Coronary Artery Disease

Treatment

Treatment for CAD may involve traditional surgery or, increasingly, a less-invasive interventional procedure done through a Band-aid-size incision by threading a plastic tube, or catheter, into the coronary arteries. There may be more than one "right" option, so you need to understand the pros and cons of the alternatives. Don't be shy about asking why a particular procedure was recommended.

In this section on treatment you will find:

• Nonsurgical options, including angioplasty and stenting
• Surgical options, including bypass surgery

Nonsurgical options

If a diagnostic catheterization reveals significant CAD, your and your doctor will need to discuss treatment options. The following are considered nonsurgical because they are done through a tube or catheter instead of through a long incision.

Conventional balloon angioplasty: In this procedure, blocked coronary arteries are reopened by inflating a tiny balloon inside the blockage, compressing the fatty plaque against the artery walls and widening (dilating) the vessel.

Angioplasty with stenting: In most cases, angioplasty is generally combined with a procedure called stenting, in which a tiny tube of metal mesh, or stent, is used as a scaffold to help keep the artery open. It usually is placed over an angioplasty balloon, and the assembly is pushed into a narrowed artery and the balloon is inflated, expanding the stent. The balloon is then deflated and withdrawn. Over a period of several weeks your artery heals around the stent.

Stents, too, can become blocked. However, stents coated with a drug—called drug eluting stents—discourage reblocking, or restenosis. These have restenosis rates of less than 10 percent. Almost all stents implanted now are drug-coated.

Other drugs have been developed to stop reblocking before it starts. As one of the initiating steps in restenosis, platelets (tiny particles in the blood) collect at the site and promote clotting (thrombosis). Drugs called glycoprotein IIb/IIIa inhibitors block the chemical that encourages the platelets to collect. The glycoprotein IIb/IIIa inhibitors may be given intravenously (IV) just before the intervention and then continuously for a period of time, depending on which is used.

Angioplasty, with or without stenting, is often raised as a treatment possibility even before a diagnostic catheterization, so that the diagnostic procedure can proceed directly to treatment while you are in the cath lab, if warranted. Also, angioplasty and stenting may be combined with the use of other specialized procedures or catheters, including:

Rotoblation (percutaneous transluminal rotational atherectomy, or PCRA): In this procedure, a special catheter with an acorn-shaped diamond-coated tip is guided to the narrowing in your coronary artery. The tip spins at a high speed and grinds up the plaque on your arterial walls. The microscopic particles are safely washed away in your blood stream and filtered out by your liver and spleen.

Cutting balloon: A balloon tip with small blades is inserted through the catheter and moved to the narrowing in the artery. When the balloon is inflated, the blades are activated. After the small blades score the plaque, the balloon compresses the fatty matter into the artery wall.

Although the above treatments are considered nonsurgical, they entail risks and require special expertise. Ask your doctor and hospital how many such procedures they perform each year. According to American Heart Association guidelines published in 2001, hospitals should perform at least 400 percutaneous coronary interventional (PCI) procedures each year.

Learn more about what to expect and the recovery process.

What to expect

What to expect: From the patient's point of view, angioplasty and stenting are done much the same as a diagnostic catheterization. You will receive medication to relax and sedate you, but you will be awake throughout the procedure. Then the cardiologist numbs the site where the catheter will be inserted, usually the femoral artery in the groin, with injections of a local anesthesia. A thin plastic sleeve, or sheath, is inserted into the artery. The catheter, a long, narrow, hollow tube, is passed through the sheath and guided up the blood vessel into the coronary arteries. A small amount of contrast dye is injected into the blood vessels, valves, and chambers, which can be clearly seen on a special TV screen.

Once the catheter is placed into the narrowed artery, the doctor will perform the interventional procedure. The procedure usually lasts about 1 1/2 to 2 1/2 hours, but preparation and recovery time add several hours. Patients typically stay overnight in the hospital.

Recovery: Your doctor will discuss with you when you can resume your normal activities. Generally, however, you will need to take it easy for a few days after returning home: Avoid heavy lifting or any other strenuous activities. You may climb stairs, but you'll want to climb more slowly than usual.

Gradually increase your activities until you have returned to your normal level of activity by the end of one week.

Carry nitroglycerin for the first six months. Be sure it is fresh.

If your symptoms return, alert your doctor immediately. Angina that feels like the angina you had before your procedure might be a warning that your coronary artery has reblocked or that you have new blockages in other arteries. Other symptoms might include discomfort in your chest or in any other area where your previous pain occurred, excessive shortness of breath, dizziness, irregular heartbeats, nausea, excessive sweating, or inability to perform normal daily activities without becoming overtired or exhausted.

Surgical options

Coronary artery bypass (coronary artery bypass graft, CABG) surgery: In this type of surgery, one or more blocked coronary arteries are bypassed by a length of blood vessel grafted in place to restore normal blood flow to the heart. These grafts usually come from the patient's own arteries and veins located in the chest, leg, or arm. The graft goes around the clogged artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart.

The goals of bypass surgery are to relieve symptoms of coronary artery disease, including angina, and to lower the risk of a heart attack or other heart problems.

The surgery generally lasts from three to five hours, depending on the number of arteries being bypassed.

In this section on bypass surgery you will find information on:

• Procedures
• Bypass grafts
• Recovery

Procedures

Traditional coronary artery bypass graft surgery: In this operation, a surgeon makes an incision down the center of the chest, cuts through the sternum or breastbone, and opens the ribcage to access the heart directly. During surgery, the heart-lung bypass machine takes over the work of the heart and lungs, allowing the blood to circulate to all the other bodily organs. This is called "on-pump" surgery. The heart's beating is stopped to permit the surgeon to perform the bypass on an unmoving, "stilled" heart. Bypass surgery also can be performed "off pump" on the beating heart (see below). After surgery, the surgeon closes the breastbone with special wire and sews the chest closed with special internal or traditional external stitches.

Minimally invasive direct coronary artery bypass (MIDCAB) surgery:

Before your surgery, your doctor will review all your diagnostic tests to decide whether you are a candidate for minimally invasive direct bypass surgery, which involves smaller incisions and does not require the rib cage to be opened. In some patients, MIDCAB surgery can be performed through a small incision in the thorax. And newer robotic techniques are allowing surgeons to perform bypass surgery through even smaller keyhole incisions.

The benefits of minimally invasive direct bypass surgery include:

• Smaller incision, so smaller scar
• Shorter hospital stay--in some cases, only three days are needed (instead of the average five to six days for traditional surgery)
• Faster recovery
• Less bleeding
• Less chance of infection
• Less postoperative pain and trauma

Off-pump or beating-heart bypass surgery:

This procedure allows surgeons to work on the heart while it is still beating. The heart-lung machine is not used. The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.

Bypass grafts

Surgeons use several different blood vessels as bypass grafts. These blood vessels are available because other pathways can carry blood to and from the tissues of your chest, arms, and legs. The surgeon decides which graft(s) would be best depending on the location of the blockage, the size and number of blockages, and the size of your coronary arteries.

Internal mammary arteries (thoracic arteries, IMA grafts): The internal mammary artery is the most commonly used vessel for bypass grafts because it has proven to remain patent or open the longest and has thus produced the best long-term results. The arteries usually can remain attached at one end and the free end can then be attached to the blocked coronary artery just below the obstructed area. If the surgeon completely detaches the mammary artery at both ends, it is called a "free" mammary artery. Over the past decade, more than 90 percent of all patients have received at least one internal mammary artery graft.

Radial artery: The radial artery is the second most commonly used arterial graft. The arm has two arteries, the ulnar and radial arteries. Most people receive blood to their arm from the ulnar artery and will not have any side effects if the radial artery is used. Careful preoperative and intraoperative tests determine if the radial artery can be used. If you have certain conditions (such as Raynaud's, carpal tunnel syndrome, or painful fingers in cold air) you may not be a candidate for this type of bypass graft. The radial artery incision is in your forearm, about 2 inches from your elbow and ending about 1 inch from your wrist. After this type of bypass, patients are routinely placed on a medication called a "calcium channel blocker" for about six months after surgery to help keep the radial artery widely open.

The gastroepiploic artery to the stomach and the inferior epigastric artery to the abdominal wall are less commonly used for grafting.

Saphenous veins: These veins are removed from your leg, then sewn from your aorta to the coronary artery below the site of blockage.

To bypass the blockage, the surgeon makes a small opening just below the blockage in the diseased coronary artery. The graft is sewn into the opening, redirecting the blood flow around this blockage. If a saphenous (leg) or radial (arm) vein is used, one end is connected to the coronary artery and the other to the aorta. If a free mammary artery is used, one end is connected to the coronary artery while the other remains attached to the aorta. The procedure is repeated until all affected coronary arteries are treated. It is common for three or four coronary arteries to be bypassed during surgery.

A note about minimally invasive vein removal: Minimally invasive saphenous vein removal is accomplished by a small incision in the groin and one to two 1-inch incisions in the leg, near the knee. The surgeon uses special instruments to delicately remove the vein and close the incision with little blood loss and small risk of infection. Removing the saphenous vein by this method reduces patient discomfort and results in smaller scars and a quicker recovery.

Recovery

After surgery: If the procedure was done "on pump," electric shocks start the heart pumping again after the grafts have been completed. The heart-lung machine then is turned off. Pacing wires and a chest tube to drain fluid are placed before the sternum is closed surgically with special sternal wires and the chest incision is closed with special internal or traditional external stitches. Sometimes a temporary pacemaker is attached to the pacing wires to regulate the heart rhythm until your condition improves.

The patient is transferred to an intensive care unit for close monitoring for about one to two days after the surgery. The monitoring during recovery includes frequent checks of vital signs and other parameters, such as heart sounds and oxygen and carbon dioxide levels in arterial blood.

Once the patient is transferred to the nursing unit, the hospital stay is about three to five more days.

Recovery: Your medical team will provide you with information about your recovery, including how to care for your incision, as well as guidelines for returning to work and your other activities. Generally, however, full recovery takes two to three months.

Coronary artery bypass graft surgery does not prevent coronary artery disease from recurring. Lifestyle changes and prescribed medications can reduce the risk. Lifestyle changes include quitting smoking; exercising most days; taking off pounds if you are overweight; sticking to a diet low in fats and trans fats; treating high cholesterol and LDL; carefully managing any diabetes with strict adherence to diet and medications; keeping your blood pressure within normal levels; taking prescribed medications as directed; and following up with your doctor for regular office visits.