Is Bypass Surgery or a Stent Better for Me?
Coronary artery disease (narrowing or blockage of the arteries that supply the heart) is one of the most common heart diseases in the world. As this disease progresses, it can lead to serious problems such as chest pain (angina), shortness of breath, heart attack, and heart failure. When significant narrowing is found in the arteries, one of the questions patients most often ask is:
- "Is a stent or bypass surgery better for me?"
- There is no single right answer
- to this question. This is because the choice of treatment
- is individualized based on many factors, such as the patient's age, the number of affected arteries,
- the structure of the arteries, the presence of diabetes,
- the pumping strength of the heart, coexisting
- conditions, and the patient's expectations,
- and is determined
for each person. Today, international cardiology and cardiac surgery guidelines recommend that treatment decisions be made using a "Heart Team" approach. In this team, an interventional cardiologist, a cardiovascular surgeon, and other specialists as needed evaluate the patient together to determine the most appropriate treatment method.
Treatment Options for Coronary Artery Disease
There are three main treatment approaches for coronary artery disease:
1. Medication and lifestyle changes
2. Percutaneous coronary intervention (stent)
3. Coronary artery bypass grafting (CABG) surgery
One or more of these methods may be suitable for each patient.
What Is a Stent?
A stent is a thin metal mesh structure placed inside a narrowed or blocked coronary artery after it has been widened with the help of a balloon.
Advantages of a Stent
The chest is not opened. General anesthesia is usually not needed. The procedure is usually performed through an artery in the wrist or groin. The hospital stay is short. Recovery is fast. Return to daily life can occur within a few days. Disadvantages: Renarrowing may occur in some patients. Repeat procedures may be needed in complex disease involving more than one artery. Dual blood-thinning therapy (aspirin + a second anti-clotting medication) must be taken for a certain period.
What Is Bypass Surgery (CABG)?
In bypass surgery, a new vessel (graft) is connected beyond the blocked artery so that blood can reach the heart muscle by going around the blocked area. The vessels used are usually:
- The internal mammary artery in the chest wall
- The saphenous vein taken from the leg
- The radial artery taken from the arm
.
Advantages of Bypass
Long-term success is high in multivessel disease.
It often gives better results in patients with diabetes. It may provide an important advantage in left main coronary artery disease. The need for repeat procedures is lower. Arterial grafts in particular can remain open for many years. Disadvantages: It is open-heart surgery. General anesthesia is required. The recovery period is longer. In the early period, surgical risks such as infection, bleeding, and stroke are higher. The hospital stay is longer.
In Which Patients Might a Stent Be More Suitable?
In general, a stent may be preferred in the following situations:
- Single-vessel disease
- Two-vessel disease (with suitable anatomy)
- Rapid opening of a blocked artery during a heart attack
- Patients at high surgical risk
- When the structure of the artery is technically suitable for a stent
However, each patient should be evaluated individually.
In Which Patients Might Bypass Be More Suitable?
Bypass may generally provide greater benefit in the following situations:
- Left main coronary artery disease (especially with complex anatomy)
- Three-vessel disease
- Widespread and long-segment narrowings
- Multivessel disease in patients with diabetes
- Selected patients with left ventricular dysfunction
- High anatomical complexity (high SYNTAX score)
Which Is Better for Patients with Diabetes?
Scientific studies show that in patients with diabetes and multivessel coronary artery disease, bypass surgery can reduce the risk of death, heart attack, and the need for repeat procedures more than a stent. For this reason, bypass is considered first in suitable patients.
What Is the SYNTAX Score?
The SYNTAX score is a scoring system that assesses how widespread and complex coronary artery disease is. In general:
Low score: A stent may be suitable. High score: Bypass may be more advantageous. This assessment should only be made by a specialist team.
Which Lasts Longer in the Long Term?
In general:
The need for repeat procedures is lower with bypass surgery. Recovery is faster with a stent, but some patients may need a repeat procedure over the years. The new-generation drug-eluting stents used today provide much more successful results than older stents.
How Is the Treatment Decision Made?
According to international guidelines, the following factors should be evaluated together when making a decision:
- The patient's age
- Symptoms
- Presence of diabetes
- Kidney function
- The pumping strength of the heart
- Number of affected coronary arteries
- Anatomical structure of the arteries
- SYNTAX score
- Surgical risk
- The patient's life expectancy and preferences
Conclusion:
- Stenting and bypass surgery are not alternatives to each other; they are complementary treatments that provide the best results
- in different patient groups. While a stent is often the first choice in single-vessel disease, simpler coronary lesions,
- and acute heart attack, bypass surgery may provide greater long-term advantage in three-vessel disease, complex
- coronary anatomy, diabetes, and some patients with left main coronary artery disease. The best decision
- is the one made by the Heart Team by evaluating together the patient's clinical condition,
- angiography findings, and personal characteristics, and it
should be made. Can an artery become blocked again after a stent is placed? Yes. With new-generation drug-eluting stents, this risk has decreased markedly compared with older stents, but it has not disappeared completely. Can a person who has had bypass surgery develop heart disease again? Yes. Bypass does not completely eliminate atherosclerosis (hardening of the arteries). A healthy lifestyle and medication remain important for life. Does bypass last longer? Many studies have shown that in multivessel and complex coronary artery disease, bypass has advantages in terms of long-term durability and the need for repeat procedures. Is a stent safer? Each method has its own advantages and risks. When the right method is chosen for the right patient, both are safe and effective.
References:
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Lawton JS, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Jan 18;145(3):e18-e114. Vrints C, et al. ; ESC Scientific Document Group. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024 Sep 29;45(36):3415-3537. Farkouh ME, et al. FREEDOM Trial Investigators. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012 Dec 20;367(25):2375-84. Serruys PW, et al Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. SYNTAX Investigators. N Engl J Med. 2009 Mar 5;360(10):961-72.