Do you want a stent or a bypass?
- ‘Sir, how many veins will you wear?’
- ‘Hide the veins that come out, I want to see them too’
- ‘Do you find the vein to insert, do we supply it?’
- ‘Don’t cut too much’
- ‘Our gentleman is very curious about these things, even if we give you a camera and shoot it during the surgery’
- ‘Yesterday I felt very sorry for our boy, it means that four veins were clogged at night..’
- ‘Change all the clogged vessels so that I can continue smoking with peace of mind’
- ‘They told me to apply here to pass tomorrow, are we right?’
All of them are the reflections of the deep phrase ‘I’ll be fine, right’, which I personally heard, naive, well-intentioned, curious about the details of the event, and most importantly, cannot be asked.
Each of them has been answered by me with the seriousness of a medical question, each in detail and intelligibly as if I was telling it to someone from my own family. Let’s elaborate on the question in the title of the article in the next lines.
The disease that we call ischemic coronary artery diseases medically and that our patients define as ‘stenosis-occlusion of the heart vessels’, ‘I have a coronary’ or ‘I have a heart’ is actually one of the most important causes of non-accidental-traumatic deaths all over the world. The definition is: The disease that occurs as a result of narrowing (stenosis) or obstruction (occlusion) of the arteries (coronaries) feeding the heart due to calcification (atherosclerosis). If you notice, I did not use the term heart attack, because even very serious narrowings can sometimes be detected purely by chance, so not every vascular disease has to cause a heart attack as the first symptom. Years ago, a patient of ours, who was waiting for the 14.00 flight at the airport, applied to the hospital because his chest hurt, and the emergency bypass surgery had already started at around 16.30.
Now let’s get some information first. The heart has an arterial (coronary) network that we have described in two anatomically and clinically four different systems. This vascular network has a very high flow of blood, which is balanced by excellent auto-regulation. In case of a decrease or complete cessation of this blood flow, the most common symptom is chest pain that occurs during exercise, after meals, or sometimes even at rest. Chest pain is usually a pressure-type pain that makes you say ‘as if someone sat on me’. and a symptom that can also be felt in the left arm. After the meal, excessive blood is directed to the gastrointestinal tract for digestion, and the narrowing of the heart can cause pain due to less blood passing through it. Especially in diabetics, due to the deterioration in the mechanisms of feeling pain, the tables that we will describe can occur without feeling any pain. Sometimes, sudden rhythm disturbances, rupture of the muscle layer between the heart ventricles or the rupture of the valves between the ventricles and the auricle may be life-threatening. Even if these clinical pictures are overcome and/or the problem vessel is intervened, the contraction power of the heart may weaken, leading to signs of heart failure in the long term.
Well, your angiography was done, your chest pain only occurs during serious exertion, you don’t have an emergency. Stent or bypass? One of the best sentences I have heard on this subject so far is Prof. Dr. By David Taggart: ‘No patient wants to have surgery, but every patient has the right to know which treatment option is most suitable for him’. If we add the phrase ‘there is no disease, there are patients’ of Hippocrates, who is accepted to have laid the foundations of medicine 2500 years ago, we can more easily search for the answer to the question in the title of the article.
First of all, there are patients who are close to all of us, in our family and around us, who owe their lives to the developing stent applications. Thanks to the development and widespread use of stent applications in the world, there are millions of patients who survived by intervening at the onset of heart attack. In the past, emergency bypass was performed for such patients, and the life-threatening risk of the surgery performed under these conditions was very high. Today, the need for an emergency bypass has decreased considerably.
The issue of whether to treat patients with stenosis and occlusion in their arteries, elective, that is, with a stent or by-pass under non-emergency conditions, can sometimes be the most controversial issue in cardiology and cardiac surgery practices. There are a lot of variables to consider here. The patient’s age, which vein is the problem, how many veins are problematic, presence of concomitant diseases, especially diabetes, contraction strength of the heart, other problems in the heart-valve failures, etc.
The most important point of difference in comparison of surgery or stent is that the patient may need to be taken to angiography repeatedly, such as re-admission to the hospital in the long term, narrowing, obstruction, and problems in new vessels after the stent procedure, which we call re-intervention. Although stent technology has improved over the years, the rate of occlusion in the early postoperative period is higher than in bypass. We know that the 30-year patency rate of the inner chest wall artery, which we use to provide blood flow to the LAD vein in front of the heart, especially in bypass surgery, is at a satisfactory level today. As a matter of fact, suppose that a young patient with no additional disease and an older patient who does not exert much effort have exactly the same vascular stenosis, it can be thought that surgery may provide a more permanent solution in a young patient in the choice of stent/surgery.
As a result, we rarely ask our patients whether you want a stent or a bypass. In the light of medical information and up-to-date guidelines, the treatment to be recommended in most patients is at least at a level where the surgeon and cardiologist ‘agree’. If the choice is so obvious that the choice is left to the patient, we clearly and understandably share the advantages and disadvantages of both with our patient and leave the decision to him.
Medicine, contrary to popular belief, is a science where two and two are not four, and different options can be suggested/applied to the same problem in relation to the physician’s theoretical knowledge, clinical experience, and the general condition of the patient. In cases where there is not a single correct one, the job of us physicians is a little more difficult, I wonder which is the most correct option? My simplest suggestion to our patients is to ask their physicians about the treatment to be applied, its advantages and disadvantages, risks and alternatives. And.. please, please, get this information from their physicians first, not the internet by running to the computer. The internet can only tell you about diseases, it cannot apply the principle of ‘there is no disease, there are patients’, which has not changed since Hippocrates. There are also correspondence sites/blogs that ‘unfortunately we’re in trouble’. Sometimes I stumble upon what I see, and stay away. Don’t be confused by thinkers who say the same thing happened to our aunt :))
One of my family elders had to undergo angiography years ago. At that time, I was my assistant, I helped as much as I could, I arranged a nice room, I asked the head of the cardiology department to do the angiography, and even my own teacher gave his best support so that we can keep a room empty in the operating room and if surgery is needed, we will get it right away. Fortunately, as you know, my relative went to the angiography bed, and a mild sedative was given. Almost all standard angiographies are performed on the right side of the patient. My cardiologist teacher anesthetized the right groin and said to me, if you want to go out, you don’t need to be here anymore. Just as I was leaving the room, my relative’s voice said, ‘Ardaaaaaaa come,’ and I came back running.
- ‘Heart is on the left, this man is trying to get in from my right groin, look at this, don’t be wrong!!!’
Here, when it comes to our own life, everything should be perfectly right, there should be no problems, and it is in the nature of all of us to check it out, unfortunately, this time it resulted in disappointment for me (against my teacher) :))
I wish you all a healthy day..
prof. Dr. Arda ÖZYÜKSEL
Biruni University, Medicana International Hospital
Department of Cardiovascular Surgery
Beylikduzu – Istanbul
