Angioplasty and bypass surgery, a new hybrid procedure

DEAR READERS:

In yesterday’s column, a reader asked why a friend had undergone both bypass surgery and an angioplasty to restore blood flow to the heart. The reader had thought that a person had either one or the other, but not both. I replied that this has been the case until recently: When one or more blocked arteries were discovered, cardiologists and cardiac surgeons had traditionally decided whether to do one procedure or the other.

However, a new hybrid approach is gaining favor. It makes sense only for some patients — and it sounds as if the reader’s friend is one of those patients. In yesterday’s column, I explained both angioplasty with stenting and coronary artery bypass graft (CABG) surgery.

With that groundwork, let me explain the thinking behind the new hybrid approach:

  • Angioplasty cannot reach and open all blockages of the heart’s arteries. For example, it can’t open blockages that extend a long distance in the artery or that are located at a fork of the artery. Significant blockages that can’t be opened by angioplasty need bypass surgery.
  • However, when arteries can be opened by an angioplasty using the latest types of stents (called drug-eluting stents), the long-term results are very good. And angioplasty is far easier to endure than CABG: It doesn’t require general anesthesia, causes fewer complications and has a shorter recovery time.
  • Traditionally, in people with multiple blocked arteries, if CABG had to be done for one artery, the surgeons often performed bypass surgery on the other blocked arteries as well, while the chest was opened. Yet performing surgery on arteries that could be opened just as well by angioplasty prolonged the time of surgery, and the potential for complications from surgery and anesthesia.

The new hybrid procedure seeks to achieve the best of both angioplasty and surgery:

  • It uses surgery when a blockage occurs in the biggest artery that supplies blood to the heart, the left anterior descending (LAD) artery.
  • The surgery on that artery is minimally invasive. It requires only a small incision in the chest (not cutting through the breastbone). The heart is left beating; no heart-lung machine (with its potential complications) is needed.
  • The artery used for the bypass is an artery in the chest called the left internal mammary artery (LIMA). This restores blood flow to the LAD for many years, longer than when veins are used or when angioplasty opens the LAD blockage.
  • The other blocked arteries are then opened via angioplasty, either immediately following the bypass or within the next day or two. (I’ve put an illustration of the hybrid procedure below.)

The new hybrid approach has not been proven to be superior in any way to traditional CABG. However, several good studies have found that it is not inferior. And since it involves less surgery and allows a faster recovery, this may make it preferable.

 

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In hybrid heart surgery, the blocked or narrowed left anterior descending artery is bypassed with the nearby left mammary artery, while another blocked artery (in this case, the right coronary artery) is opened with angioplasty plus a stent.