Stents vs. Bypass Surgery for Treating Coronary Artery Disease

Coronary artery disease (CAD) can be treated with medical management (medications) or with procedures such as stents or bypass surgery. Deciding on the best treatment option is a very individual process.

There are risks and benefits to each approach. Your healthcare provider will also consider things like how many blockages you have and where they are. Your preference and your healthcare provider's preference will be taken into account, too.

CAD researchers are looking into differences between the outcomes of medical treatment, stents, or bypass surgery. They are also interested in finding out which conditions favor one option over the other. In some situations, the answers are clear. There are also gray areas, however. Sometimes one option does not seem to be better than the others.

This article is focused on the different surgical treatment options for CAD and their risks and benefits.

When Surgery Is Needed

CAD is a disease of the coronary arteries. These are the blood vessels that supply blood to the heart muscles so the heart can pump. Sometimes early CAD doesn't produce symptoms. In some cases, it may cause angina (chest pain).

Disease in the coronary arteries puts you at risk for blood clots. These may block the blood flow to the heart muscle, causing a heart attack. They could also travel to the brain and interrupt blood flow, causing a stroke. If you are diagnosed with CAD, you need the right treatment to reduce your risk of these life-threatening complications.

Medical therapies for treating CAD include:

• Prescription blood thinners
• Drugs to lower cholesterol
• Antihypertensives, medication that treats high blood pressure
• Medications that help manage heart disease symptoms

Often, however, these aren't enough to reverse CAD. In these cases, the diseased blood vessels may need to be surgically repaired. This can decrease the risk of death compared to medical therapy alone for people who have symptoms of CAD, and even for some who don't.

What Is Revascularization?

Revascularization is a procedure that restores blood flow by clearing the blockage from a severely diseased artery or creating a new route. This can be done with angioplasty (possibly including stent placement) or with coronary artery bypass grafting (CABG), also called open-heart surgery.

Stenting

An angioplasty involves threading a wire to the coronary artery through a small puncture. The puncture is usually made in the groin or the arm. This procedure physically widens the diseased blood vessel.

Sometimes a stent is permanently inserted to keep the artery open. This is a small, tube-shaped device. Stents coated with medication help prevent blood clots and are associated with better survival than regular stents.

Angioplasty is considered minimally invasive. This means it is done using only small incisions.

Bypass Surgery (CABG)

Coronary artery bypass grafting (CABG) is considered a major surgery. Your surgeon will get access to your heart through an incision in your chest. During this procedure, the surgeon will remove the diseased part or parts of the artery and suture the ends together.

Sometimes, a portion of the coronary artery is replaced with a short part of one of your other arteries. An artery from your leg could be used, for example. This is called a graft.

The Benefits of Revascularization

For non-emergency treatment of CAD, both procedures can help significantly reduce symptoms. Often, though, they are not better than other kinds of therapy.

Generally speaking, non-emergency revascularization by either method doesn't improve survival. It is also difficult to know if it helps reduce the rate of subsequent heart attacks.

However, both stenting and CABG can improve outcomes for patients who are experiencing acute coronary syndrome. This term describes an emergency heart condition like a heart attack. Both procedures can also improve outcomes for patients who have:

• Complex lesions in several coronary arteries
• Disease of the left main coronary artery (which provides the largest blood supply to the heart)
  

Revascularization can also be a good option if you have pain that doesn't seem to be improving with medication.

Deciding Which Is Better

Many factors will go into deciding which procedure could be safer or more effective for you. Both interventions may cause complications. This can include:

• Heart attack
• Cardiac arrhythmia (irregular heartbeat)
• Stroke

If you are diagnosed with CAD, your healthcare provider will refer you to a heart specialist called a cardiologist or to a heart surgeon. That specialist will weigh the following:

• The severity of your CAD
• How many vessels need repair
• Whether you have already tried medication
• The presence or history of other illnesses like diabetes, arrhythmias, or previous heart attacks
  

When the best option isn't clear, your case may be presented in a multidisciplinary conference. That way your treatment plan can be discussed by a whole team of healthcare providers.

Stenting Pros and Cons

Stenting is a quick way to open a blocked artery. In an emergency, it is usually preferred over CABG. An acute ST-segment elevation myocardial infarction (STEMI) is the most dangerous kind of heart attack. If you have this kind of heart attack, an angioplasty can save your life.

Another advantage of angioplasty and stenting is that stents come in different sizes, shapes, and materials. This gives your healthcare provider options when it comes to your treatment.

Angioplasty is minimally invasive, so the recovery is usually easier than it is with CABG. It is considered a high-risk procedure, however. Rarely, unexpected complications can occur. For example, severe bleeding could mean the procedure needs to be rapidly converted to open surgery.

CABG Pros and Cons

If your coronary artery disease is severe, your healthcare provider may recommend CABG. CABG is believed to yield better long-term outcomes in people with three-vessel CAD. This is a serious form of CAD that involves all three major coronary arteries.

People with diabetes also tend to have better outcomes after CABG surgery than with stenting.

There are some situations that require CABG. Angioplasty might not be possible when a blood vessel is extremely frail and diseased, for example. It may also not be a good choice if the anatomy of the arteries is unusually complicated. Instead, your healthcare provider may determine that the vessel needs to be replaced.

Typically, CABG is considered to be a more complete treatment.

Summary

The choice between a stent and CABG will depend on many different factors. Your healthcare provider will consider the specifics of your disease, whether or not you have other diseases, and if you've tried medication.

In general, stenting has a shorter recovery time. Bypass surgery may be better for complicated cases. Both procedures can help reduce symptoms and have similar outcomes, though. 

A Word From Verywell

A CAD diagnosis is a major warning that you need to take care of your health. Often, by the time CAD is diagnosed, the risk of a heart attack or stroke is already very high. An interventional procedure may be necessary.

Speak openly with your healthcare provider about your questions and concerns. Ask why one procedure may be recommended over the other. The path ahead starts with confidence in your treatment decisions.