Simpler Bypass Surgery Makes a Difference 

Minimally invasive technique more effective than other procedures, study finds

The increasing availability of a surgical technique that uses a small incision for bypass surgery is making a difference.

The technique, minimally invasive bypass surgery, now is preferable for many patients who otherwise would be treated with the artery-opening procedure called angioplasty, says a report in a recent issue of the New England Journal of Medicine. Angioplasty is a procedure in which thin balloons and other devices are threaded into a coronary artery and inflated to remove plaque that has blocked blood flow.

With the minimally invasive technique, the surgeon can do a bypass procedure through an incision as small as 4 inches, rather than sawing open the breastbone, as is done in conventional bypass surgery. Minimally invasive surgery can be done on the beating heart; conventional surgery requires the heart be stopped and the patient put on a heart-lung machine.

In the latest study, cardiologists at the University of Leipzig Heart Center in Germany compared the outcome of the minimally invasive technique to angioplasty followed by the implantation of a stent, a tube designed to keep the blood vessel open. Included in the study were 220 patients with blockage of a major heart vessel, the left anterior descending coronary artery.

This is "a very important coronary artery, and one that is at high risk for restenosis," says lead author Dr. Gerhard Schuler, a professor of medicine at Leipzig. Restenosis is a potentially life-threatening closing of the artery after its blood flow has been restored by angioplasty or a bypass.

The study was done because balloon angioplasty followed by stenting has become the standard procedure for the condition, but no studies have compared stenting with minimally invasive bypass, Schuler says. In the study, half the patients had stenting, the other half had minimally invasive bypass surgery.

Overall, the results favored bypass surgery, Schuler says. The incidence of complications immediately after the procedure was higher for the surgery patients, but after six months only 21 percent of the bypass patients had angina—chest pain caused by artery blockage—compared with 38 percent of the angioplasty-stent patients. Restenosis occurred in 29 percent of the stent patients, compared with 5 percent of the bypass patients. And 31 percent of the stent patients had a major cardiac event such as a heart attack, compared to 16 percent of the bypass patients.

Those results indicate that bypass surgery is a preferable treatment, but only if it is done with the minimally invasive method, in which "surgical trauma is much less severe and the hospital stay is shorter," Schuler says.

Other medical conditions influence the decision, he adds: "For patients at high risk of stenosis, such as those with diabetes, we feel that they should undergo bypass surgery, conventional or minimally invasive."

Also, the arrival of a new generation of stents that are coated with drugs designed to prevent the artery from closing might make a difference, says an accompanying editorial by Dr. Thomas E. MacGillivray and Dr. Gus J. Vlahakas, both of Massachusetts General Hospital.

"Recent studies using drug-coated stents suggest that these devices reduce...recurrent stenosis, although long-term data are not yet available," they write.

Always consult your physician for more information.