Study: Bypass better than stents in long term

By MARIA CHENG
02 sept 2008--For heart patients with clogged arteries, the choice between bypass surgery or an angioplasty may come down to one question: How many procedures would you like to have?
In research presented Monday at the European Society of Cardiology meeting in Munich, experts concluded that while bypass surgery and angioplasty offer comparable results, patients who have angioplasties are twice as likely to require another procedure within a year.
"If you don't want to have another heart operation for at least a decade, you should pick the surgery," said Dr. Heinz Drexel, professor of medicine at the University of Innsbruck in Austria and spokesman for the European Society of Cardiology. Drexel was not connected to the research.
"But that means you have to have your chest cracked open," he said.
When arteries become blocked, doctors have two main options. Traditionally they have done a bypass surgery, which reroutes blood vessels to detour around blockages.
But in recent years, angioplasties have become increasingly popular. An angioplasty is a non-surgical procedure where a balloon is pushed into a blood vessel to flatten the blockage, leaving a stent to prop the artery open.
In the study results announced Monday, European doctors compared the effectiveness of open-heart surgery versus angioplasty in a trial of more than 3,000 patients in Europe and the United States.
About a third of the patients had medical conditions that required surgery. The remaining patients were randomly assigned to receive either surgery or an angioplasty.
The study was paid for by Boston Scientific, makers of heart stents.
After one year, researchers found that the death rate among the two groups was virtually the same: 7.7 percent among surgery patients and 7.6 percent among angioplasty patients.
In patients who had an angioplasty, nearly 14 percent needed another procedure after a year, compared with about 6 percent of surgery patients.
But patients who had surgery had about a 2 percent stroke risk versus nearly zero risk for patients who had an angioplasty. Doctors said that any surgery had an inherent stroke risk, compared with an angioplasty.
In January, a study published in the New England Journal of Medicine found that bypass surgery was still the best option for heart patients with more than one clogged artery.
"Surgery still comes out as the winner in a head-to-head trial," said Dr. Douglas Weaver, president of the American College of Cardiology, who was unconnected to the research.
"This comes down to a conversation with patients and making sure they know that with an angioplasty, there will be a higher rate of revascularization," he said, referring to the need for repeat procedures.
Patients typically need at least a month to fully recover from an open-heart surgery, a five-hour long operation under general anesthesia.
Angioplasty patients, however, are often up and walking around after three days.
"You invest more in terms of recuperation with surgery," said Dr. Tim Gardner, president of the American Heart Association. "But the advantage is durability."
When drug-coated stents were first introduced in 2003, they became the fastest-selling medical device in recent history. Doctors thought that the tiny tubes, which leak drugs to prevent tissue regrowth, would make angioplasty a much better alternative to surgery for patients.
But in 2006, studies began to emerge showing that patients with the drug-coated stents were more likely to develop potentially fatal blood clots months and even years after they were implanted.
Stent sales plummeted and doctors have become more wary of their use, saving them only for certain patients with no other options.
Doctors cautioned that more data is still needed about the pros and cons of bypass surgery versus angioplasties, and that patients needed to be tracked for at least five years.
"This only tells us what happens after one year," Drexel said. "We need to wait for at least five years to get a good answer about which therapy is really better."