Plaque Removal
To remove plaque from arteries, the following procedures are performed:
Angioplasty
Angioplasty, also called percutaneous transluminal coronary angioplasty or PTCA, involves inserting a long flexible tube called a catheter into a blood vessel through a small incision in your skin. The catheter has a deflated balloon on its tip. Once the catheter reaches the blocked blood vessel, the balloon is inflated and compresses the plaque against the sides of the blood vessel. The balloon may be inflated and deflated several times. Often, the procedure is done in conjunction with a small metal tube called a stent that is left in the artery to serve as a scaffold to keep the artery open and prevent the plaque from springing back toward the center of the vessel.
Coronary Artery Bypass Graft
Coronary artery bypass graft (CABG) surgery is an operation in which an artery or a piece of vein taken from elsewhere in your body is attached to the blood vessel to detour blood around the blockage. Conventionally, this is done through open-heart surgery. The surgeon makes a large incision and cuts through the breastbone to access the heart; during part of the operation, your heart will be stopped and a heart-lung machine will be used to pump your blood and help you breathe. UCSF offers an alternative minimally invasive bypass surgery in which the surgeon accesses the heart through a small incision without having to cut bones. There's no need to stop your heart, and most patients don't have to be on a heart-lung bypass machine. The recovery time is 10 days to two weeks, compared to the three to four months it typically takes to recover from open-heart bypass surgery. CABG is the most successful and most common major heart surgery in the Western world.
Coronary Stent
A coronary stent is a small, latticed, high-grade stainless steel tube that is used to hold the coronary artery open and minimize the chance of abrupt closure after angioplasty. It is placed in the coronary artery using the same procedure as the angioplasty. The stent is typically positioned at the narrowed area of the artery. When the catheter's balloon is inflated, the stent expands and is pressed against the vessel wall. The balloon is deflated and withdrawn, leaving the stent permanently in place. After a stent is placed, you will be prescribed an antiplatelet medication, Clopidogrel, also known as Plavix, for one month. This is used to minimize the risk of clot formation in the stent while tissue grows around the stent to incorporate it into the blood vessel wall. Within a month, the body no longer "sees" the stent, and the medication is no longer needed. You should continue to take aspirin, if it has been prescribed, along with the Clopidogrel.
Rotational Atherectomy
Rotational atherectomy widens narrowed arteries using a high-speed rotational device to "sand" away plaque. This technique is used in particular situations, such as with plaque with large amounts of calcium or to widen blockages within a stent.
The study of patients with coronary artery disease, led by the Smidt Heart Institute Chair of Cardiac Surgery, Joanna Chikwe, was published in the Journal of the American College of Cardiology. Chikwe directed the study when she was with the Mount Sinai Health System in New York.
"Our study highlights that thousands of coronary bypass patients may not be getting the best treatment option," Chikwe said.
Coronary artery disease occurs when cholesterol builds up and blocks arteries. Untreated, this can lead to an unpleasant feeling of heaviness, tightness or pain in the chest, jaw or left arm, often during exercise. However, many patients have coronary disease with few or no symptoms, so it can be very difficult to recognize and treat. This is important because every day in the U.S., about 1,000 people die from coronary artery disease.
To treat advanced coronary disease, patients have several options:
- Coronary bypass surgery -- A cardiac surgeon attaches a healthy artery from the chest wall and usually a vein from the leg, to the heart, thereby diverting blood flow around the blocked arteries. Chikwe’s study shows that patients who received two arteries had better long-term results than those who got one artery and veins. This was especially true among patients who were younger than 70 years old.
- Coronary stent – A cardiologist threads a catheter via a small puncture in the arm or the groin into the heart, allowing the insertion of a tiny metal frame called a stent into a blocked coronary artery to hold it open, thereby increasing blood flow. Although this is a less invasive option than traditional surgery, the benefits of stents are not as long-lasting as coronary bypass surgery.
- Hybrid procedure – The newest option is a combination of robotic heart surgery and stents. This allows patients to enjoy the immediate benefits of a minimally invasive procedure, with the long-term benefits of surgery. In a hybrid procedure, patients receive one arterial bypass through a small incision. A few days later, the other blockages are treated with stents.
“For many patients, two arteries are often better than one,” Chikwe said. “But many patients who need a double- or triple-bypass surgery prefer getting stents because they can go home the same day and feel better almost immediately. However, over the long term, having stents puts these patients at higher risk of dying or having a heart attack, especially if they are also diabetic.”
Chikwe and her team of investigators surveyed all 42,714 coronary artery disease patients in New Jersey who had coronary bypass surgeries from 2005 to 2012. After excluding patients who underwent emergency surgery or had multiple diagnoses, the study found:
- Of 26,124 patients who had coronary bypass surgery, only 3,647 or 14% had multiple arterial bypasses. The majority had a single arterial bypass. These findings mirror the rest of the U.S.
- Patients who had multiple arterial bypasses were more likely to be alive 10 years after the procedure, and less likely to have had a heart attack than patients who only had a single arterial bypass and veins.
“We concluded that multiarterial bypass grafts are underused, especially in younger patients,” Chikwe said. “Eighty-five percent of patients in the U.S. having coronary bypass surgery only get one artery combined with veins, and this study shows that the best treatment for many patients is multiarterial coronary bypass.”
Said Eduardo Marbán, MD, PhD, director of the Smidt Heart Institute, "With the recent addition of Dr. Chikwe to our leadership team, the Smidt Heart Institute is poised as never before to offer each patient highly-individualized, state-of-the-art treatment for their coronary artery disease.”
Chikwe's advice for anyone diagnosed with coronary artery disease: Talk with your cardiologist and a cardiac surgeon to see if you would benefit from a multiarterial coronary bypass or a hybrid procedure.
"The hybrid procedure can give you the best of both worlds," Chikwe said. "It's the long-term benefit of an arterial bypass combined with minimally invasive stent placement that ensures a fast recovery."
Read more from Discoveries magazine: A Pioneering Heart Procedure