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Medical Edge Newspaper Column from Mayo Clinic
REPEAT BYPASS SURGERY NOT INEVITABLE
DEAR MAYO CLINIC: I had quadruple-bypass surgery just two years ago. Is it likely that I'll need to have it performed again? I am a 58-year-old woman. — Manitoba
ANSWER: Another bypass procedure could be required, but is not inevitable.
A bypass operation provides an alternate path for blood flow when one or more of the heart’s arteries are atherosclerotic — clogged with hardened deposits (plaques) of fat, cholesterol, calcium and cellular waste. While bypass surgery is an effective way to reduce the symptoms of coronary artery disease and prevent a heart attack, the procedure is basically a “plumbing” strategy. It does not cure the disease. If the disease later progresses, the bypassed arteries could develop new blockages or previously unaffected vessels could become blocked. Even the transplanted conduits — the bypasses themselves, which are arteries or veins taken from different parts of the body — might clog.
Under such circumstances, another bypass procedure could be required. But the specifics of the original procedure, the patient’s other medical problems and how well they are treated, and the degree to which the patient adopts necessary lifestyle changes all can influence the need for future surgery.
Another factor that influences the longevity of the bypasses is this: Were arteries or veins chosen for the bypasses? While arteries are the most desirable — they are very adaptable to the heart’s environment and typically remain blockage free — only a few are available. Veins are plentiful, but they are not as robust as arteries and tend to clog within a few years.
The best vessels to use in coronary bypass are the internal thoracic arteries of the chest wall. However, there are only two — not a problem for single- or double-bypass but a dilemma when three or more bypasses are needed. My own tendency in such cases is to reserve them for the heart’s two most important conduits — the left-anterior descending coronary artery and the obtuse marginal branch of the circumflex coronary artery — if they are clogged, and use veins for any lesser bypasses. That way, even if coronary artery disease progresses and those lesser bypasses become blocked, the patient may not need another operation because the main conduits can carry the load.
Lifestyle choices after bypass surgery also have a major impact on whether additional bypasses will be needed later. The patient may be able to slow the progression of coronary artery disease if he or she stops smoking, reduces cholesterol levels, maintains a healthy weight, keeps blood pressure under control, manages diabetes and exercises regularly. Such self-help is especially important for young coronary artery disease patients like you, who run greater risk of later atherosclerotic buildup simply because they have more years during which it can occur. Though the risks vary widely among individuals, overall statistics suggest that 25 to 30 percent of coronary-bypass recipients will need the procedure again within 15 years.
Some patients wonder why we don’t bypass nature’s limitations by using synthetic materials — now common in surgeries involving the aorta — to provide a permanent solution, at least for the replacement vessels. But while the aorta’s massive blood flow keeps its new section clear, the relatively modest flow rates of the heart’s smaller arteries cannot prevent the tendency of artificial conduits to clog or collapse. Research is continuing in this area, however.
One viable alternative to bypass surgery is angioplasty — a procedure in which a balloon is inserted into the artery and inflated to compress plaque against the artery wall, opening the vessel. This process often is accompanied by the placement of stents — wire mesh tubes that prevent the artery from clogging again, at least for a while. While the angioplasty/stent option may be a good intermediate solution, another operation could still be in a patient’s future because of recurrent blockages.
— Kenton J. Zehr, M.D., Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
Additional Resources:
Bypass Surgery
Appointment Information
More Information on Bypass Surgery
Heart Center
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© 2005 TRIBUNE MEDIA SERVICES, INC.
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