New Delhi: Cardiovascular Artery Bypass Graft (CABG) is an open-heart surgery and was introduced in 1968, which created a shift in the treatment of coronary artery diseases. Right after nine years, Percutaneous Coronary Intervention (PCI), which is a non-surgical alternative, was invented in 1977. Since then, the debate CABG Vs PCI is on! Many clinical trials have been done to prove which one is more effective but each of them has its own ills or benefits.
Which One to Go For?
CABG or bypass surgery is recommended when there are multiple blood vessels blockages or when the patient is diabetic or having other complex diseases involved. PCI or stenting is advised when the patient is suffering from single blood vessel blockage or when the patient is very young or very old, be it men or women. “People who are young and have single vessel blockage, there is no reason to give them risks and stresses of bypass surgery when I am able to tackle the condition with a single stent,” Dr Aparna Jaswal, senior consultant cardiologist, Escorts Heart Institute and Research Centre, New Delhi told India Medical Times. According to her both the procedures complement each other and the patient is advised what is beneficial for him or her.
Dr H K Chopra, chief cardiologist, Moolchand Medcity, New Delhi also believes PCI to be much preferable in case of single vessel blockage. “If the patient has any significant disease or has multiple artery blockages, in that case only we suggest bypass surgery,” he told IMT.
“As per the Cardiology Society of India (CSI) document on ST Elevation Myocardial Infarction (STEMI), in the case of acute heart attack, clot busters should be immediately given to the patient. Afterwards angiography should be done which decides whether to go for PCI or bypass surgery. If the patient is having single or two vessels blockage and having no other disease then PCI or stenting should be provided in the time window of around 90 minutes, except in the cases of multiple arteries blockages or diabetic conditions, which require a bypass graft surgery to be done. Unfortunately, most of our patients don’t reach to the PCI equipped hospitals in time due to traffic,” said Dr Chopra, who is also president of CSI.
Dr Harinder Singh Bedi, head of cardiovascular, endovascular and thoracic surgery, Christian Medical College and Hospital, Ludhiana, holds a different opinion, which he supports with the findings of SYNTAX trials that suggest CABG has much better results over PCI. “There have been six studies and all of them have shown that bypass surgery provides better longevity and quality of life than PCI, in the case of multi-vessel diseases. In the case of single vessel blockage, we prefer PCI,” Dr Bedi told IMT.
“Long term results are not good with stenting,” Dr Prakash Hiremath, senior consultant, cardiothoracic surgeon, Narayana Hrudayalaya Heart Centre, Davanagere told IMT.
The Risk Factor Involved
Dr Hiremath said, “Stenting has more risks involved because when a foreign substance is placed in the body, a patient needs to be careful and be on regular medication as advised by the doctor. The patient tends to be careless at times, skipping medicines et al.”
To avoid involved risks, certain factors have to be implied. “Patients who have raised abnormal kidney parameters, we have to remember that due to angioplasty the kidneys can get dysfunctional and hence we have to recommend a bypass graft surgery. When the patient is very old in age or very morbidly obese and having a single vessel disease, then there is no reason to risk them with bypass surgery since healing is difficult in them,” said Dr Jaswal on the factors to determine the mode of treatment.
We can estimate the exact risk possibility only if we take equivalent case mix into consideration. “Generally, the case of bypass surgery could be 10 times riskier than the angioplasty because patients who come for the surgery are usually the failed cases of angioplasty with damaged hearts, dysfunctional kidneys, diabetic patients, which make the surgery even more complicated and vulnerable to mortality,” Dr O P Yadava, CEO and chief cardiac surgeon, National Heart Institute, New Delhi told IMT.
Dr Yadava further said, “If we look at the national database, the risk of mortality in angioplasty is around or lesser than one per cent while in the case of surgery it is around three to four per cent, which is due to the failed angioplasty cases.”
Questioning Medical Ethics
According to recent media reports, Dr T S Mahant, cardiovascular & thoracic surgeon and executive director at Fortis Hospital, SAS Nagar (formerly Mohali) raised concerns that doctors are more oriented towards business than serving patients and hence they advise expensive drug-eluting stents (PCI) to the patients who are actually in a need of bypass surgery.
“Unfortunately, this happens due to an economic threshold. It all depends on who is the first point of contact to a patient. If a patient with simple arterial disease who is suitable for angioplasty goes to a surgeon, he will get the bypass surgery done because that’s his ulterior motive. When he operates, he gets paid. Similarly, when a patient with multiple arteries blockage goes to a cardiologist, he will advise for stenting,” said Dr Yadava.
How Much the Treatments Cost?
CABG has a fixed cost, which may vary with the institutions while PCI’s cost depends upon the number of medicated stents used. “The bypass surgery’s cost depends upon which category of the rooms a patient takes. The lowest i.e. for General Ward, the cost for a bypass surgery could vary between Rs 1.75 lakh to Rs 2.5 lakh. However, for angioplasty putting one medicated stent will cost around Rs 70,000 to Rs 80,000 and the cost will multiply with the number of stents used, which make stenting an expensive affair,” said Dr Yadava.
Also, a bypass surgery takes around 3-4 weeks to recover with a minimum stay of at least 5-7 days while in angioplasty the patient can get back to work in about 4-5 days, which is also one of the key factors to determine the cost.
“Even though angioplasty seems costly initially but it has more benefits,” said Dr Chopra, who finds PCI more practical, feasible, effective and acceptable mode of treatment. He said that PCI is given first preference all over the world while admitting the significance of bypass surgery as well.
“Whenever we give a solution to our patients, we have to give them the most perfect or near perfect recommendations. We are here to deliver the good healthcare. We do individualised patient care. Whatever is best for the patient at their situation, be it CABG or PCI, we provide the same,” concluded Dr Jaswal.
by Priyanka V Gupta