Angioplasty versus coronary artery bypass graft (CABG) surgery

It is important to understand that the decision to undergo angioplasty (with or without stent placement) or coronary artery bypass graft (CABG) surgery to treat coronary artery disease (CAD) depends on many different factors.

For this reason, you may find it helpful to learn more about how your doctor decides between recommending angioplasty or CABG surgery. (Angioplasty and related techniques are known as percutaneous coronary intervention [PCI].)

Your doctor can answer the following questions using tests performed during cardiac catheterization:

1. Which coronary arteries are blocked? CABG surgery may be a better choice if you have a blockage in your left main coronary artery or a completely blocked vessel.
2. How many arteries are blocked? CABG surgery may be a better choice if you have blockages in two or more arteries.
3. How well is your heart pumping blood? CABG surgery may be a better choice if your heart is having trouble pumping, which is called a decreased ejection fraction.
4. Do you also have heart valve disease? CABG surgery is a better option if you also need surgery to repair or replace a heart valve.

The answers to these questions help your doctor decide whether you would benefit more from angioplasty or CABG surgery.

What to do with two blockages

If you have blockages in three or more of your coronary arteries, there is a good chance that your doctor will recommend CABG surgery. If you have blockages in only two of your arteries and neither of those is your left main artery, the choice may not be as clear. In such cases, you may have to make a personal choice by weighing the risks of CABG surgery against the long-term benefits. But there are two cases in which CABG surgery may be a better choice for someone with blockages in only two arteries:

1. People with diabetes may benefit more from CABG surgery if they have significant coronary artery disease affecting two or more arteries.
2. People with a reduced ejection fraction may benefit more from CABG surgery if they have significant CAD affecting two or more arteries. Ejection fraction is the percentage of blood that the left ventricle is able to pump during each heartbeat.

Two very different procedures

Although angioplasty is invasive:

• You will be awake during the procedure, and recovery is generally very quick-you may go home the next day or possibly even the same day.
• You can generally return to your normal activities within a few days.
• The risk of complications with angioplasty is very low and most people who experience complications have only minor problems, such as bruising where the catheter was inserted.
• Drug-eluting stents, which are coated with medicine that prevents the growth of new tissue that often causes the treated artery to close up again, may offer improved long-term results. But experts do not know yet how safe the drug-eluting stents are over the long term or how well they work over the long term.

CABG surgery requires open-heart surgery:

• You will have general anesthesia and will need to recover for about 1 to 2 days in the intensive care unit, possibly on a ventilator, and then for a few days in an intermediate care or step-down unit.
• After you leave the hospital, it generally takes several weeks for you to recover fully and return to your normal activities.
• As an open-heart procedure, CABG involves significantly more risk than angioplasty. These risks include complications during and after surgery, such as internal bleeding or infection.

Weighing the risks

Because CABG surgery involves more risk and more recovery time than angioplasty, your doctor will generally recommend CABG only if you will benefit more from it and if the benefits appear to outweigh the risks of open-heart surgery. If there is a chance that angioplasty can effectively treat your CAD, your doctor may recommend angioplasty because of the lower risk. Finally, it is important to weigh the risks of angioplasty and CABG surgery with the short-term and long-term benefits of each procedure.

Short-term versus long-term benefits

With angioplasty, there is a chance that the vessel can become narrowed again, although the use of drug-coated stents has lowered that risk. Narrowing can also occur with CABG surgery, although generally it is rarer and takes longer to occur than with angioplasty. Although CABG surgery has more risks and a longer recovery time, in some cases the long-term benefits may outweigh these disadvantages.

Advantages and disadvantages

Angioplasty versus coronary artery bypass graft surgery

Procedure	Advantages	Disadvantages
Angioplasty	Less invasive (avoids the risks of surgery)	Greater chance that the artery will become narrowed again (restenosis) within the first year
	Can be repeated in the future if necessary
		May be less effective for people with diabetes who have significant coronary disease affecting two or more arteries
Coronary artery bypass graft (CABG) surgery	Can bypass blockages in several arteries	Higher risk of complications in the short term after surgery, including death and stroke
	May benefit people with many blocked arteries, blockages in the left main artery, or weakened heart muscle	Longer stay in the hospital and longer recovery time

Who decides?

Keep in mind that you may not always be able to make your own choice between angioplasty and CABG surgery. In the case of an emergency, for example, the doctor will choose the procedure that is most likely to save your life. Your doctor may also feel strongly that one of these procedures is more appropriate, given the severity of your coronary artery disease and your overall health. If you agree to angioplasty before your cardiac catheterization, it may be done during the same procedure based on the judgment of the doctor performing your catheterization. You will have a choice to make only if the results of your coronary angiogram and other factors indicate that you will probably benefit the most from CABG surgery.

If you do have the opportunity to choose between angioplasty and CABG surgery, your doctor may lean toward one choice or the other depending on your particular circumstances. If the choice between angioplasty and CABG is not clear-cut, you may have to weigh the potential long-term benefits of CABG against the lower risk and easier recovery time for angioplasty. You should discuss this decision with your doctor thoroughly so that you understand the advantages and disadvantages and can make a personal choice that best suits your health and your lifestyle.