Ask the Heart Doctor: Coronary Artery Disease Part 2

Podcast Transcript

Announcer:
Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic, and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Betsy Stovsky:
We're here today with Dr. Ellis and Dr. Bakaeen, who are both experts in coronary artery disease and management of coronary disease, to answer questions that were sent in by our audience on the topic. And we're going to focus on the second part, on treatment options. So, welcome to both of you. And we're going to start up with some questions starting with treatment, and I'm just going to go through some of these questions. The first one is about treatment or innovation. The person says, "For arteries that are shriveled up and cannot be stented or bypassed." Dr. Ellis, do you want to start, and then?

Dr. Stephen Ellis:
A little hard to know what to say there, Betsy, because I think you need to see the heart catheterization to know what shriveled up actually means. I might interpret it, for instance, as just a totally blocked artery, which sometimes can be either opened with a stent or bypass surgery. If patients are totally, can't have either of those options and are refractory to medication, sometimes we use EECP, or enhanced external counterpulsation. But again, it's a little hard to know what to say without looking at the picture. I think, to some physicians and artery that can't be treated isn't necessarily the same for Dr. Bakaeen and myself.

Betsy Stovsky:
Do you have anything?

Dr. Faisal Bakaeen:
Yeah, I agree with Dr. Ellis completely. In fact, we were just discussing a case before we went on to this podcast. If you look at the cath, and you can try and get some cues as to whether that vessel is bigger than it seems on the cath. One thing that I found helpful that we were discussing was getting a CT coronary angiogram, because that can give you an idea about the dimension of the vessel, about the calcification of the vessel, and whether you have a suitable landing zone. It doesn't have to be a perfect vessel to bypass. We often find just the right piece of real estate to land that bypass on. So, yes, I caution that conclusion without careful evaluation.

Betsy Stovsky:
Next question is about somebody that has 100% blocked LAD. They've had multiple, eight stents, brachytherapy, and now the LAD is 100% blocked with collaterals growing and told a graft is not possible. What do you say to a patient like that?

Dr. Stephen Ellis:
Well, I think if they've had that many stents and radiation therapy, that artery is probably shot as far as stenting goes. If they really have no symptoms, then probably it's not worth taking a risk to do anything in terms of revascularization. But if they were having symptoms, I would refer the patients to Dr. Bakaeen.

Dr. Faisal Bakaeen:
Yeah, I totally agree. I think if they have no symptoms, there is no need to do anything. But if they do have symptoms, then we will get a CT scan to look at the anatomy and suitability of that landing spot. This patient could be even a candidate for a minimally invasive procedure where we go through a mini left thoracotomy and do a off-pump bypass. It's called the MIDCAB, or minimally invasive direct coronary artery bypass, but not every patient is a candidate for that. So that is something that we could study and discuss with the patient, but there may be options if the patient's symptomatic. And if there's any question, also a viability study could be done to see if that part of the heart is still alive and would actually benefit from receiving extra blood. Most patients do benefit from revascularization. So these are my recommendations.

Betsy Stovsky:
We often get questions from patients who've had multiple, multiple, multiple stents. Is there a time when they should maybe get an opinion about what is the best treatment for a patient? I mean, you two work together a lot when you're discussing patients. How does that work for you in the practice?

Dr. Stephen Ellis:
There's not an absolute number. I think if the patient is having a recurrence in the same spot after maybe two or even three treatments, then maybe that spot's simply not going to respond to stents. And if they need revascularization, then the surgical options is better. I mean, some of our patients might have five or seven stents and they're all open, and that's great. It's hard to say there's a number, but the more stents you put in, I think at some point you have to say, "Well, this isn't really working. Maybe there's another way."

Dr. Faisal Bakaeen:
Actually, my record of operating on somebody after multiple stents is 52 stents. I was able to land four bypasses way down towards the apex of the heart, and that patient actually did well. It all depends who's putting the stent and who's the patient. So if Dr. Ellis is putting those stents, you presented your series of the patency or how long they stay open. And in the newer generation stents, they are amazing in terms of staying open for a long time, up to five years with results very similar to actually, if not better than historic data for vein graft. So again, the operator and the type of stent and the type of disease and the patient can determine how those stents perform. But generally speaking, if a patient is young and they're not having luck with the stents, it's probably better to consider bypass surgery.

Dr. Stephen Ellis:
Betsy, I think there's another piece to that. And that is the stentor needs to be really careful that they don't put stents so far down the coronary arteries, they don't leave any spot for a bypass if the stents reblock. That's a real mistake that we see sometimes.

Betsy Stovsky:
One person asked, what is the best stent to use to prevent restenosis?

Dr. Faisal Bakaeen:
We have the Ellis stent.

Dr. Stephen Ellis:
I don't have a stent named after me. I think there's little to choose between the current stents, quite honestly, the so-called second-generation drug-eluting stents. I think that there are several that are very, very good. And quite honestly, we seldom use, for instance, bare metal stents, and we certainly don't use first-generation drug-eluting stents. We looked for a while at stents that would totally dissolve, as you may know. At least to date, they haven't worked out so well.

Betsy Stovsky:
A person asks, they're 71 years old. They had five bypasses in 2003. And then in 2017, they had another heart attack. They said the artery in the back of their heart was blocked, but was not treated. They're taking ramipril and metoprolol. Is there any suggestions for that?

Dr. Stephen Ellis:
They don't really mention symptoms, I don't think. If the patient is symptomatic, they certainly should have an updated cath. Oftentimes blocked arteries, whether they're totally blocked or not totally blocked, can be opened with stents. And under some circumstances, they might even be a good candidate for bypass surgery.

Dr. Faisal Bakaeen:
Yeah, I agree. I think symptoms in terms of having chest pain, angina, or shortness of breath should warrant further investigation. If the vessel is small and inconsequential, maybe medical management. But if the vessel is big enough, then Dr. Ellis, interventional cardiologists will be able to possibly stent that vessel and improve the symptoms. If that vessel supplies a huge territory of the heart, and it's difficult to stent or impossible to stent, then consideration for coronary artery bypass is certainly on the table.

Dr. Faisal Bakaeen:
Now, if the mammary artery or internal thoracic artery is open, we usually think twice before we are operating, especially if the LAD ... The most important vessel is a big one that wraps around the heart ... because the studies from this institution showed the surgery can improve symptoms, but may not improve survival because the survival is determined by that vessel bypass with the lead to LAD, or the LIMA to LAD, the mammary to the lad. So in summary, you got to look at the anatomy. You got to look at the symptoms and look at the risk-benefit ratio.

Betsy Stovsky:
Somebody asks about when do they decide to do stents and when to do bypass surgery. This patient has multi-vessel coronary disease with blockages in the LAD, circumflex, and RCA.

Dr. Stephen Ellis:
Well, there are a number of things that should be considered. First of all, I think it should be a joint decision between the surgeon, the interventionalist, and the patient, because there are a number of things to look into. But the main things that we look at are: how many are there, where are they located, are they stentable? And particularly if the patient has diabetes, then, in general, surgery is preferred.

Dr. Faisal Bakaeen:
I agree with Dr. Ellis, I think in diabetics and in general, the higher the atherosclerotic burden, meaning the burden of disease and the distribution of the disease, the more likely surgery becomes the preferred option. But again, it's all risk-benefit ratio and discussion with the heart team to make the best possible choice of therapy.

Betsy Stovsky:
A patient's brother was a smoker. He has COPD. He was told he needs coronary bypass surgery, but would be high risk. Disease in two main vessels. He takes five nitro a day. What should he do?

Dr. Faisal Bakaeen:
Well, depends how bad the COPD. 20% of our patients have a documented history of COPD. It depends. Are they on any medications, such as inhalers? Are they on nebulizers? Are they on steroids? What's their performance status? Can they go up one flight of stairs without being short of breath? These are the kind of questions we look at. We look at the pulmonary function tests, and we look at the patient. And we get a CT scan to look at the lung parenchyma, meaning the lung tissue, how much destruction there is. But generally speaking, it's not an absolute contraindication for bypass, but we have to assess the severity and the performance of the patient before we determine the risk and whether that risk is worth taking. Stopping smoking is important. It's critical, in fact. Yeah.

Betsy Stovsky:
Well, you mentioned a minimally invasive bypass approach. A person is having ... They need to be on bypass, or need a bypass. And they want to know if they need to be on the bypass machine, and if there are minimally invasive options for them.

Dr. Faisal Bakaeen:
The debate about whether using or not using the heart-lung machine is the best way to go, it's this controversy that is ongoing. There's no evidence that doing the procedure without the heart-lung machine is better than with the heart-lung machine. Our preference, and the general preference actually at this point in time is using the bypass machine. It's very safe. It allows a bloodless field, a still heart. It allows to perform perfect and complete revascularization of the heart.

Dr. Faisal Bakaeen:
Now, there are situations where doing the procedure without the heart-lung machine makes sense. For example, somebody with a bad aorta that you don't want to manipulate, somebody with liver disease, a patient who needs one or two bypasses and very accessible and sizable vessels. Those are situations where it makes sense to do the off-pump procedure.

Dr. Faisal Bakaeen:
Now, minimally invasive procedures generally entail going through the side, and they can be done either hands-on or with robotic assistance. And it's typically offered for patients with an LAD Legion, which is left anterior descending artery, the artery that supplies the front of the heart, the most important branch. And it depends on the anatomy, again. If somebody's super obese, if there's chest wall deformity, if the vessel is too deep or too small, they may not be candidate for minimally invasive options. Experimentally or in certain centers, more bypasses are done in addition to the LAD through a small incision. But frankly, we don't have the numbers or the data to support the safety or efficacy or long-term durability.

Betsy Stovsky:
This gentleman's dad is diabetic. He's been diabetic since 15, had multiple surgeries and procedures on his legs to improve his feet circulation. Now he has bad blockage in his heart. He has chest pain. His doctors feel he cannot have heart surgery because there are no grafts for him. Are there other options?

Dr. Faisal Bakaeen:
It seems to me like they've used the veins in the legs. So in this patient, the conduit limitation makes the procedure interesting and certainly risky in the sense that you need to have enough conduits to do enough bypasses to achieve complete revascularization if possible. So what we would do is that we will do a vein map. We'll do an ultrasound of the legs to look and make sure that we have absolutely nothing to go for. Because sometimes they use the greater saphenous, but they don't use the lesser saphenous, which is the back of the leg. That is something that we could harvest.

Dr. Faisal Bakaeen:
We could look at the radial arteries in both arms. Hopefully, the cardiologist would have cathed them through the leg, because if they cathed them through the arm, we have to wait at least three months after that cath to be able to use that arm vessel. So we look at both arms, and then we use both arteries from inside the chest. These are usually the conduits that we use. Rarely, we go into the abdomen and take what's called the gastroepiploic artery, which is the artery that supplies the stomach. And finally, as a desperate measure which I don't recommend is we use a cryopreserved vein, which is a vein from another human being that has been frozen preserved.

Dr. Faisal Bakaeen:
So the answer to the question is we will look hard to find the conduits. And sometimes if they're not perfect, we'll cut them, splice them, join them together, or take them off each other, what's called a composite graft, to make it work. And if we absolutely can't find a conduit, then we'll send them to Dr. Ellis to try and stent them.

Dr. Stephen Ellis:
I think it's fair to say that for somebody that hasn't had prior bypass surgery, it's very unusual not to have conduits if all you need is an LAD.

Dr. Faisal Bakaeen:
If it's just a single vessel, I've certainly never run by this scenario. I think you'll always find the one to use if they haven't had previous heart surgery. Unless they've had a just deformity or an accidental or a previous surgery, I don't see why we can't find the vessel to bypass.

Betsy Stovsky:
Do you ever stent to open up a blocked bypass graph?

Dr. Stephen Ellis:
That's an area of some controversy. The short answer is yes, but there is some risk of dislodging the plaque as you open it up and having the plaque embolize into the heart and causing a heart attack. So it's technically feasible, but probably only should be done under somewhat rare circumstances where there aren't any other good options and the patient's quite symptoms.

Betsy Stovsky:
A patient says that they have a stent in their RCA that's 10 years old and now blocked, and they have no angina. They think they have plenty of collateral flow. What options are there to reopen the stent bypass and/or build more collateral?

Dr. Stephen Ellis:
So in the absence of symptoms, it's probably not worth taking the risk of trying to do something with that. The success rate of opening up total blocked stents with another stent at many institutions is quite high, although it varies a lot around the country. And again, the patient might be a candidate for surgery. But I would say generally in the absence of symptoms, probably should just be treated with medicines.

Betsy Stovsky:
What do you do for somebody that has chest pain and an anomalous coronary artery recently diagnosed?

Dr. Stephen Ellis:
Depends on the anomaly, is the answer. Some of them are best managed with surgery. Some best with stenting. Generally, there is a treatment option, but it depends on the anomaly.

Dr. Faisal Bakaeen:
Yeah, I mean, if they're symptomatic. I mean, some patients are at increased risk for sudden death because of those anomalies. What we usually do is a CT coronary angiogram to really delineate the anatomy, and then there are proven, standard surgical techniques to correct this problem, so it's certainly worth treating.

Dr. Stephen Ellis:
The main concern is an anomaly that runs between the aorta and the pulmonary artery that can get squeezed. So in that circumstance, we often treat even in the absence of symptoms because of the risk of sudden death. An anomaly that doesn't run between those vessels is typically not any more risky than an artery in its more usual location.

Betsy Stovsky:
If somebody had stents and they closed, and then they had CABG surgery six months ago, what's the chance they will close up too?

Dr. Faisal Bakaeen:
Sometimes stents do not work well for certain patients. Maybe the runoff of a vessel is not that good. Maybe the bypass vessels might be more durable, certainly if it's an arterial graft that's used that's good quality. So I wouldn't worry about it. I would just see how things go. If they develop symptoms, they can be reinvestigated. But there's no correlation that if the stents went down quickly, then the bypasses will go down quickly. Unless that target vessel is small and heavily diseased, and no matter what we do it's not helping.

Dr. Stephen Ellis:
We talked briefly, or you alluded to our studies about the durability of stents. I'll make the point that the average stent that we put in at this institution last about 12 years. What is the risk of closure? We often say patients are cured after surgery. I'm not trying to belittle surgery at all. But what do you tell patients about the risk of the bypasses closing?

Dr. Faisal Bakaeen:
Well, the one that we know stays open for a long time, and I usually say if you leave the OR with an open mammary or internal thoracic artery to LAD, then they should stay open for life. And that's generally held true because the patency at 20 years is about 90%. Maybe some of those 10% that went down, many went down early on, maybe related technical issues.

Dr. Faisal Bakaeen:
Now, the vein graphs are interesting. Why? For two reasons. One, they get effected by arthrosclerosis, unlike the internal mammary or internal thoracic, which is usually immune to atherosclerosis. But also, the veins can go to suboptimal targets. I mean, oftentimes you come out of the OR, you say, "I did four or five bypasses." Two of them go to really marginal vessels, but they're sizable enough you thought that they could benefit from a vein graft, and that vein graph does a good job because they do stay open.

Dr. Faisal Bakaeen:
But on average, at least historically, we don't really have up-to-date data. We know that half of them are going to be down by 10 years. Now, with optimal medical management and statin therapy, many believe that we're seeing less and less vein disease. In other words, if you put a good quality vein on a good quality target vessel and you stick to good medical regimen, then that vein might stay open longer than we thought they did, meaning that they might stay open beyond five to 10 years.

Dr. Faisal Bakaeen:
We can discuss more about the different types of conduits. Radials, for example, from the arm. There's recent data to show that they still open longer than veins. Some people advocate using unblocked vein no-touch technique, meaning that you go back to the old days with a big incision and strip the vein with everything surrounding it. Some have advocated doing that and achieving patency rates similar to arteries. But that's probably beyond the scope of our discussions.

Dr. Faisal Bakaeen:
I think to summarize, the gold standard is the internal mammary artery to the LAD. That stays open for a long time. But veins, it depends on the patient, the target vessel, and the vein itself, the quality of the vein.

Betsy Stovsky:
Quite a few questions about post-procedure, how to stay healthy longest, how to prevent future disease. Maybe you both can talk about what your typical medical regimen and advice is for patients after stent, and then bypass surgery.

Dr. Stephen Ellis:
We sort of touched upon this the first session, but it's certainly worth repeating. This would generally involve a referral for cardiac rehabilitation with a focus on diet and exercise. And diet and exercise are very, very important. You need to manage your risk factors as best you can. That means getting the blood pressure down, making sure you're not a diabetic, or if you are a diabetic treating it, not smoking, getting your cholesterol down. All those things are very important. In terms of the medications, the patients are typically on aspirin and Plavix, or aspirin and clopidogrel for a period of time after stenting. That period depends on the patient's clinical presentation. It could be as short as a month or as long as forever, and there are a lot of nuances in between.

Dr. Faisal Bakaeen:
I think recovery after heart surgery is kind of similar overlaps in terms of the importance of medical management and secondary prevention, because you want to have those graphs to open for a long time. So controlling your lipids, your glucose, your blood pressure all contributes to a durability of your bypass procedure.

Dr. Faisal Bakaeen:
In terms of recovery, when you break an arm, you put it in a cast for eight weeks for the bone to heal completely. When we split the bone in the middle, we put it back together with wire. We've used the wire for many, many, many decades, and very effective in terms of putting the sternum together and allowing it to heal. But we don't put you in a cast like that for eight weeks, we ask that you be careful for eight weeks. Meaning, to hug yourself when you cough, or hug a pillow, and avoid strenuous activity or heavy lifting. But my father had heart surgery, and he went back to desk work within two to three weeks. And indeed, you'll be out of bed the next day. You'll be able to do the activities of daily living, but no strenuous activity, typically for eight weeks.

Betsy Stovsky:
After you're treated and you haven't had a heart attack, but you've been treated for your coronary disease, are you considered to have heart disease for the rest of your life?

Dr. Stephen Ellis:
Yes.

Betsy Stovsky:
So those things that you're suggesting is not just for recovery. It's really a life-long ride.

Dr. Stephen Ellis:
It's a chronic illness. It needs to be managed with an eye for the long term and not just the short term.

Dr. Faisal Bakaeen:
I agree. Just take care of yourself. The better you take care of yourself, the better the long-term outlook.

Betsy Stovsky:
Well, thank you both for being here today and answering a lot of questions. I know people will be very happy to listen to your information.

Dr. Faisal Bakaeen:
Thank you.

Dr. Stephen Ellis:
Great. It's been a pleasure.

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