Coronary Blockage vs. Stenting: Key Considerations for Elderly Patients

Q: Coronary Blockage vs. Stenting: Key Considerations for Elderly Patients

Hello： In the case of all three coronary arteries being narrowed or blocked, both catheterization and bypass surgery can immediately improve cardiac blood flow and enhance quality of life. <br>The survival rate for early bypass surgery is better than that of catheterization; howe

Coronary artery obstruction vs. cardiac stenting

Grandfather (79 years old) underwent a cardiac catheterization last May.
After the examination, the physician informed that all three arteries were significantly blocked.
The physician explained that the treatment options included bypass surgery (which is complicated due to the patient's age) and stenting.
One artery required the placement of over ten stents, which is more complicated, while the artery that was easier to manage required two stents.
If stenting was considered, only the easier artery could be treated (requiring two stents), while the others were deemed more challenging by the physician.
The physician did not analyze the pros and cons of the options and left the decision for further medical action to the family.
The family, feeling anxious and unsure, thought about the surgery and casually requested the physician to proceed with the placement of self-paid stents (presumably in the right artery, which was the easier one, while the others were not addressed).
Recently, grandfather's legs have been somewhat swollen, and the physician arranged to address the troublesome artery (which had previously been indicated to require over ten stents) without much further discussion.
The family was then asked to fill out forms for the planned stenting in mid-June with Dr.
Huang.

1.
The physician did not evaluate the pros and cons of bypass surgery versus stenting, leaving the decision solely to the family.
Will the family's decision to proceed with stenting affect grandfather's lifespan?
2.
Is it safe to place that many stents at once? Can the body handle it?
3.
Is the technical aspect a consideration when placing so many stents? Should the procedure be done at a larger hospital?
4.
Cost is also a significant concern.
Will health insurance cover it? With so many stents, self-paying is truly not an option.
5.
If considering transferring to another hospital for evaluation, will there be a need for a complete re-examination?

Xiao Xia Mi, 20~29 year old female. Ask Date: 2020/05/21

Dr. Huang Yinghe reply Cardiology

Hello: In the case of all three coronary arteries being narrowed or blocked, both catheterization and bypass surgery can immediately improve cardiac blood flow and enhance quality of life.
The survival rate for early bypass surgery is better than that of catheterization; however, due to advancements in materials and techniques for catheterization in recent years, the outcomes have become comparable to surgery.
Nevertheless, in terms of long-term vessel patency, bypass surgery remains superior, as patients who receive stents have a higher rate of restenosis requiring further catheterization compared to those who undergo bypass surgery.
Catheterization with stent placement only requires local anesthesia, which allows for quicker recovery, with most patients returning to normal activities within a day.
However, there may be instances where technical difficulties prevent successful recanalization of the artery.
Although there is no limit to the number of stents that can be placed in one procedure, the more stents that are inserted, the greater the technical difficulty and surgical risk.
Bypass surgery requires general anesthesia and thoracotomy, typically necessitating a hospital stay of one to two weeks, and there will be a scar on the chest.
In terms of costs, bypass surgery is covered by health insurance, while drug-eluting stents or certain specialized materials used in catheterization may require out-of-pocket expenses.
In cases of narrowing in all three vessels, the costs associated with catheterization can be significantly higher than those of bypass surgery.
Both catheterization and bypass surgery are significant decisions; if the situation is not urgent, it is advisable to discuss with your grandfather's physician (and the cardiac surgeon) the aspects that are most important to you before making a final decision together.
If considering transferring to another hospital, it is best to request medical records (outpatient and inpatient) and previous catheterization imaging discs from the original hospital for reference.

Reply Date: 2020/05/21

More Info

When considering treatment options for coronary artery disease (CAD) in elderly patients, such as your grandfather who is 79 years old, there are several key factors to weigh between coronary artery bypass grafting (CABG) and stenting. Each option has its own set of benefits and risks, particularly in older populations who may have multiple comorbidities.

1. Understanding the Procedures: CABG involves surgically creating a bypass around blocked arteries using veins or arteries from other parts of the body. This is typically recommended for patients with multiple blockages or significant artery disease. On the other hand, stenting is a minimally invasive procedure where a small mesh tube is inserted into the artery to keep it open after balloon angioplasty. While stenting is less invasive and has a quicker recovery time, it may not be suitable for all cases, especially when multiple arteries are severely blocked.

2. Risks and Benefits: In elderly patients, the risks associated with surgery, such as CABG, can be higher due to factors like age, overall health, and the presence of other medical conditions. However, CABG may provide a more durable solution for multiple blockages compared to stenting, which has a higher rate of restenosis (re-narrowing of the artery). The decision should consider the patient's functional status, life expectancy, and personal preferences.

3. Number of Stents: While there is no strict limit on the number of stents that can be placed during a single procedure, the complexity of the case increases with the number of stents. Each additional stent can raise the risk of complications, including procedural risks and potential for future blockages. Therefore, it is crucial to evaluate whether the patient's body can tolerate multiple stents and if the procedure can be performed safely.

4. Cost and Insurance Coverage: The financial aspect is also significant. Stenting, especially with drug-eluting stents, can be expensive, and while some costs may be covered by insurance, others may not. CABG is generally covered by insurance, but the overall cost may be higher due to hospitalization and recovery time. Discussing these financial implications with the healthcare provider is essential to understand what options are available.

5. Consulting Specialists: If there is uncertainty about the best course of action, seeking a second opinion from a cardiologist or a cardiac surgeon can provide additional insights. They can help clarify the risks and benefits of each procedure based on your grandfather's specific health status and the severity of his coronary artery disease.

6. Post-Procedure Care: Regardless of the chosen treatment, post-procedure care is critical. This includes regular follow-ups, medication adherence (such as antiplatelet therapy), and lifestyle modifications to manage risk factors like hypertension, diabetes, and hyperlipidemia.

In conclusion, the decision between CABG and stenting should be made collaboratively with the healthcare team, considering the patient's overall health, preferences, and the specific characteristics of their coronary artery disease. It is essential to have open discussions with the cardiologist about the risks, benefits, and potential outcomes of each treatment option to ensure the best possible care for your grandfather.

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