A tough call for doctors, patients

When 68-year-old Mike Gavin began to develop chest pain last December, he wasted little time before seeing his doctor. A coronary angiogram revealed that several of the arteries supplying blood to his heart were partially blocked. The doctors with whom Gavin consulted agreed that something had to be done quickly to restore healthy blood flow. They disagreed, however, on how that should be accomplished.

Two cardiologists recommended a bypass. In that surgery, healthy blood vessels from the leg, chest or arm are transplanted to the heart to detour blood around the blocked portions of the coronary arteries.

The treatment requires that the chest be opened and -- in most cases -- that the heart be temporarily stopped. (A heart-lung machine is used to oxygenate the blood and circulate it throughout the body during the procedure.) The risk of complications, including strokes, is relatively high. Patients typically spend about four days in the hospital and may not fully recuperate for weeks or months.

A third cardiologist, however, thought surgery could be avoided. "He suggested he could do it with angioplasty and a stent," recalls Gavin, who lives in Encino.

In this approach, a balloon-tipped catheter is inserted into a large blood vessel in the arm or leg and gently guided toward the heart, where it can be threaded into a coronary artery. Once in place, the balloon is inflated, stretching the artery from the inside. The plaque that is causing the blockage is compressed to create a wider passage for the blood. To reduce the likelihood that the vessel will close up again, a wire mesh tube, or stent, is then placed inside the vessel.

Angioplasty is less invasive than bypass surgery, complications are less common, and recovery is much quicker. Many people leave the hospital the day after they have the procedure and are able to resume normal activities -- including work -- within several days.

Both angioplasty and bypass surgery are currently in wide use for the treatment of coronary artery disease, and deciding which procedure is more appropriate can be challenging for patients and physicians alike.

Although bypass surgery is clearly riskier than angioplasty, it appears to offer some long-term advantages. In people with extensive coronary disease, surgery does a more complete job of restoring blood flow to the heart. Reclogging of the vessels, or restenosis, is also less likely after bypass surgery than angioplasty.