What are the surgical treatments for Coronary Artery Disease?

Ok, so you’ve tried a variety of medications and made all the lifestyle changes your doctor recommended and you still have chest pain. You have been through the cardiolyte stress tests and echocardiograms and your doctor thinks you have some blockage in one or more of your coronary arteries.

At this point your cardiologist will probably want to schedule you for a Coronary Angiogram. Basically this is like a video x-ray of your heart while dye is being injected into your coronary arteries. This allows the doctor to locate and determine the size of any blockage(s) in your coronary arteries. During this procedure your doctor may decide that you need an intervention. I have listed the most common types of interventions here with simple explanations. If the procedure your doctor mentioned is not here and/or you need more details, contact your doctor’s office for information about the procedures that your doctor may perform. It is your right to be informed about the procedure by your doctor before you sign the consent…… if you are not sure that you understand fully, please ask before you sign. The staff in most Cardiac Cath Labs are very well educated and eager to help, if needed they will contact the doctor to come talk to you.

The first set of surgical treatments are minimally invasive and are called ‘Percutaneous Coronary Interventions.’ With these proceduresthere is no large incision, just one or two small insertion sites into the femoral artery (this is in the groin area). You will be given medications that make you very sleepy but you will still be awake enough to tell the doctor if you have any chest pain. The doctor will first numb the area and then insert a catheter into your femoral artery and guide it to your aorta and up to the coronary artery openings.

When the catheter reaches the openings to one of the coronary arteries the doctor injects an iodine based dye and takes a series of x-rays to help locate the blockage. After locating the blockage your doctor may decide to perform one of the following procedures.

PERCUTANEOUS CORONARY INTERVENTIONS (PCI):
Coronary angioplasty (aka Balloon PTCA). The indications for PCTA are unstable angina (persistent chest pain) and blockage of only one or two coronary arteries. This procedure involves locating the blockage as above and inserting a small guide wire into the middle of the blocked area. A ‘balloon’ catheter is then advanced over the guide wire into the blockage and the balloon is inflated.

The balloon pushes the plaque against the walls of the artery to increase the width of the opening that the blood must pass through. The doctor may repeat this procedure several times to open multiple blocked areas and to make sure the plaque is as compressed as possible. If the blockage won’t stay open the doctor may place a device called a ‘stent’ which is a latticed wire tube that holds the vessel open. Coronary radiation implant therapy or coronary brachytherapy. This is a more recent intervention, approved in 2000 by the FDA. This procedure involves delivering radiation therapy directly into the coronary arteries. FDA approval of brachytherapy is currently restricted to treatment of stent-related problems, although brachytherapy is being studied as a first-line treatment of coronary disease. At this time the long-term effects of radiation are unknown.

Coronary atherectomy uses a laser catheter that vaporizes the plaque, or a rotating device on the end of the catheter that shaves off the plaque. Balloon angioplasty or stenting may be used after an atherectomy.

Catheter-based thrombolysis and mechanical thrombectomy. Basically this involves either injecting a medication into the artery that will disolve any blood clots that are blocvking the artery (thrombolysis), or actually removing the clot from the artery with a type of catheter that can grab it with out breaking it up.

OPEN HEART SURGERY
If the blockage is not too difficult to reach you will be able to have a Percutaneous Coronary Intervention but in some cases such as when all major arteries are blocked, the blockage is too difficult to get to, or if there are problems with one of the valves inside your heart, your doctor may recommend open heart surgery.

There are basically two types of open heart surgery:
Coronary artery bypass surgery (aka CABG) this surgery creates a detour or "bypass" around the blocked part of a coronary artery to restore blood flow to the heart muscle. This surgery involves actually stopping the persons heart during surgery and placing them on a heart-lung machine.

Minimally invasive heart surgery this refers to several approaches for bypassing the blockage of the coronary arteries in areas that are not difficult to reach (i.e. on the front side of the heart). These methods restore blood flow to the heart muscle without having to use the heart-lung machine. Hopefully this will help you make an informed decision about the procedures you need, but as I said before if you don’t know …ask your doctor or nurse.