Treatments for Advanced Atherosclerosis

Drugs are usually the first choice of treatment, even in the late stages of atherosclerosis. Sometimes, though, more aggressive treatment is needed.

Narrowed arteries can frequently be reopened with one of two treatments: stenting or bypass surgery. Because these atherosclerosis treatments come with risks, they are typically reserved for emergencies or when medications fail.

1. Angioplasty and Stenting

A coronary angiogram is a special X-ray test that doctors use to identify coronary artery blockages and sometimes take action to open them up. In an angioplasty, a doctor first introduces a catheter (a narrow tube) into an artery in the leg or arm. The catheter is then moved to the area of concern. Usually this is the coronary arteries in the heart, or the arteries in the legs or brain.

By injecting dye that is visible on live X-ray screens, the doctor can see blockages in the arteries. Using tiny tools on the catheter tip, he or she can often open blockages.

A stent is a tiny cylinder of wire mesh. During an angioplasty, a balloon on the catheter tip is inflated inside a blockage to open it. Stents can be placed during this process and are left behind once the balloon and catheter are removed.

Stents can relieve chronic symptoms of chest pain (angina), or reopen a blocked artery during a heart attack.

Coronary angioplasty with stenting has a low complication rate. The recovery time is often less than one day.

2. Coronary Bypass Surgery

In bypass surgery, a surgeon "harvests" a segment of a blood vessel from the leg, arm, or chest. He or she sews this healthy vessel onto the coronary artery, rerouting blood around the clogged artery.

Coronary artery bypass surgery -- or CABG (pronounced "cabbage") -- is the most commonly performed bypass surgery. CABG can provide relief from chest pain caused by atherosclerosis. Bypass surgery also leads to increased survival in people with multiple or severely blocked coronary arteries.

As you would guess, CABG is major surgery. Although low overall, the risk of serious complications is similar to coronary stenting. The recovery time can take weeks, even months. Newer less-invasive forms of CABG, with shorter recovery times, are under evaluation.

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Stents vs. Surgery for Atherosclerosis Treatment

Which is the better treatment for the late stages of atherosclerosis -- stents or bypass surgery? Each procedure has advantages and disadvantages. Certain situations may make one procedure the clear choice, but often it's a judgment call.

  • Living longer when you have multiple blockages. CABG is the best treatment for extending life in people with multiple severe blockages. CABG has been shown to extend life for patients with several patterns of severe blockages, and is clearly superior to stenting in these cases. Stenting has not been demonstrated to help people live longer.
  • Pain relief. Sometimes treatment with drugs can't control chronic chest pain. Both CABG and stenting provide near-complete relief from angina more than 90% of the time. Angina often returns over time, though, which may lead to future procedures.
  • Emergency treatment. During a heart attack, stents are usually better than CABG. Stents can be placed in minutes, without the risks and recovery time of major surgery.

Atherectomy for Arteries Blocked by Atherosclerosis

In rare circumstances, other tools and procedures may be used to help open arteries blocked by atherosclerosis plaques.

  • Rotational atherectomy: A diamond burr rapidly spins and pulverizes plaque into tiny particles. The particles dissipate without causing major damage.
  • Directional atherectomy: A rotating blade cuts slices of plaque, which are captured by the catheter and removed from the body.

These procedures have good commonsense appeal, but they don't work as well as stenting or bypass surgery. They are rarely used, and only in special cases. Usually, atherectomy is used to improve the success of placing a stent.

After Atherosclerosis Treatment

Stenting and coronary bypass surgery open blocked arteries, but they do nothing to prevent other atherosclerotic plaques from causing problems. After a procedure to open a blockage, it's more important than ever to reduce risk factors for atherosclerosis.

After stenting or coronary bypass surgery, most people should take a daily regimen of anti-atherosclerosis medication that includes:

  • A statin, to lower cholesterol levels
  • An aspirin, to prevent blood clots
  • Plavix (clopidogrel), Effient (prasugrel), or Brilinta (ticagrelor) also work to prevent clots, especially if a stent was placed. They are normally taken for one month up to a year depending on the type of stent.
  • Blood pressure drugs, especially beta-blockers and angiotensin-converting enzyme (ACE) inhibitors

Also important are three lifestyle habits proven to reduce heart disease:

WebMD Medical Reference Reviewed by James Beckerman, MD, FACC on July 25, 2016

Sources

SOURCES:

News release, FDA. American Heart Association web site, "What is Coronary Angiography?" "Stent Procedure," "Bypass Surgery, Coronary Artery," "Minimally Invasive Heart Surgery."

Epstein, A. Journal of the American College of Cardiology, 2004; vol 43: pp 1755-1762.

WebMD Medical Reference from Healthwise: "Cardiac Catheterization."

Eagle, K. Circulation, 2004; vol 110: pp e340-439.

Hannan, E. New England Journal of Medicine, 2005; vol 352: pp 2174-2183.

Smith, S. Journal of the American College of Cardiology, 2006; vol 47: pp 216-235.

Smith, S. Journal of the American College of Cardiology, 2006; vol 113: pp 2363-2372.

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