PCI (stent) vs coronary bypass surgery

Coronary artery disease narrows the arteries supplying the heart muscle with fatty plaque. PCI treats a narrowing locally, from inside the artery. CABG creates new routes for blood to flow around blockages, using vessels taken from the chest wall, arm or leg.

Both relieve angina; they differ in invasiveness, in how well they suit different patterns of disease, and in the chance of needing another procedure later.

Under local anaesthetic and mild sedation, a catheter is passed from the wrist or groin to the narrowed artery. A balloon is inflated to open it, and a drug-coated stent, a small mesh tube, is left in place to hold it open. The procedure usually takes under a couple of hours and many people go home within a day.

Risks include bleeding at the access site, damage to the artery, stroke or heart attack (uncommon), and kidney strain from contrast. Dual antiplatelet tablets are taken for a period to stop clots forming on the stent. A stent can later narrow again or clot, and further procedures may be needed.

CABG is performed under general anaesthetic through a cut in the breastbone, often with the heart stopped and a heart-lung machine used, although some operations are done on the beating heart. Surgeons usually use an artery from the chest wall to bypass the main artery at the front of the heart, and other grafts for other vessels. The hospital stay is typically several days, followed by cardiac rehabilitation.

Risks are greater in the short term than for PCI, including stroke, infection, bleeding, heart rhythm problems and temporary confusion, but for suitable patients grafts can last many years and may reduce later events in complex disease.

In stable disease, NICE stable angina guidance (CG126) advises that the choice between PCI and CABG be made by a team and takes account of the extent and complexity of disease, other health conditions and patient preference. People with left main or complex multivessel disease, especially with diabetes, are often advised to have bypass surgery, while PCI suits simpler lesions or those whose surgical risk is high.

In acute heart attack caused by a blocked artery, urgent PCI is the usual treatment because speed preserves heart muscle. The team also considers medicines alone for some stable patients, since not all narrowings need a procedure.

• One or two narrowed arteries and symptoms despite medicines: PCI is commonly suggested.

• Three-vessel disease, left main disease or diabetes: ask whether bypass surgery would give better long-term outcomes.

• High surgical risk because of lung disease, frailty or other illness: PCI may be safer.

• Heart attack symptoms such as crushing chest pain with sweating or breathlessness: call 999 immediately.

• Unsure: ask for the Heart Team discussion and for the scoring of your disease complexity.

A stent does not "cure" coronary disease; it treats one narrowing, and the disease can progress elsewhere. Bypass surgery likewise is not a cure; lifestyle and medicines remain essential. Also, bypass surgery is not always the more dangerous choice for the person; the right option depends on the pattern of disease.

Another misconception is that all narrowings need a stent. Many are best treated with medicines and lifestyle change.