If you and your physician decide that your coronary arteries need surgical repair or bypass of blockages, several options are available. There are procedures to open the artery mechanically (angioplasty) or to bypass the obstruction in the blood vessel and get the blood flowing again. Studies show that a bypass yields better results for people with diabetes.
A balloon attached to a catheter is inserted into the narrowed artery and inflated to open it. The balloon is inflated many times during the angioplasty to increase the likelihood of the artery staying open. When the balloon is expanded, the cholesterol deposit is reshaped and there is usually a small, controlled tear in the lining of the blood vessel.
A stent is a small device, usually made of metal in the shape of a spring or mesh cylinder, that may be positioned in the coronary artery at the site of the obstruction. It is compressed until the balloon inflates it to hold the vessel open and prevent the cholesterol deposit from blocking the artery again.
Some blood vessels cannot be dilated with a balloon with or without a stent. These blockages may be opened with a rotablator, which has a motorized burr (much like a dentist’s drill) located at the tip of the catheter. Some devices actually remove some of the cholesterol plaque. Stents are frequently used in this procedure, too.
Recent data suggests that an angioplasty may not be the best choice for people with diabetes. There are serious complications. In some cases, the coronary vessel will re-close abruptly because of clotting at the site of the dilation or tearing of the vessel. Nearly all patients who have angioplasty, with or without stents, receive drugs to prevent clotting. A stent appears to reduce the likelihood of the vessel closing abruptly. Without stents, as many as one-third of the vessels that are opened may re-narrow over 3-9 months. However, even when stents have been used, the blood vessels of people with diabetes are more likely to renarrow after angioplasty.
Coronary artery bypass surgery is often chosen because it is effective for patients with extensive CAD and those with less serious disease but depressed heart pump function. Studies have shown that bypass is much more successful than angioplasty in people with diabetes over time. During bypass surgery, an artery taken from the inside of the chest wall or veins removed from the leg are used to bypass the narrowed portion of the vessel and to deliver blood beyond the blockage. This procedure relieves symptoms of angina, may help damaged heart muscle to improve its pumping ability, and, in some patients, prevent heart attack and prolong life.
The veins used for bypass grafting are usually removed from the lower portion of one or both legs, depending on how many bypasses are necessary. The surgical procedure may require 4-6 hours, or even longer if it is a repeat procedure or if a heart valve must be repaired or replaced at the same time. Complications of bypass surgery include heart attack, bleeding, infection of the breast bone (sternum), or infection of the site from which the veins are taken. Complications are more frequent in people with diabetes, especially infection and difficulties with healing. However, most people with diabetes have coronary artery bypass surgery with excellent results.