By Pass Surgery Vs Angioplasty

Dear Doctors at CCF, These are the details of my father in India. The big dilemma that we have
been facing is the surgery (by pass) vs angio plasty. The following are the diagnosis of the thallium stress test and angiography done 2 weeks ago.

Ppatient is 62 yr old male , hypertensive & on medication for last 10 yrs. Used to feel fatigued & a vague tightness in the chest while walking for last 2 1/2 yrs. EKG never showed ischaemia. Stress TMT was normal . Stress thallium showed reversible ischaemia. angiography : dominant artery - right coronary artery

left ventricle ejection fraction -60%,no wall motion abnormality
left main - normal
lad-95% mid stenosis
lcx(left circumflex) 70%proximal  stenosis
rca--100% mid stenosis
for rca , good collateral system has developed

Questions:
Q1: Should patient go for CABG or for medicated stents in rca & lad.
Comment: Doc here says rca is a  chronic total occulusion  & and  may require drilling.

Q2: How is the success rate of medicated stents. In india usage of mdeical stents is fairly new, is that the case in US as well. Any thought from you folks the best, will surely help.

Thanks,
Rajeet.
***@****

[CCF-M.D.-BJ]

Rajeet,

It is really difficult to specifically tell you one versus the other without seeing the actual pictures from his angiography.  Currently, the standard of care is still bypass for 3 vessel disease, especially in patients with diabetes. Some factors that would influence that decision are other comorbidities, calcification of the vessels, the size of the vessels, the availability of grafts to harvest.  We say this, because this is primarily where the data we have available still guide us.

The availability of coated stents is changing the field. The success rates of deployment are similar to other stents. What is the big advancement is the decreased risk of these stents stenosing down over time.  This allows the stents to be used more redily and in places that stents have not been as successful in the past.  

Given then fact your father is suffering from anginal symptoms, he certainly needs something done with respect to revascularization.

One thing you could do is to submit your films and records to the e-consult service here and get firmer recommendations.

good luck

[Healthyself2]

It sounds like your father has slowly developed his disease over 30 years or so.  The fact that some cardiac event didn't kill him and that the heart remains in fairly good health is probably indicative that he is not the type of person that will die suddenly from this problem.

I have a similar problem with a longstanding 100% blockage of the RCA (well collateralized), a 70-90% ostial occlusion of the circumflex and a "cratered" plaque in my left main.

My take on the RCA is to leave it alone.  They are very hard to open using traditional angioplasty, and even when opened, have a high rate of re-occlusion.  With the collateralization your father has, it probably doesn't pose a problem and is not worth the risk.

The LAD is most likely the source of your father's increasing angina and should be the primary focus.  If you want to intervene, probably the first stop there is a drug coated stent - they seem to have pretty good success in the LAD.

Whatever is done, the progression of your father's disease needs to be stopped.  It's becoming fairly clear that aggressive cholesterol control via modern drug therapy with moderate daily exercise will stop the disease.  In my case, I have been on Lipitor + Niaspan + Welchol for several years and continue to live in good health with good physical ability.

After 2 failed attempts to open my RCA, I finally decided that it wasn't worth it.  It's quite amazing how the heart has formed it's own bypass over the years.

Best Regards

[Rajeet]

Thanks for your comment and sharing your personal experience, that was some good news. Can you share the name of the brand of the medicated stent that is most reliable. How long have medicated stents been in use in the US? Regards.....Rajeet.

[innate]

how has the beating heart portal entry technic been accepted and how succesful is it