Diabetic bypass apparently better than stent

Coronary heart disease is often the result of diabetes

01/02/2013

Over the years, most diabetics experience consequential damage from the chronically elevated blood sugar level. Often it comes to diseases of the coronary arteries - which is why again and again the question is discussed and examined in new research projects, which is more useful for the treatment of diabetic patients: the bypass surgery or the onset of a so-called „stents“, a medical implant, which is introduced into the constricted vessels to keep them open.

New international study shows: A bypass is the most meaningful treatment
This question now seems to be clarified by a recent international study, as the results of the long-term study published at the beginning of November 2012 in the "New England Journal of Medicine" clearly show that patients suffering from multiple constricted coronary arteries should undergo bypass surgery rather than themselves to have a stent set. In fact, the study found that diabetic patients who received a bypass had fewer deaths and heart attacks within five years than those who had received a vascular brace.

Participants in the study: 1,900 diabetics worldwide
From 2005 to 2010, the study involved a total of 1,900 diabetics from 140 clinics worldwide, including treatment centers in the US, Canada, Brazil, India, France and Spain. The patients studied, 71% men and 29% women, were on average 63 years old and all suffered from multiple constricted coronary arteries, in 83% of the subjects the vessels were narrowed in three passages. Two groups were formed: one was bypassed to bypass the clogged coronary vessels, while the other group was catheterized with drug-loaded stents placed in the narrowed vessels to dilate them and through the release of small amounts of medication to prevent re-closure.

With bypass: Significantly fewer deaths and heart attacks, slightly more strokes
After the interventions, a follow-up period of five years followed, after which the physicians had a clear result: While in the group of bypass patients within the five years 10.9 percent of those affected had died, the proportion of the deceased in the group those who had received a stent at 16.3 percent. The number of heart attacks was also significantly higher in the stent group: 13.6 of the patients were affected, whereas the proportion in the bypass group was only 6 percent.

However, the number of strokes was exactly the opposite: here, of the implanted stent patients, only 2.4% had a stroke within five years, while the proportion in the bypass patients was 5.2%.

Vascular changes occur earlier in diabetics
According to Professor Friedrich-Christian Rieß, Chairman of the Albertine Heart and Vascular Center Hamburg and Head of Cardiac Surgery, the positive results within the bypass group have several reasons: First, the diameter of the coronary vessels is often smaller in diabetic patients than in people without diabetes. On the other hand, especially in diabetic patients vascular changes in the sense of atherosclerosis, also known as „hardening of the arteries“ or. „hardening of the arteries“ occur much earlier than non-diabetics. For the vessels would change according to the professor in the diabetic much faster, also these changes are more diffuse: „That is, it comes not only to the outlets of the arteries to bottlenecks, but they often pull themselves through the whole vessel to the top. But that also means that they are often long-range constrictions. And the longer the distance, which often needs to be provided with stents, the greater the risk that it will come to restraints again, "said the physician.

Study result also clear for heart specialists of the UKE
The result of the study is also clear for the cardiologists at the Department of General and Interventional Cardiology at the University Heart Center of the Eppendorf University Hospital: "The procedure at the UKE is the first to treat bypass surgery in diabetic patients with diseases of several coronary arteries Choice ", says the director of the clinic Prof. Stefan Blankenberg.

Stroke rate could be reduced by gentle surgical techniques
The slightly higher number of strokes after a bypass operation could be further reduced according to Professor Rieß - through more gentle surgical techniques. Because in this country would - as in the US - often operated on the heart-lung machine and partially used for the bypasses veins, which would be implanted in the main artery. However, according to the professor, these procedures would entail risks, as calcifications could be released from the wall of the main artery, which could reach the brain via the blood stream and trigger a stroke there.

Alternative method for bypass: Use of sternum arteries
For this reason, according to Professor Riess in the Albertinen Heart and Vascular Center Hamburg, a method was used in most cases, in which the main artery is not affected at all. Instead, another path would be taken: "We operate patients on the beating heart without using the heart-lung machine and use the sternum arteries connected to the coronary arteries for bypassing." According to Rieß, a stroke can almost be ruled out by this procedure - because in the sternum arteries, for reasons yet to be explained, it would never lead to deposits due to atherosclerosis, which in turn only minimizes the risk of renewed vascular occlusion. According to the professor, this would be different with the use of venous vessels, because "these become part of the arterial system, they begin to arm themselves against the unusually high blood pressure by altering their vessel wall." But this increases the risk that it will be there comes to new restrictions ". According to Rieß, a study would have shown that only about two-thirds of the venous bypasses were still open after ten years.

German Diabetes Society calls for stronger education
From the point of view of the German Diabetes Association (DDG) there is an urgent need for action in view of the study results: „Advice and treatment for people with diabetes with diabetes must improve“, so Professor med. Stephan Matthaei, President of the DDG. It is urgent that physicians educate their patients about the survival benefit of bypass surgery before a catheter exam, because this is the only way cardiac patients with diabetes can make an informed decision.

This opinion is also Professor. med. Andreas Fritsche, press spokesman for the German Diabetes Society in Tübingen: „Diabetic patients with diabetes should already know this before a scheduled catheterization so that they can make an informed decision for bypass or stent“. Only in this way can it be ensured that the patient has enough time, „to thoroughly discuss his therapy decision with his family, the treating heart team and his diabetologist.“ Because in the light of the study results, the physician would have to assume that many cardiac patients with diabetes would not be treated properly at present. (Sb)

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New stents improve heart attack prognosis
Blood type influences risk of heart attack
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Number of children with diabetes is increasing rapidly
New hope for heart attack patients

Image: Dieter Schütz, Pixelio