With the improvement of people’s living standard, the change of diet structure, the accelerated pace of work and life and the increase of pressure, the incidence of coronary artery atherosclerotic heart disease, which we usually call coronary heart disease, is on the rise year by year, not only seriously threatening the lives of middle-aged and elderly people, and the age of onset tends to be younger, and its death and disability rate is second only to tumors.
Once you have coronary heart disease, what kind of treatment should you choose? In addition to taking relevant medications, we can also choose coronary artery bypass grafting and interventional methods to treat the disease. So, what are the disadvantages and disadvantages between them? How to choose? Let’s briefly introduce them.
The full name of what we usually call interventional therapy is percutaneous coronary intervention (PCI), i.e. all techniques to reduce coronary stenosis via an interventional route; PCI does not require surgical open-heart surgery and therefore does not require general anesthesia, and the stenosed coronary artery is opened from within the lumen of the coronary artery by puncture and catheter placement under X-ray surveillance. The basic technique currently used is percutaneous transluminal coronary angioplasty (PTCA), in which a catheter is inserted into the vessel through skin puncture so that a specially designed balloon catheter reaches the lumen of the stenosed coronary artery and dilates the stenosed vessel by pressurizing the balloon outside the body to reconfigure the diseased coronary artery. lesions require stent implantation. The advantage of coronary stenting over PTCA is that it allows for more optimal dilation of stented lesions. It reduces the restenosis rate by half after PTCA and allows for rapid intimal apposition of intraoperative torn coronary arteries to reduce intraoperative complications and improve the success rate and safety.
Indications for coronary stenting are
1.Severe stenosis of a single coronary artery with objective evidence of myocardial ischemia and a large blood supply area of the diseased vessel.
2.Multi-branch coronary artery lesions, but with more limited lesions
3, those with recent complete occlusion of the vessel, with surviving myocardium in the vessel supply area and distal visible collateral circulation
4, those with severely reduced left ventricular function (EF <30%)
5, angina pectoris after coronary artery bypass grafting.
6, restenosis after PTCA.
Interventional therapy is less invasive and less painful for patients to experience, and it is used as an important coronary revascularization technique not only for stable angina, but also for reperfusion treatment of acute myocardial infarction, resulting in a further reduction of morbidity and mortality compared with thrombolytic therapy. The results of a larger randomized clinical trial conducted in the early 1990s showed that in patients with single-branch lesions suitable for both intervention and coronary artery bypass grafting (CABG), as well as in patients with good left heart function and multiple lesions without left main lesions and recent myocardial infarction (MI), the survival rates of patients without mitral regurgitation in the immediate and long-term (1-5 years) periods were similar for PTCA and CABG, but in the interventional group with combined diabetes mellitus The morbidity and mortality rates were higher in the interventional group than in the bypass group, and the interventional group had more recurrences of angina due to restenosis and more target vessel revascularization (3 to 10 times more than in CABG). The main problem of interventional therapy is that it is not effective for certain lesions such as severe calcific lesions, significant eccentricity, multiple stenosis or diffuse stenosis and complete occlusion of coronary arteries, and patients also need long-term anticoagulant medication after the procedure. Although the indications for intervention are expanding and the efficacy is improving with the development of interventional techniques and materials, the most important problem facing interventional treatment is still restenosis, which is related to surgical technique such as stent selection and adequate release, lesion characteristics such as multiple or diffuse lesions, and the presence of co-morbidities such as diabetes mellitus. Coronary artery stenting, because it effectively avoids elastic retraction of the vessel wall and vascular remodeling after balloon dilation, results in a more pronounced initial lumen enlargement and a significantly lower restenosis rate, but because the stent itself can stimulate smooth muscle cell proliferation, the restenosis incidence is still around 13% to 20%.
The outstanding advantage of surgical bypass surgery is that it can completely cure 100% occluded coronary lesions with definite results, and fewer people need reoperation to reconstruct blood flow. However, bypass surgery requires general anesthesia to open the chest, exposing the heart and aorta, and sometimes needs to be performed under extracorporeal circulation, which results in greater surgical trauma, longer hospital stay, and slower return to normal activities. The good or bad condition of one’s own peripheral vessels is also the key to decide whether bypass surgery can be performed and the postoperative result. If one’s own blood vessels are varicose, calcified or sclerotic, the effect of using them as bridging vessels will not be good, or they will not be suitable for bypass surgery at all.
Selection of indications for coronary artery bypass surgery for coronary artery disease.
1. Patients with variant angina pectoris with poor drug efficacy.
2. Grade III-IV angina with poor drug efficacy.
3. Myocardial ischemia or postoperative restenosis after PTCA failure.
4. Post-infarction angina pectoris.
5. Acute infarction within 6 hours.
6. Acute infarction cardiogenic shock.
7.Post-infarction, mechanical complications (perforation, incomplete valve closure)
8.Patients who are not suitable for interventional treatment or restenosis or even stent occlusion after interventional treatment
Coronary artery bypass grafting and stent implantation are two different surgical methods which have better results, which is always a concern of the majority of patients. Current clinical trial data show that bypass surgery provides more complete revascularization, but there is no difference in the composite endpoint (death, stroke, and myocardial infarction) between the two at one year postoperatively, except for a higher incidence of cardiac events in the stenting group. For patients with coronary artery disease, whether they are treated with coronary artery bypass grafting or stent implantation, the treatment should be decided according to the patient’s own condition, especially the characteristics of coronary artery lesions. In addition, the clinical experience of the operator is important and sometimes determines the success or failure of the procedure. Stent interventions are mostly performed in internal medicine by physicians as operators, preferably with strong cardiac surgery to provide safety, because in case of accidents such as bleeding during the intervention, surgeons can quickly open the chest to save the patient’s life. Coronary artery lesion characteristics are a prerequisite for the decision of bypass or stenting, while the functional status of each organ of the patient (liver and kidney function, whistling function, cardiac function, etc.) is also necessary for the selection of the procedure.
First of all, both coronary artery bypass grafting and PCI can completely reconstruct blood flow. If there is no contraindication to the procedure, bypass surgery should be preferred for treatment because of the good long-term effect of the procedure and the absence of complications such as restenosis after stenting. However, PCI should be considered for treatment if the lesion is mild or if the liver or kidney function is poor due to less trauma and less pain. Patients with combined apical ventricular wall tumor can only choose surgical bypass plus ventricular wall tumor resection.
Secondly, patients with complex coronary lesions who cannot achieve complete hemodynamic reconstruction by stenting should undergo bypass surgery if there are no surgical contraindications. However, if the patient has poor whistle function and cannot tolerate surgery, stenting can also be considered to selectively perform partial hemodialysis to improve clinical symptoms and quality of life.
Third, if the patient’s liver or kidney function cannot tolerate bypass surgery, or cannot tolerate the damage of contrast agents during stent implantation, only non-surgical – pharmacological conservative treatment is also an option.
In conclusion, the correct surgical procedure is determined by the physician based on a comprehensive assessment of the patient’s coronary lesions, age, medical history, physical signs and the functional status of each organ. Patients should trust and respect the doctor’s recommendation as to which surgical procedure to choose, and only by cooperating with the treatment according to the doctor’s recommendation can they achieve the desired results.