Stent Placement After Bypass Surgery: Key Concerns

Q: Stent Placement After Bypass Surgery: Key Concerns

Hello, the prognosis of coronary artery disease (CAD) is determined by two main factors： cardiac function and the extent of hypoxia. <br>The treatment for CAD primarily involves medication, but for specific high-risk populations, relying solely on medication is insufficient; inte

Issues Related to Stent Placement After Coronary Bypass Surgery

Hello Doctor: My mother underwent coronary artery bypass surgery in October 2014.
Recently, during myocardial perfusion scans at two major hospitals, the doctors indicated that there is an issue with cardiac hypoxia and mentioned that one of the blood vessels requires stenting (the doctor mentioned a significant extent, but I'm unsure what that refers to.
Does it mean the extent of the blockage?).
The doctor advised us to consider whether to proceed with the stenting, as surgery carries risks, but he suggested it would be best to go ahead.
We have scheduled a follow-up appointment after the New Year to confirm.

Question 1: Why is there still an issue with cardiac hypoxia after having undergone coronary artery bypass surgery? Could it be due to the collapse of the grafted vessels? (My mother has been very strict with her diet since the surgery...)
Question 2: Since my mother has no symptoms, such as angina, shortness of breath, or any signs of heart weakness, what would happen if we choose not to proceed with the stenting? Would it lead to heart failure or myocardial infarction?
Question 3: In the past six months, my mother's blood test results showed: NT-pro BNP (N-terminal pro b-type natriuretic peptide) at 219 (reference value <125) and BNP (b-type natriuretic peptide) at 129.8 (reference value <100), both exceeding the reference values.
Is this a common phenomenon for someone who has undergone coronary artery bypass surgery, or does it indicate a recurrence of cardiac hypoxia? If she undergoes stenting, will these values return to normal?
Question 4: Initially, in October 2014, at Hospital A, the cardiology department planned to place a stent, but once on the operating table, the doctor determined that the blockage was too severe and the vessels were too narrow and tortuous, leading to a transfer to cardiac surgery for bypass.
If the doctors at Hospital B recommend stenting this time, I am concerned that they might encounter the same issues as last time and be unable to place the stent.
This would be a significant blow to the patient.
Is it possible to perform another coronary artery bypass surgery?
Thank you, Doctor.

Ivy, 40~49 year old female. Ask Date: 2017/01/24

Dr. Li Han reply Cardiology

Hello, the prognosis of coronary artery disease (CAD) is determined by two main factors: cardiac function and the extent of hypoxia.
The treatment for CAD primarily involves medication, but for specific high-risk populations, relying solely on medication is insufficient; interventional procedures such as catheterization or bypass surgery are necessary for a better chance of longevity and quality of life.

In response to your inquiries:
1.
It should be noted that any surgical intervention for coronary artery disease (bypass) or catheter-based intervention (stenting) is temporary.
The autologous veins or arteries used for bypass may also become narrowed or obstructed.
A notable example is former U.S.
President Bill Clinton, who initially underwent bypass surgery and later required catheter-based intervention.
2.
Sometimes, patients may appear asymptomatic clinically, but exhibit high-risk characteristics during stress testing.
For long-term stability, revascularization therapy becomes a recommended option.
3.
B-type natriuretic peptide (BNP) is an objective factor used to assess heart failure, but its use as a recommendation for catheter-based intervention or bypass surgery seems inappropriate.
Regardless of its positive predictive value, patients with heart failure may still have normal coronary arteries.
4.
Revascularization therapy can be categorized as complete or incomplete (partial), and can be performed as a single procedure or in stages.
Bypass surgery is generally considered a more complete and single-session treatment option.

For these concerns, it may be more appropriate to consult your cardiologist directly and obtain integrated opinions from both internal and surgical specialists.
Wishing you peace and health, Changhua Hospital, Ministry of Health and Welfare.

Reply Date: 2017/01/24

More Info

Dear Patient,
Thank you for your detailed inquiry regarding your mother's heart condition and the potential need for stent placement following her bypass surgery. I understand that this is a concerning situation for you and your family, and I will do my best to address your questions comprehensively.

1. Why is there still a problem with heart oxygenation after bypass surgery?
After a coronary artery bypass graft (CABG) surgery, the goal is to restore adequate blood flow to the heart muscle by bypassing blocked arteries. However, several factors can lead to ongoing issues with heart oxygenation. These include the possibility of graft failure, where the bypassed vessels may become narrowed or blocked over time due to a process called atherosclerosis, which can affect both the native coronary arteries and the grafts themselves. Additionally, if the original arteries were severely diseased, there may still be areas of reduced blood flow. The "range" mentioned by the doctors likely refers to the extent of blockage in the artery that requires stenting.

2. What are the consequences of not placing a stent if there are no symptoms?
Even in the absence of symptoms such as chest pain or shortness of breath, untreated blockages can lead to serious complications, including myocardial infarction (heart attack) or heart failure. The heart muscle can become ischemic (lacking adequate blood flow), which may not present immediate symptoms but can lead to long-term damage. It is essential to weigh the risks of the procedure against the potential for serious complications if the blockage worsens.

3. What do elevated NT-pro BNP and BNP levels indicate?
Elevated levels of NT-pro BNP and BNP are markers of heart strain and can indicate heart failure or other cardiac issues. In patients with a history of heart disease, these values can be elevated due to various reasons, including ongoing ischemia, heart muscle dysfunction, or fluid overload. While it is not uncommon for these levels to be elevated in patients with a history of heart surgery, it is crucial to interpret these results in the context of her overall clinical picture. If a stent is placed and blood flow is restored, it is possible that these values may improve, but this is not guaranteed.

4. Concerns about the feasibility of stent placement and future options:
It is understandable to be apprehensive about the possibility of stent placement, especially given your mother's previous experience. If the current assessment indicates that the artery is still too narrow or tortuous for stenting, the medical team may consider alternative options, including medical management or potentially revisiting bypass surgery if necessary. It is essential to have open communication with her healthcare providers about these concerns, as they can provide insights based on the latest imaging studies and her overall health status.

In conclusion, while the decision to proceed with stent placement involves weighing the risks and benefits, it is crucial to address any blockages that could lead to further complications. I recommend discussing these concerns with her cardiologist, who can provide a tailored approach based on her specific condition and the latest diagnostic findings.

Wishing you and your mother the best in her treatment journey.

Sincerely,
Doctor Q&A Teams

Similar Q&A

Understanding Complications After Stent Placement: Risks and Recovery

Dear Dr. Huang, On the morning of August 20, I thought I was experiencing gastroesophageal reflux and went to the emergency department of a municipal hospital. However, the electrocardiogram and blood test results indicated an acute myocardial infarction. I was informed that sev...

Dr. Huang Yinghe reply Cardiology
Hello Mr. Chen: Recent studies indicate that at least one-third of patients with acute myocardial infarction die before reaching the hospital. Among those who survive to receive treatment, the mortality rate within a year due to various complications of the disease remains at 5-1...

Timing and Considerations for Drug-Eluting Stent Placement in Cardiology

Hello Dr. Lee, my father underwent a cardiac catheterization today and had two drug-eluting stents placed. I would like to ask you a few questions: 1. Why can't a blocked artery just be treated with balloon angioplasty? After dilation, the artery should improve significant...

Dr. Li Han reply Cardiology
Hello, the principle of coronary balloon angioplasty is to expand and rupture the narrowed atherosclerotic plaque, resulting in a larger lumen than the original lesion. However, this is an ideal scenario, and it is often accompanied by vascular recoil, dissection, or hematoma for...

Understanding Heart Stents: Key Questions and Concerns for Patients

Hello Doctor, my husband often feels chest tightness and discomfort. He went to the hospital for a heart examination, and the doctor arranged for a coronary angiography, stating that his heart oxygen levels are very low and that he needs to have a stent placed. They have schedule...

Dr. Wu Xueming reply Cardiology
In cases of left main coronary artery disease or complex conditions involving multiple vessel lesions, bypass surgery is recommended. However, it is essential to discuss with both cardiologists and cardiac surgeons to determine the most suitable treatment option for the patient.

Consequences of Incorrectly Placed Heart Stents: Risks and Replacements

What are the potential complications if a heart stent is implanted incorrectly? Additionally, will there be any effects, and will it need to be re-implanted? Thank you for the information!

Dr. Wu Xueming reply Cardiology
The issue of incorrectly placing a coronary artery stent can be resolved by selecting the appropriate size and positioning it at the lesion under fluoroscopy, which constitutes successful treatment.