </li></ul><ul><li>Limitation of blood flow to the heart causes ischemia of the myocardial cells, leading to a myocardial infarction </li></ul><ul><li>This leads to heart muscle damage, heart muscle death and later scarring without heart muscle regrowth </li></ul>
  4. 4. Pathophysiology Cont. <ul><li>CAD can be thought of as a wide spectrum of disease of the heart </li></ul><ul><li>At one end is the asymptomatic individual with fatty streaks within the walls of the coronary arteries </li></ul><ul><ul><li>Over time these streaks will increase in thickness and may affect the flow of blood through the arteries </li></ul></ul><ul><ul><li>As the plaque continues to grow and obstruct the vessel to more than 70% the patient typically develops symptoms of obstructive coronary artery disease </li></ul></ul><ul><li>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 </li></ul>
  5. 5. Pathophysiology <ul><li>As CAD progresses, there may be nearly complete obstruction of the lumen of the coronary artery </li></ul><ul><li>Patients at this level have typically suffered from 1 or more myocardial infarctions, and may have angina at rest and pulmonary edema </li></ul><ul><li>An individual may develop a rupture of a plaque at any stage of the spectrum. </li></ul><ul><ul><li>The acute rupture a plaque may lead to an acute MI </li></ul></ul>
  6. 6. Risk Factors <ul><li>Family history of premature CAD </li></ul><ul><li>Smoking </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>HTN </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>obesity </li></ul>
  7. 7. Presentation/Diagnosis <ul><li>Generally patients present with stable angina, unstable angina, or a myocardial infarction </li></ul><ul><li>Coronary angiogram is currently golden standard for determining the presence of obstructive coronary artery disease </li></ul><ul><ul><li>Yields a 2D picture of coronary arteries </li></ul></ul><ul><ul><li>A catheter is inserted into the coronary arteries and injected with dye </li></ul></ul><ul><ul><li>The dye allows the physician to pinpoint the number and location of blockages in the coronary arteries </li></ul></ul>
  8. 8. Treatment Options <ul><li>There are many different treatment options available </li></ul><ul><li>A physician will look into the patients’ individual risk factors, severity of the blocked artery, and analyze the benefits and risks for possible procedures </li></ul><ul><li>Two popular procedures are PCTA/stent implantation and CABG surgery </li></ul><ul><li>Medical therapy is also available for a more conservative treatment </li></ul>
  9. 9. Overview of Stents <ul><li>1/3 of patients with CAD will undergo coronary angioplasty with stents or Percutaneous Transluminal Coronary Angioplasty (PCTA) </li></ul><ul><li>Angioplasty involves temporarily inserting and expanding a tiny balloon at the site of blockage to help widen the narrowed artery </li></ul><ul><li>Usually combined with stent implantation in the artery to help prop it open and decrease the chance of it narrowing again or restenosis </li></ul><ul><li>Performed in cardiac catheterization lab and are non-surgical treatment </li></ul><ul><li>Usually last about 1-2 hours and most patients are usually discharged in 1-2 days after a procedure </li></ul><ul><li>Stents are a stainless or nytinol mesh like device </li></ul><ul><li>Angioplasty and Stents </li></ul><ul><li>YouTube Stent </li></ul>
  10. 10. Stents <ul><li>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. </li></ul><ul><li>The risk of emergency referral for CABG and need for subsequent revascularization procedures has reduced by more than 50% because of coronary stents </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><ul><li>In previous years these patients were only candidates for bypass surgery </li></ul></ul>
  11. 11. Risks/Benefits of Stents <ul><li>Benefits: </li></ul><ul><ul><li>Shorter procedural and recovery time than CABG </li></ul></ul><ul><ul><li>Angina relief about 75% of the time </li></ul></ul><ul><ul><li>Decreases the risk for heart attack </li></ul></ul><ul><ul><li>Increases blood flow to the heart </li></ul></ul><ul><li>Risks and Limitations: </li></ul><ul><ul><li>Risk of death <1% </li></ul></ul><ul><ul><li>Risk of heart attack, thrombosis and bleeding <4% </li></ul></ul><ul><ul><li>Major limitation of procedure is a high rate of restenosis and need for revascularization </li></ul></ul><ul><ul><li>Scar tissue formation </li></ul></ul><ul><ul><li>Not a cure to the disease, still need to reduce risk factors and make lifestyle changes to prevent future disease progression </li></ul></ul>
  12. 12. Research… <ul><li>Patients receiving stents had lower incidence of death, MI, and stroke at 30-day follow-up compared to CABG. </li></ul><ul><li>However, patients receiving stents had a higher incidence of repeat revascularization procedures </li></ul><ul><ul><li>25% of patients at 1 year and 47% at 5 years </li></ul></ul><ul><li>This high risk of restenosis is one of the major reasons for patients refusing angioplasty and opting for other treatment modalities like surgery </li></ul><ul><li>The introduction of drug-eluting stents may shift patients from surgical procedures back to angioplasty and stent use. </li></ul>
  13. 13. Drug-eluting Stents <ul><li>These are stents that are coated with a drug that is known to interfere with the process of restenosis </li></ul><ul><li>As of December 2007, the FDA has approved of 2 DES: sirolimus-eluting stents and paclitaxel-eluting stents </li></ul><ul><li>Studies show that there is a 70-90% reduced rate of restenosis when compared with bare-metal stents </li></ul><ul><li>DES were first introduced in April 2003, and just 9 months later made up 35% of all stent implantations in the United States </li></ul>
  14. 14. Problem with DES? <ul><li>1. They are expensive </li></ul><ul><ul><li>It costs about $2200 for a DES, when compared to bare-metal stents which costs about $600. </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><li>2. The drug agents can interfere with the healing process and found to hamper natural vascular healing process </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>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 </li></ul>
  15. 15. Overview of CABG <ul><li>CABG is still the best therapy for reintervation for most patients with proximal left anterior descending, multivessel, and left main-stem coronary artery disease </li></ul><ul><li>Of the patients with CAD, about 10% will undergo CABG surgery </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul><ul><ul><li>Most commonly used are the saphenous vein and internal thoracic artery </li></ul></ul><ul><li>This procedure is performed with assistance of a heart-lung machine, which supports the patient’s blood during surgery </li></ul><ul><li>CABG Surgery </li></ul>
  16. 16. Risks/Benefits CABG surgery <ul><li>CABG was introduced about 50 years ago and is now performed in 1 million patients at a cost exceeding $20 billion annually </li></ul><ul><li>Many benefits such as decrease in angina, improved life-span, and providing an effective route for blood with prevention of new plaques to form </li></ul><ul><li>Surgery is however a much more serious operation that lasts a long time, with a long recovery time </li></ul><ul><li>Some complications seen after surgery are atrial fibrillation, increased risk of stroke, and cognitive dysfunction </li></ul>
  17. 17. Research… <ul><li>Less than 5% chance of heart damage and less than 2% chance of death </li></ul><ul><li>Stroke or other neurological injury occurs in 5% patients </li></ul><ul><li>Atrial fibrillation occurs in 20-40% of patients after CABG </li></ul><ul><li>2 reasons as to why CABG offers survival advantages for multivessel and left main-stem coronary artery disease </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><ul><li>Where stents only treat immediate culprit lesion, with no protective effect against the development of new disease </li></ul></ul></ul><ul><ul><li>2. failure of stents to achieve complete revascularization in most patients with multivessel disease reduces survival proportional to the degree of incomplete revascularization </li></ul></ul>
  18. 18. Isolated LAD and Left-main stem CAD <ul><li>CAD in LAD has been reported as high as 50% among patients who undergo CABG </li></ul><ul><li>CABG is regarded as an accepted golden standard for left main coronary artery disease </li></ul><ul><li>CABG has generally been considered the golden standard of therapy for left-main stem stenosis for the last decade. </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Restenosis rates in a study were 30.3% in bare-metal stents, 7.4% in DES group, and 3.7% in CABG group </li></ul></ul>
  19. 19. Multivessel CAD <ul><li>MVD accounts for approximately 60% of the CAD patients </li></ul><ul><li>The use of stents in these patients has resulted in higher restenosis and repeat vascularization rates than in patients treated with surgery </li></ul><ul><ul><li>Stents group had 16.8% restenosis rate as compared with 3.5% who underwent surgery </li></ul></ul><ul><li>CABG patients also experience fewer MI and major adverse cardiovascular events </li></ul><ul><li>DES have decreased the difference between CABG and bare-metal stents </li></ul><ul><li>In order for PCI to replace CABG as the preferred therapy in MVD, clinical trials must demonstrate long-term outcomes that are equivalent </li></ul>
  20. 20. What about the Diabetic Patient? <ul><li>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 </li></ul><ul><li>Revascularization of diabetic patients has been a huge dilemma and a great challenge </li></ul><ul><li>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% </li></ul><ul><ul><li>Also found that there is a huge difference in the need for revascularization in both; 18% of CABG patients and 80% of PCI </li></ul></ul><ul><li>Studies state that the preferred revascularization strategy in the diabetic patient with MVD is CABG surgery </li></ul><ul><ul><li>Lower mortality in CABG patients vs. PCI patients (1.4% vs. 12.8%) </li></ul></ul><ul><ul><li>Lower major adverse cardiovascular events (8.6% vs. 26.6%) </li></ul></ul>
  21. 21. The Future <ul><li>Minimally invasive direct coronary artery bypass (MIDCAB) is on the rise </li></ul><ul><li>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 </li></ul><ul><li>Yields shorter hospital stay with lower postoperative complications and better quality of life with similar safety and long-term efficacy as conventional CABG </li></ul><ul><li>Robotic instrumentation is also developing </li></ul><ul><ul><li>Surgery does not have a single chest incision of any kind, this surgery requires 3 pencil-sizes holes made between the ribs </li></ul></ul><ul><ul><li>2 robotic arms and an endoscope gain access to the heart, making surgery possible without opening the chest </li></ul></ul><ul><ul><li>Has been proven that these patients get out of the hospital 1-2 days earlier </li></ul></ul><ul><ul><li>This technique may develop into new technology that might be used more often in the future and may replace open heart surgery </li></ul></ul>
  22. 22. Conclusion <ul><li>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. </li></ul><ul><li>These affects are magnified in the diabetic patient </li></ul><ul><li>PCI with stent is still chosen as treatment option for single-vessel disease, and now considered for 2 or 3-vessel disease </li></ul><ul><li>Each patient is evaluated for the best treatment option based on their own risk factors and progression of disease </li></ul>
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