 | Joseph P. Galichia, MD is the founder and Medical Director of the Galichia Medical Group, PA. He is an internationally recognized pioneer in the field of interventional cardiology. In the 70's, Dr. Galichia studied in Zurich, Switzerland with the inventors of the balloon angioplasty technique for treating heart disease. As a result of his experience, he was able to bring this historic technique back to the United States where he was one of the first physicians to perform coronary angioplasty here. A noted medical spokesman, he appears on a weekly Newstalk segment on KWCH Channel 12 and has a weekly syndicated radio talk show on KNSS 1330 AM every Saturday live from 11:00 am to noon. Dr. Galichia may be contacted by sending an e-mail to service@galichia.com |
Health & Medicine
2008-04-01 12:10:00
Angioplasty surgery - not for everyone
Question: I came to the hospital with unstable chest pain and hoped to have an angioplasty procedure done. However, when my doctors evaluated me, they found my vessels were blocked in too many places and I was told I was a better candidate for bypass surgery. Is it safe for me to have this surgery?
Answer: Bypass surgery is a very frequently performed procedure in the United States today. The results vary from institution to institution and are generally related to the frequency of procedures performed and skill of the individual surgeon in concert with the skill of the surgical and hospital team. Higher frequency centers tend to have better results and better across the board mortality rates, in the range of 1.5 percent for a reasonably healthy younger patient with good heart function to approximately five percent for older, frail patients who experience other multiple coexisting diseases.
The decision to perform angioplasty versus bypass surgery is often a difficult one for the cardiologist and the surgeon to make. Indeed, each of the physicians involved may have a different opinion about the best approach to treating this kind of patient. Most cardiologists would favor a bypass operation in individuals who had multiple heart artery blockages and also multiple heart blockages with particularly complex anatomy. Certainly the incidence of blockages within the heart vascular system plays a major role. Also, if a previous artery has been totally occluded, a physician could assume that it would probably be difficult to balloon dialate that type of vessel and may also direct a physician to make a surgical recommendation. Furthermore, if the main artery of the heart on the left side is severely narrowed, otherwise known as left main disease, most centers would still recommend bypass surgery. We know that patients over the age of sixty five that are scheduled for bypass surgery, particularly in their seventies and eighties are higher risk patients. Interestingly as well, due to their smaller stature and smaller vessels, women are overall higher risk bypass candidates. Yet having coexisting lung disease, cancer or other major health problems may lead a physician to perform a balloon or stent procedure even though the anatomy may favor a bypass operation. In my own practice, patients who are older and with more disease, may actually give us the better opportunity to do a balloon or stent procedure as a low risk intervention. By strategically identifying what we think may be the “culprit” lesion, we may indeed be able to give the patient relief from their angina and provide long term improvement in circulation in that particular area. As a cardiologist, I evaluate all aspects of this individual patient to assess their risk of bypass surgery versus an angioplasty or stent procedure. Interestingly, on some patients with left main disease who previously were an “open and shut” candidate for surgery, now may have a stent placed in this particular vessel, a procedure which we are successfully doing increasingly in our laboratory. A good example would be a patient with severe emphysema, unable to undergo general anesthesia safely, may in fact be able to have a stent placed in the left main artery with what we have defined as a low, less than one percent, risk to the patient.
The technology in cardiology has advanced extremely rapidly and continues to do so in cardiac surgery as well. Most of our patients now have their surgery without using a bypass pump, otherwise known as op cab bypass or “beating heart” surgery. This not only lowers the risk of surgery, it also decreases recovery time, lowers the chance of depression, loss of intellect and other problems that we see in patients that are placed on a bypass pump. In my own experience, the risk associated with an angioplasty procedure is less than one per thousand. If one compares this to bypass surgery with an expected 1.5 to two percent overall risk, you can easily see that the risk of surgery, even in the best of circumstances, is about ten times higher than the risk of an angioplasty or a stent procedure.
Recent studies show that patients that have bypass surgery actually do extremely well in the long term and fewer of them have to come back to the heart catheterization laboratory for second procedures or admissions for unstable chest pain. Nevertheless, given the risk, the cost and the recovery time, most circumstances favor stenting in conditions where there are one or two blockages. Fortunately, the risk of interventions in a single vessel in cardiac cath labs around the country is low. Further and ongoing studies are being done to define the indications for a bypass procedure versus a stent procedure in these complex patient groups. Both of these procedures provide patients with a high chance of immediate success and good long term results.
