Clearing the pipes

Which procedure is best when plaque reduces blood flow to part of the heart muscle?

Angioplasty or bypass surgery? Which is best when cholesterol-laden plaque narrows a coronary artery and chokes off blood flow to part of the heart muscle?

There's no simple answer. It depends a lot on your situation: how many arteries are blocked, where the blockages are, your overall health, and your preferences.

It also depends on how you define "best" - most durable, shortest recovery, fewest complications, or longest survival.

At first glance, angioplasty with stent placement seems to be a clear winner. It requires a small nick in the groin, local anesthesia, an overnight hospital stay, and a relatively rapid recovery.

In comparison, bypass surgery requires opening the chest, general anesthesia, a several-day hospital stay, and weeks of sometimes painful recovery.

These differences are one reason why nearly 1.3 million angioplasties were performed in 2007 in the United States alone, compared with 470,000 bypass surgeries.

On the other hand, surgery is the king of the hill when it comes to durability and freedom from chest pain. Far fewer people need a repeat procedure after bypass surgery than angioplasty.

Simplest cases

For an uncomplicated blockage in a single coronary artery, angioplasty is becoming the first choice for most cardiologists and their patients. It is quick, relatively painless, and has you back to your usual activities in a few days.

A number of large studies show that survival after angioplasty is as good as after bypass surgery.

The convenience of angioplasty comes with a price. Up to one-quarter of people who have angioplasty must have it repeated, or have bypass surgery, within a few years.

And anyone who gets a drug-eluting stent must take medicine for at least a year to prevent the formation of potentially deadly clots around the stent.

More complex problems

Bypass surgery was once thought to be the only solution for blockages in two or three coronary arteries, at the junction of two arteries, in a heart with poor pumping power in the left ventricle, or in an individual with diabetes or kidney disease.

But even here, angioplasty is catching up. It's hard to be sure how comparable the two procedures are, since there are no data yet from head-to-head trials for such complex situations. But there are inklings from other sorts of information.

The latest comes from a review of data collected by the state of New York. It included all 17,000 bypass surgeries and angioplasties performed in 2003 and 2004 in the state's non-federal hospitals.

Investigators compared deaths immediately after these procedures, deaths within 18 months, and heart attacks within 18 months.

News reports about this work, which was published in the January 24, 2008 New England Journal of Medicine, bore headlines like "Surgery better than stents for multiple blockages." That isn't the whole story.

Bypass surgery was better, but not by much. An extra 1.6% to 2% of people in the bypass group were still alive and had not had a heart attack after 18 months.

Of course, that small difference isn't anything to sneeze at when more than a million of these procedures are performed each year.