Bypass Surgery Opens 'New Path' When Stents Fail, Surgeon Says

The coronary arteries supply oxygen and nutrients to the heart. When these vessels narrow or become blocked, conditions such as angina and myocardial infarction develop, and the heart muscle can undergo necrosis and fail to function, potentially leading to sudden death. Treatment must open the blocked vessel, and while stent procedures are commonly the first thing that comes to mind, not every patient can be treated with stents alone. Surgery may be more advantageous when the lesion is long, when it involves the left main coronary artery, or when risk factors such as diabetes or renal failure are present.

On the Seoul Economic Daily TV program "Now, Master Physicians" at 9:25 p.m. Tuesday, Professor Kang Jun-kyu of the Department of Cardiovascular and Thoracic Surgery at Catholic University Eunpyeong St. Mary's Hospital discussed coronary artery disease, coronary artery bypass surgery, and hybrid coronary revascularization.

Professor Kang cited chest pain as the representative symptom of coronary artery disease. "Patients may experience severe chest pain for the first time in their lives, and in elderly patients or those with long-standing diabetes, symptoms such as shortness of breath or indigestion may appear before pain," he said. In particular, people with risk factors such as high blood pressure, diabetes, high cholesterol, family history, or smoking who feel severe chest pain should go to the emergency room without delay.

◇ Coronary Artery Disease Where Stents Are Difficult: Consider Bypass Surgery

Among the coronary arteries, the left anterior descending artery is a very important vessel, as it supplies 50 to 60 percent of the heart's blood supply. If this vessel narrows or becomes blocked, serious problems such as reduced heart function can occur. "How well we can save the left anterior descending artery is one of the biggest purposes of coronary artery bypass surgery," Kang explained.

About 80 percent of coronary artery disease can be treated with stent procedures. But the remaining 20 percent are cases where surgery is necessary or more advantageous. For example, in patients where disease occurs at a branching point such as the left main coronary artery, where the lesion is long, or where diabetes has persisted for a long time, multiple stents may need to be inserted, or the risk during the procedure may increase. In such cases, surgery can be the better choice in terms of long-term survival rates and restenosis rates.

Coronary artery bypass surgery is not surgery that opens the blocked vessel itself. It is surgery that connects the patient's own blood vessel behind the blocked area to create a "new path" through which blood can flow. Kang used an analogy: "If a stent is like drilling a tunnel through a mountain, bypass surgery is like building a new road around the back of the mountain."

◇ Using Vessels From the Patient's Own Body

The surgery uses vessels from the patient's own body rather than artificial vessels. The most important vessel is the internal thoracic artery, or internal mammary artery, located inside the chest. When connected to the left anterior descending artery, this vessel has a very high long-term patency rate. According to Kang, the internal thoracic artery is well maintained at over 95 percent even 10 years later. The radial artery in the arm has a 10-year patency rate of about 90 percent, and the great saphenous vein in the leg is at about 60 percent.

In the past, surgery was often performed with the heart stopped, but recently the number of bypass surgeries performed while the heart is still beating has increased. In Korea, about 50 to 60 percent of all coronary artery bypass surgeries are performed without stopping the heart. "When the surgery is scheduled and received on time, the success rate is 98 to 99 percent," Kang said. "The results are far better than surgeries performed after being brought in as an emergency."

Recovery has also become faster than in the past. A typical coronary artery bypass surgery takes about three hours, and 90 percent of patients move to a general ward after spending about a day and a night in the intensive care unit. After recovering for five days to a week afterward, discharge is possible. Kang also emphasized the importance of early walking and cardiac rehabilitation after surgery. "Just as you should drive a car rather than park it in the garage after repairing its engine, it is important to return to daily life quickly through rehabilitation after heart surgery," he explained.

◇ Hybrid Treatment Combining Procedure and Surgery

A treatment method drawing attention recently is hybrid coronary revascularization. This treatment combines the advantages of surgery and procedure. The most important left anterior descending artery is connected to the internal thoracic artery through minimally invasive surgery, while the remaining vessels are treated with stent procedures. Because the incision range can be reduced, pain and hospital stays are reduced and recovery is faster. The surgery time is also shorter than conventional surgery, often taking about an hour and a half to two hours.

However, hybrid treatment is not applicable to all patients. Each patient's lesion location, vessel condition, and comorbidities must be comprehensively evaluated. For this, the role of the "heart team," in which cardiology and cardiovascular and thoracic surgery discuss together, is important. "Whether surgery is advantageous, whether a procedure is advantageous, or whether hybrid treatment is appropriate must be decided in the heart team's best direction," Kang said.

Advanced age is not an absolute reason to give up on surgery. Kang said he has experience performing coronary artery bypass surgery even on a 93-year-old patient. Of course, older patients may take longer to recover, but he explained that thanks to shorter surgery times and advances in post-operative care techniques, advanced age itself is not an absolute contraindication.

◇ "Diabetes and Smoking Are Like Pouring Oil on a Fire"

Coronary artery disease is not only a problem of the heart's vessels. It often appears together with cerebrovascular and peripheral vascular disease. Therefore, vascular disease should be viewed as a systemic disease, and risk factors such as high blood pressure, diabetes, high cholesterol, and smoking must be thoroughly managed. Kang particularly warned strongly about smoking and diabetes. "Diabetes and smoking are like pouring oil on a fire," he stressed. "Smoking cessation, exercise, and cardiac rehabilitation are absolutely necessary even after surgery."

Finally, Kang urged patients not to miss the timing of treatment due to a vague fear of surgery. "Just as you take medicine when you catch a cold and have surgery for appendicitis, you should have a procedure when a procedure is needed and surgery when surgery is needed," he said. "If you are recommended surgery at an institution where heart surgery is active, it is better not to be too afraid and to actively choose treatment."

The most frightening thing about coronary artery disease is sudden death. In some patients, the first symptom appears as sudden death. "If someone middle-aged or older who has high blood pressure, diabetes, high cholesterol, family history, or a smoking history feels chest pain while exercising, they should go to the hospital without hesitation," Kang said. "Not ignoring the warning signals the heart sends is the first step in protecting your life."