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Fall 2007

Stents or Bypass State of the Heart in Coronary Care

Patients who need more than drug therapy to treat their coronary artery disease have two choices: 1) performing coronary artery balloon angioplasty or stenting to hold open the arteries, or 2) getting coronary artery bypass graft surgery. Picking the right path for treatment requires the combined knowledge of many experts who know the strengths and weaknesses of each approach for any given patient, UCSF heart physicians say.

"You have to have a close, working relationship between the primary care doctor, the heart surgeons, the cardiologists and others," says Yerem Yeghiazarians, M.D., an assistant clinical professor of cardiology at UCSF. "Most importantly, we need to educate and inform our patients of the treatment options and together make the best decision in each case."

All agree that advances in stent technology have been dramatic. "Percutaneous coronary interventions have advanced tremendously over the last decade and have changed the field of interventional cardiology," says Yeghiazarians. "It has clearly been shown that angioplasty works better than just the clot-busting medications in the setting of a heart attack."

Starting in the 1980s, balloon angioplasty revolutionized the process of opening coronary arteries. During the procedure, a small incision is made either in the thigh or the arm artery, through which interventional cardiologists thread a narrow catheter up into the coronary vessels, where a balloon is inflated to widen the atherosclerotic blood vessels.

Arteries opened in this way tend to recoil and renarrow over time, so cardiologists started inserting stents to keep the arteries open. Restenosis within stents can occur, however, as tissue can grow inside the implanted stents, constricting blood flow once again. Drug-eluting stents were then developed to limit this problem by significantly decreasing the tissue growth within the stents, but the problem has not been totally eliminated.

"The treatment of coronary artery disease has been so extensively studied that you can pretty much find an article that supports whatever you want to say,"says UCSF cardiac surgeon Scot Merrick, M.D. "After any new study comes out, you will have either surgeons or cardiologists saying the question wasn't studied well."

Coronary artery bypass graft surgery was developed in the 1960s, and has remained fundamentally the same. Arteries or veins from elsewhere in the body are grafted to the coronary arteries on each side of the atherosclerotic narrowing, thus giving blood a path to bypass the blockage.

One of the drawbacks of the procedure is that it requires open heart surgery. Recovery can be painful and require multiple days in the hospital, whereas recovery from stenting is much quicker.

Surgeons believe that coronary artery bypass has such proven efficacy that it will always be a worthwhile option. "When I was a medical student in 1974, I heard about research in stents and asked my adviser whether I should study heart surgery," Merrick says. "My adviser told me there would always be a need for good heart surgeons."

All parties agree that the key to picking the best therapy is to consult with those who know enough not to use a single approach. "All options may have a role," Yeghiazarians says. "The therapy has to be individualized to the patient."

To contact Dr. Yerem Yeghiazarians, call (415) 353-3815.

To contact Dr. Scot Merrick, call (415) 353-1606.

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