The Wall Street Journal-20080124-Bypasses Outshine Stents in Study- Patients Fared Better By Choosing Surgery For Multiple Blockages
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Bypasses Outshine Stents in Study; Patients Fared Better By Choosing Surgery For Multiple Blockages
Patients with multiple clogged arteries are better off getting bypass surgery than stents, a study found.
The analysis, published in the New England Journal of Medicine, isn't likely to settle the dispute between cardiac surgeons, who perform bypasses, and the interventional cardiologists who implant stents. But it gives further ammunition to those who argue that stents -- metal scaffolds that keep arteries propped open -- are overused.
Both procedures fall under the umbrella of revascularization -- attempts to relieve chest pain by opening up arteries clogged by heart disease. In the most severe cases, revascularization has also been shown to reduce heart attacks and deaths.
The study looked at the newest kind of stents, those coated with drugs to keep arteries open, made by Johnson & Johnson and Boston Scientific Corp. in the U.S. Previous studies saw similar results with older, bare stents.
In stenting, introduced in the 1990s, doctors thread a stent up through a small incision in the leg, widening clogged arteries instead of replacing them. A patient can be back at work the next day. A bypass requires open-heart surgery and has patients laid up for weeks.
As a result, bypass surgeons have been left to treat only the most severe cases of heart disease. The number of bypass surgeries has declined and bottomed out recently at about 300,000 procedures in the U.S. last year, according to Millennium Research Group. That compares to about a million stentings. The average cost of a multivessel bypass surgery and office follow-up visits over two years was put at about $28,000 in one study, versus about $20,000 for multivessel stenting.
But patients who opt for stenting may be paying a price down the road. In this week's study, doctors at the University at Albany looked at patients who received a stent or bypass in New York state in 2003 and 2004, comparing subsequent rates of death and heart attacks. The actual death rates between the competing procedures didn't differ. But after adjusting for risk factors -- bypass patients were sicker to start out -- the study found substantial differences.
After adjustments, New Yorkers with two clogged arteries who received a bypass had a 29% lower death rate over the next 18 months than those who received stents. Three-quarters of such patients had opted for stenting. For the sickest patients -- those with three clogged arteries -- surgery yielded a 20% lower death rate. Two-thirds of those patients received surgery.
Donald Baim, Boston Scientific's chief scientist, said the fact that the differences in death rates arose only after statistical adjustment is cause for skepticism. The company has funded a study that will assign patients randomly to stenting or surgery, eliminating the need for such adjustments. "People are voting with their feet that they would rather have the less-invasive procedure," Dr. Baim said.
