Jewish World Review March 19, 2003 / 15 Adar II, 5763

Angioplasty procedures performed more often than bypass graft surgery

By Ed Sussman | Around the world, more than a million angioplasty procedures are performed each year to try to relieve pain in people with blocked heart arteries. The less invasive catheter procedure appears to be preferred by patients who would rather risk having to do a repeat angioplasty than undergoing open-heart bypass graft surgery.

"Patients believe that angioplasty is a better procedure, and we as surgeons have to recognize that coronary artery bypass graft surgery may be becoming obsolete,'' said Timothy Gardner, M.D., the chief of the cardiothoracic division for the University of Pennsylvania Health System and clinical director of cardiac surgery at the Hospital of the University of Pennsylvania.

In angioplasty, doctors make an incision -- usually in the thigh -- to allow access to the arterial system. Then under X-ray guidance, a catheter is advanced through the blood vessel system until the tip of the catheter is positioned at the site of a blockage in the coronary artery. At that point, a balloon at the end of the catheter is inflated, crushing the blockage material to the sides of the arterial wall. Usually in the United States, and increasingly in Europe and the rest of the world, a tiny -- and very expensive -- coil called a stent is deployed, as well, to prop open the artery wall.

Patients can often go home the same day or the next; recovery is almost immediate. The drawback with angioplasty is that 50 percent of the time, the procedure results in the need for another procedure, although that occurrence is about halved with stents.

In open-heart bypass surgery, the patients undergoes general anesthesia, an incision is made the length of the chest, the bones of the chest are sawed open, and arteries or veins from other parts of the body are harvested and are sewn into place around the blockages. More frequently, the heart is stopped and patients are placed on a heart-lung machine, although a number of doctors can now perform the procedure on a beating heart.

Patients are hospitalized about a week, and their time to complete recovery can be months. The open-heart procedure costs in the neighborhood of about $30,000, compared to about $10,000 for angioplasty.

The advantage of open-heart bypass graft surgery it that is usually remains successful in preventing heart pain caused by angina for a higher percentage of patients than does angioplasty.

"A lot of people are willing to take the 50-50 chance that they will never have to do open-heart surgery,'' Gardner said during the 39th annual meeting of the Society of Thoracic Surgery in San Diego, Calif.

And a study presented at the meeting shows that more and more people are willing to take that gamble. Researchers scrutinizing the records at the Nashville, Tenn.-based Hospital Corporation of America said that angioplasty procedures appear to be increasing at the rate of about 6.8 percent a year, while bypass surgery is declining at the rate of 1.9 percent a year.

@Michael Mack, M.D., a practicing cardiothoracic and vascular surgeon at Cardiovascular Surgery Specialty Associates of North Texas in Dallas, @explored the database of the hospital group @between Jan. 1, 1999, and March 31, 2002, reviewing trends in how the procedures were being performed at the corporation's 76 hospitals located in 17 states in the south, southeast and southwestern United States.

He said that the hospital staffs in that time frame performed 154,701 heart procedures -- approximately 7 percent of all the procedure performed in that period in the United States. In the 69 institutions of the corporation in which both angioplasties and bypass surgery were done, a total of 148,396 operations were performed.

The analysis of the data:

-- About 65 percent or 97,045 procedures were angioplasties; 51,351 were bypass surgery, a ratio of 1.9-1 in favor of the percutaneous procedures.

-- Percutaneous procedures rose at the rate of 6.8 percent a year. However, he noted , the increase in these operations increased at a slower rate -- 1.7 percent -- in the last year.

-- The rate of bypass surgery procedures fell at the rate of 1.9 percent a year.

-- The mortality rate for the percutaneous procedures remained constant at 1.25 percent over the course of the statistical review.

-- The mortality for bypass surgery procedures fell from 2.81 percent in 1999 to 2.28 percent in 2002.

"I am more encouraged than discouraged,'' said Mack. "I was somewhat surprised that bypass surgery is not decreasing at a greater rate. I was also encouraged that it appears we are doing a better job at the procedure, too.''

Dr. Thoralf Sundt, M.D., a cardiovascular surgeon at the Mayo Clinic in Rochester, Minn., said the data should suggest to surgeons that they would be advised to look at ways that less invasive percutaneous and bypass surgery procedures can be seen as complementary, rather than as competing modalities.

Mack said the data presented at the meeting may serve as a bookmark in the field because in the future angioplasty may be performed with new "drug-eluting'' stents -- those scaffold coils that prevent regrowth of cells that lead to angioplasty failures. If the stents are widely used -- despite costs in the $3,000 range for one 20-millimeter length of coil -- it might severely impact on whether anyone could convince a patient that open-heart surgery is the way to go to relieve angina pain

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