While the buzz in treatment for Coronary Artery Disease (CAD) is all about Percutaneous Coronary Interventions (PCI) or “Stenting”, relatively little information about Coronary Artery Bypass Grafting (CABG) is available.
CABG, despite often being labeled as painful, expensive and risky, is in many ways the opposite: an efficient method of returning blood flow to the heart back to normal. Relatively healthy patients, under the care of an experienced team of surgeons, anesthesiologists and nurses, can reasonably expect to go home after less than a week in the hospital, with little more than a couple of scars, a (mild and temporary) pain pill, an Aspirin and a Beta blocker. If the operation included dividing the Sternum (breast bone), this recovery includes healing of the bone, about six weeks.
While not minor, this is in most cases a pretty smooth recovery. Once beyond that period, a patient can get on with his life and concentrate on dealing with the issue of what caused his CAD, as no method of improving blood flow reverses the process of atherosclerosis.
This means also that he or she can return to being an active participant a society that ultimately include work and thus the ability to contribute to the economy instead of a continued disability because of untreated or recurring heart disease.
The oil spill disaster in the Gulf has shown once again how difficult it is to fix something gone wrong rather than prevent it in the first place. Coronary artery interventions, whether PCI or CABG, are “fixers” not “preventers”. As such, I would qualify PCI as the “Cap”, many tries, many failures but finally some temporary success. CABG is more like the relief well, harder to do and requiring much more expertise, but also a much more durable and possibly final solution.
- CABG does not require expensive and often dangerous (if other surgery becomes necessary) medications;
- CABG does not need fixing within one year in more than 10% of cases, 51% of which include redoing the original Stent site;
- CABG as a rule returns the blood flow back to normal in all coronary arteries, not just the “culprit” lesion;
- CABG maintains and often improves the heart function back to normal levels, so that the “motor” can go back to doing its duty, which is to provide blood to the rest of the body; this in stark contrast with PCI;
Unlike PCI, where unsatisfactory results are often explained by newer techniques yet to be developed, CABG is an established procedure with principles evolved in over decades of fine tuning. Ninety percent of coronary interventions are now PCI, while CABG is reserved for the minority of cases. This also means that patients are getting older, sicker and thus riskier to operate. Despite this, outcomes have not worsened (as one would expect) but continued to improve, reflecting improved technology as well as the skills of the surgical teams involved.
On-Pump, Off-Pump (with or without the use of the Heart-Lung machine) CABG, MIDCAB, Robotic Bypass operations are now used regularly, albeit that thus far none have shown to be superior to the original bypass procedure developed during the last century.
One thing sorely missing is information to the public. In reviewing the surgical literature, I find an overflow of data about technique and management of difficult cases, but very little about the immediate and long-term benefits of a procedure that involves the no. 1 killer in the US. These include not only health, but also economic and thus societal benefits. I wish this would change, so that the public has a fair chance to participate in deciding what is best.
While in active clinical practice, I was indeed much more interested in novel or “How to” procedures than reading about these type of clinical reviews. After all, I had my own internal review based on analysis of my own cases and as long as it compared favorably with results from elsewhere, I was content to have done a good job.
What I didn’t realize at the time, is the fact that these reviews are meant to be translated for public information rather than just the physicians to whom it is written. Major news organizations such as the NY Times or the Wall Street Journal regularly include articles about heart disease but rarely review the surgical alternative to PCI, mostly because there is no news available. I understand this now, and will continue to attempt to correct this issue via this web site.
In conclusion (for now), this is not a Blog against PCI, but rather an effort to put each procedure in its proper place amongst the arsenal of treatment options for CAD,