Stroke risk in bypass surgery

[Brijesh Krishnaswami]

Hi,
My father has unstable angina. He had an angiography done, and was diagnosed with triple-vessel diesase, with normal LV function, and no mitral valve regurgitation. Blocks are 90% LAD, 90% RCA and 70% LCX. He has diffuse stenosis in his left internal carotid artery, with a 90% block close to the brain. He also has peripheral vascular disease, with diffuse blocks in the legs and renal arteries. He developed renal failure after the angio (due to the dye contrast), and recovered well after one dialysis.
The cardiologist in India who did the angio has put him on medication and recommended elective CABG after a couple of months. Another cardiologist recommended that he stay on medical management, due to high risk of stroke or other neurological problems during surgery. Also, I have come across a lot of info on the Web as to many instances of brain damage caused during CABG. As a result, I am hesitant to go in for surgery (given that he developed complications even after a relatively simpler procedure, namely the angiography).

I came across Dr. Dean Ornish's methods of treatment without surgery, as well as other programs that claim to reverse atherosclerosis without surgery, but with strict liefstyle and diet modifications. I also read in Dr John McDougal's book that surgery does not benefit people with triple-vessel disease with normal ejection fraction.

I would greatly appreciate it if I can get answers to the following:
1. is CABG surgery absolutely required for triple-vessel disease as mentioned above?
2. is the risk of stroke or other neuro problems during surgery enhanced because of the carotid artery block? if so, by how much?
3. would the Dean Ornish program or the McDougal program (along with medical management) be more suitable for my father's profile?


Thank you,
Brijesh

[CCF CARDIO MD JMF]

YOur father's case is complex and these are always difficult questions.  

1. is CABG surgery absolutely required for triple-vessel disease as mentioned above? In general, this is the therapy of choice and i would recommend this to my patients.  
     2. is the risk of stroke or other neuro problems during surgery enhanced because of the carotid artery block? if
     so, by how much?  The risk is increased and becuase of this we often consider a stent to the carotid in a separate procedure prior to surgery or a combined carotid endarterectomy  with CABG.  I cannot quote specific stroke rates.  This would vary by institution and by surgeon.  
     3. would the Dean Ornish program or the McDougal program (along with medical management) be more suitable
     for my father's profile?  This may be an option but i would recommend a more traditional approach.  The ORNish program is a very stringent diet that is difficult for people to follow and may not necessarily help in your father's advanced disease.

[Brijesh Krishnaswami]

Adding some more details to my earlier post:

My father is a Type-II diabetic (now for 15 years) and hypertensive (for 3 years). His BP/sugar are well under control now. His resting echocardiogram is normal. He feels normal but for some tiredness or leg pain after walking for some distance.
He is 59, and short in stature.

Thanks,
Brijesh

[CCF CARDIO MD JMF]

Being a diabetic is all the more reason to go ahead with surgery as the revascularization procedure of choice.