New York, NY - To stent or to bypass, that is the question, one that is being asked (yet again) in cardiovascular medicine circles. This debate, begun anew in the drug-eluting-stent era but raging since interventional cardiologists began impinging on patients historically directed into the operating rooms of venerated surgeons, is given a healthy once-over by the New York Times this week, with some doctors saying it might be time to look again to coronary artery bypass graft surgery for the treatment of plaque-clogged arteries [1].

With new safety concerns over the long-term risk of stents, in addition to accumulating data that the sickest patients, especially those with multivessel disease, might live longer if treated surgically, even interventional cardiologists are saying that bypass surgery might not be performed enough in the US, writes reporter Barnaby Feder in the February 25, 2006 issue of the Times.


"We as cardiologists have probably pressed forward on stent technology a little faster than we should have," Dr Kirk Garratt (Lenox Hill Hospital, NY) told the Times. In the past decade, the paper notes, the number of bypass surgeries has declined by one third, to 365 000 last year, whereas the number of patients receiving stents numbered nearly one million in 2006.

Feder notes that while some patients have an understandable aversion to bypass surgery, with many asking for stents instead, cardiologists, in many cases the doctors who put in the stents, are still most likely to diagnose coronary artery disease and recommend treatment. While Medicare and other insurers have reduced payments for bypass surgeries, the cost of stenting has risen with the introduction of newer devices, so much so that surgery and stenting are not that far apart in terms of cost, each at about $30 000 for patients with multiple blockages, writes Feder.

In addition, the drug-eluting-stent landscape has changed considerably in the past six months, with new data, extensively reported by heartwire, suggesting a risk of stent thrombosis after implantation. This, the Times notes, has "changed the cost/benefit calculus of stents vs surgery in cases where patients have multiple blockages in two or more arteries or have other complications."

While CABG is recommended for such patients, according to the guidelines of the American Heart Association (AHA) and the American College of Cardiology (ACC), many patients never hear about these recommendations from their cardiologists, writes Feder. A new statement from the AHA/ACC, to be released within the next month, is expected to clarify when to stent and when to operate, he adds.

In the 1800-word article, the Times quotes Dr Robert Guyton, the chief of cardiothoracic surgery at Emory University School of Medicine, Atlanta, GA, who contends that as many as 200 000 patients who get stents each year should be having bypass surgery instead. Such conclusions are based on patient data from New England, New York, and Duke University, said Guyton.

As Feder points out, hospitals expect cardiologists and surgeons to consult with heart patients when the form of treatment is in question, but few patients ever request to speak with a surgeon, thereby leaving the consult up to the discretion of the patient's cardiologist. Such cooperation depends on respect and collaboration between the hospital's cardiologists and surgeons, he notes.

Another factor responsible for the surge in interventional procedures is an unwillingness of some surgeons to take on complex cases, especially in states where the reporting of performance statistics for each doctor is mandatory, writes Feder.

Two clinical trials comparing stenting vs surgery in patients with coronary artery disease are under way, the Times reports. Boston Scientific, a major stent manufacturer, is sponsoring the first study, while the National Heart, Lung, and Blood Institute is sponsoring the other. Results from the Boston Scientific study, the first to be completed, are not expected until late 2008.