This involves three surgical interventions:
- Coronary artery bypass surgery.
- Percutaneous transluminal balloon angioplasty (or more simply, balloon angioplasty).
Today, patients with angina (often from the very first attack) enter hospital for an angiogram. This gives an X-ray picture of the blood vessels of the heart. If there is any narrowing or obstruction, it will readily show on the screen, much like a television monitor. The X-ray may indicate partial or complete narrowing of up to even four or five vessels. The greater the number and the greater the degree of blockage (occlusion), the greater and worse the anginal attacks, and the higher the risk of one or more blocking and an infarct occurring. Black-and-white transparencies can be taken from the screen, and hard copies are also available, which will later assist in treatment.
Today, more and more patients are undergoing coronary artery bypass surgery. In fact, often after one anginal attack, if the angiogram indicates irreversible coronary narrowing or occlusion, surgery is recommended as a matter of urgency. Many patients are scheduled for surgery the next day. A blood vessel from a different part of the patient’s own body (often the lower limb) is removed, and this is used to actually bypass the arterial obstruction in the heart. Anywhere from one to five (occasionally more) bypasses may be carried out. This is called open-heart surgery.
Alternatively, a vessel near the heart called the internal mammary artery may be diverted and is used as the bypass instead. These vessels seem to give better results. The patient is treated in the intensive care ward for a few days, and hooked up to monitoring devices that alert the medical staff if anything untoward is happening, in which case steps to reverse it are taken. The patient is usually up and about within a few days, and often home in about one week’s time. He or she then embarks on a routine of weight loss, exercise, and various other schemes to try to prevent a recurrence of the original problem.
The success rate for this form of surgery is extremely high. The mortality rate in well-equipped, major cardiac units is less than 1 per cent, hardly significant considering the large number (and types) of patients admitted and treated.
The future also looks good. However, some patients foolishly revert to their original lifestyle; resume smoking, drinking, become overweight again, and fail to take adequate exercise. So there is the risk of a recurrence within five to 10 years. A second operation is possible, but not desirable, for it is always more difficult getting to the chest and heart the second time. The anginal pain vanishes in most cases, allowing patients to return to their previous form of work (including heavy physical exertion) with little (or minimum) discomfort.
Another simpler operation is also very popular and carried out in most major heart units. It is called percutaneous intraluminal balloon angioplasty. The arterial obstruction is located by angiography.
Then with the same method, a fine tube called a catheter is inserted into a vessel in the groin, and worked up until it reaches the obstruction in the cardiac vessel. Then pressure is applied at the free end, and a small balloon pops out and forces away the obstruction. Being fairly soft material, it flattens against the walls of the artery, and presto!—the original normal diameter of the artery is restored. This may be done to one or more obstructions, depending on where they arc located. The operation is quick, does not involve entry into the chest cavity, and the patient is relieved of symptoms immediately, often returning home within a couple of days, and back to work within a week.
Sometimes there is a reocclusion within a few weeks or months, but many arteries remain patent (stay open) for considerable lengths of time.
To help prevent the obstruction from reforming, doctors have invented a tubular, stainless-steel mesh called a “stent.” This is inserted inside the vessel immediately after the dilatation, and within a short time, cells similar to those of the internal wall of the vessel have grown over the mesh. This gives it a firm foundation and it is claimed the risks of reocclusion are reduced. Time will tell, for it is still a new procedure. As with the bypass, post-operatively it is essential to follow all the recommendations so that there will not be another build-up of fats on the arterial walls and a recurrence of the original problem.
“Percutaneous” means via the skin (the catheter is placed into the inside of the blood vessel, intralumen, through a small skin incision). Balloon means a balloon is used to repair the vessel (angioplasty). A laser-tipped catheter has been developed and is now in use. This cuts away the obstruction, whether it be a thrombus or blocked vessel from some other cause.
This also is highly successful in skilled hands.
These days the outlook for patients with angina has become revolutionized. Lifestyles have altered dramatically, as surgery replaces the need for permanent medication. It is not yet known how longevity will be affected, for these approaches are still relatively new. However, freedom from pain in everyday living is a major contribution to happiness and wellbeing. Never neglect to report any form of chest pain to your doctor as a matter of urgency. You could be a candidate for some of the measures already described.