Sophisticated new stents are set to replace surgeon’s scalpel

At a recent cardiology conference held in Athens, eminent American Professor Jeffrey Moses from Lenox Hill Hospital cracked jokes about despairing heart surgeons hanging up their scalpels. The new surgical technique of angioplasty is beginning to replace open-heart surgery. The new generation of drug-eluting stents has contributed largely to this great leap forward in cardiology. Enhanced with chemical substances, they minimize the likelihood of the artery narrowing again. Stents have been used since the 1990s to hold arteries open. The new generation of drug-eluting stents has proved to be as effective as bypass surgery, but without the horrific experience of thoracectomy. Up until now, Professor Pavlos Toutouzas of the Hellenic Cardiological Society told Kathimerini, patients with narrowed arteries have undergone bypass operations, or they have been at risk of relapse after a procedure to open their arteries. «The picture has changed,» said Toutouzas, «and leading surgeons at heart clinics in New York, Milan, Paris and Rotterdam believe that heart surgeons will perform very few procedures in the future. Most of them will be done by cardiologists.» In 2001, according to data from the Hellenic Cardiological Society, there were 5,800 balloon angioplasty procedures and 8,000 heart operations. «A number of heart operations are to do with related heart disease and valve problems,» said Toutouzas. «So the ratio of bypass to angioplasty in Greece is 1:1. Even so, we lag behind the United States and Europe, where the ratio is 2:1. «In 1999, there were 571,000 bypass operations and one million angioplasty procedures in the US, and 240,000 bypass operations and double the number of angioplasty procedures in Europe. Since then, particularly in the past year, there have been great advances in dealing with coronary disease.» Improved techniques Commenting on the views of leading cardiologists such as Jeffrey Moses of Lennox Hill Hospital in New York and Antonio Colombo of the Centro Cuore Colombus in Milan, Toutouzas says the picture has changed dramatically. «The view is that very few patients will need heart surgery in the future. We’re talking about not just two times but eight times the number of angioplasty procedures. The progress is due to technical improvements, a better approach to the damage, and the ability to deal with multiple damage which we wouldn’t touch in the past because we were afraid the arteries would narrow again. In the 1980s there was a 50 percent chance an artery would narrow again, and a higher chance when several arteries were involved. But even in the 1990s, when stents were invented, and the likelihood fell to 30 then 20 then 15 percent, or even less if the damage was simple, we didn’t stop worrying. In the case of multiple damage, one in two patients were coming back with narrowed arteries. In those cases we didn’t perform angioplasty.» «The more complex the damage the greater the percentage or recurrence,» says heart surgeon Vassilis Spanos. «With traditional stents, about 18 percent of patients we treated for two or three malfunctions would be back within a year, not only with their arteries narrowed again but for an operation. Some of them even had bypass surgery. With bypass surgery, the percentage of recurrence does not exceed 3.5 percent.» Spanos worked with Colombo at the Centro Cuore in Milan, one of the first clinics to use drug-eluting stents systematically in patients with multiple damage to their arteries. «In Milan, Colombo did a study to establish whether the new stents were as effective in difficult types of coronary damage. There had been an earlier study, conducted in several different places, on the use of the new drug-eluting stents in cases of simple damage, which showed there was no recurrence. In the second study, drug-eluting stents were used on split coronary arteries, a very difficult type of coronary damage. Despite the techniques that have been developed, there was a high incidence of recurrence with simple stents, but with drug-eluting stents the percentage of recurrence of damage in the main artery did not exceed 5-6 percent. That percentage is higher, however, in the small artery. «From this study, to be published in the journal Circulation, we realized we have a very good tool that we need to learn how to use. «By using intra-arterial ultrasound we observed that, unlike simple stents, the drug-eluting stents do not form extra tissue at the point where the stent wounds the vessel, because of the pharmaceutical substances it is enhanced with.» The latest stents cost 4,000 euros apiece, against 2,000 euros for the older type, but insurance companies will cover the cost if it is approved by the doctor. «In the case of mild, accessible damage, where there is almost no chance of recurrence, we use simple stents,» said Toutouzas. «But in when there is elongated and difficult damage, we use drug-eluting stents. There is little chance of recurrence, and it is reasonable, in order to avoid surgery. «The way we’re going, surgical procedures will be less bloody and cardiologists will play a greater in restoring circulation. This will make surgeons develop new techniques to treat people without using extra-corporeal circulation and with as few incisions as possible.»

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