Have Stents Marginalised Bypass Surgeries?

By Dr. Ganesh Kumar Mani in Cardiac Sciences

Sep 27 , 2022 | 2 min read

Notwithstanding the mushrooming of many cath labs carrying out angioplasties and stents across the country, Bypass surgery continues as the more durable modality of Myocardial Revascularisation. 

Whereas percutaneous interventions and stents have been proven to be non-inferior to Bypass surgery in many trials in the short and intermediate term, the latter (CABG) appears to be the standard of care in Multivessel Coronary Artery disease, especially in people with diabetes (FAME 3 trial NEJM Jan 2022), in the long term. One certainly cannot trivialise the advancements in stent technology and dexterity of our angioplasters.

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However, adverse clinical outcomes are lower with CABG! Even with repeat procedures in the stented population, the durability of CABG cannot be challenged in the long run. This is of importance with complex angioplasties done on patients with higher Syntax scores (>32) or Left main stem disease (American College of Cardiology 2019).

Both cardiologists and cardiac surgeons have recognised that Bypass graft to the most important Coronary artery LAD with the Left Internal Mammary artery has stood the test of time and is possibly the only factor for the relative better durability of Bypass Grafts over the stents.

Since one arterial graft to LAD significantly improved Quality of Life (QOL), many surgeons embarked on using more than one arterial graft. The practice of total Arterial Revascularisation became the standard of care in some centres.

Whereas grafting the branches of the Left Coronary Artery (LAD and Marginals) could ensure better Quality of Life, Total Arterial Revascularisation, including arterial graft to branches of the Right Coronary artery, did not prove any superiority in the long run. It is now a practice to use both Internal Mammary Arteries and Radial arteries as bypass conduits instead of veins whenever possible.

The short-term results of comparable subsets undergoing PCI or CABG weighed in favour of PCI as the latter (CABG) had a higher incidence of cerebrovascular strokes than PCI. This was presumably due to the usage of Cardiopulmonary Bypass and manipulation of the aorta. More recently, beating heart bypass surgery has obviated the use of Cardiopulmonary Bypass and thus significantly reduced cerebrovascular complications.

Robotic techniques of CABG are presently in a tiny percentage of patients and are not universally available. However, making a smaller incision on the side of the chest instead of dividing the sternum is gaining popularity among younger surgeons, but long-term results are not yet available. Wherever triple vessel diseases are associated with the need for valve replacement, bypass surgery is the right modality of revascularization.

To conclude, On World Heart Day of 2022, wherein the theme is Cardiovascular Health for Everyone, Bypass Surgery still is the standard of care for Severe (Multivessel and Left Main) Coronary artery disease for a longer and better Quality of Life!