"I'm Not in Pain, So Do I Really Need Surgery?"—Not Every Small Coronary Artery Blockage Can Be Cleared With a Procedure

[Financial News] As patients diagnosed with coronary artery disease learn about procedures such as stent placement and catheter-based interventions, many are increasingly wondering whether there is an option simpler than surgery. However, depending on the condition of the blood vessels, coronary artery bypass graft surgery may actually be the more definitive treatment.
When these patients are advised to undergo surgery, their first concern is often the idea of "opening the chest." However, not every case of coronary artery disease can be treated with a procedure. Coronary artery bypass graft surgery (CABG) may be more appropriate when multiple blood vessels are severely narrowed, when all three major coronary arteries supplying blood to the heart require treatment, or when a catheter cannot be easily inserted because of the vessels' structural characteristics. It may also be necessary when a lesion develops at the origin of a vessel or at another critical site, making treatment with a procedure alone difficult even if the other vessels are in good condition.
Kim Shin, chief of cardiothoracic surgery at Incheon Sejong Hospital, explained, "Coronary artery bypass surgery is not simply an operation to open a blocked blood vessel. It creates a new route for blood flow by bypassing the blockage so that blood can be supplied steadily to the heart muscle." He added, "Because the condition of the blood vessels and the location of lesions vary from patient to patient, it is important to distinguish cases suitable for stent placement from those requiring surgery."
The important question is not simply how many blood vessels are blocked. Treatment should be determined by comprehensively assessing where and how severely the vessels have narrowed, the structure of the vessels, cardiac function, and the patient's overall health. "Patients may easily wonder whether a procedure would be enough, but the difficulty of treating coronary arteries varies greatly depending on the location and shape of the blockage," Kim said. "Depending on the case, bypass surgery may actually be the more definitive treatment."

A key part of CABG is securing a bypass vessel to take the place of the blocked artery. Blood vessels from the patient's own body are used, including the internal thoracic artery, radial artery, and great saphenous vein. Arteries are generally preferred because their characteristics and structure are superior to those of veins, making them better suited to maintaining blood flow over the long term. Among them, the internal thoracic artery—which branches from an artery running below the clavicle and extends along the inside of the chest—is primarily used to create a bypass around a narrowed or blocked coronary artery.
Kim explained, "Several blood vessels can be used as bypass grafts, but the internal thoracic artery often remains healthy even 10 years later. Because of this advantage, our hospital uses the internal thoracic artery in 100% of CABG procedures, except in emergency surgeries."
In the past, surgery was often performed after stopping the heart and using a cardiopulmonary bypass machine. More recently, off-pump coronary artery bypass surgery has become the primary approach, with blood vessels connected directly while the heart continues beating. This method significantly reduces the incidence of complications and adverse effects associated with cardiopulmonary bypass, including stroke and impaired kidney function, and generally produces favorable surgical outcomes. However, it requires extensive surgical experience and highly refined technique because the vessels must be connected precisely while the heart is beating.
Another reason patients hesitate to undergo surgery is the thought, "I'm not in severe pain right now, so do I really need surgery?" Angina can cause shortness of breath or excruciating, squeezing chest pain, but some patients have few noticeable symptoms. When blood flow is insufficient, the body may try to create new small blood vessels to compensate for the reduced supply, so patients may not feel that they have symptoms. Even without symptoms, however, continued insufficient blood flow to the heart muscle can gradually impair cardiac function. If the patient develops a cold or pneumonia, that barely maintained function can deteriorate rapidly, potentially leading to a serious situation such as collapse from a myocardial infarction.
The average age of patients undergoing CABG has risen in recent years, and the number of patients with diabetes has also increased. Diabetes is closely associated with coronary artery disease and can affect blood glucose management before and after surgery, as well as infection and wound healing, so careful management is essential. Once cardiac function declines significantly, it is difficult for the heart to recover fully to its previous condition. As a result, the risks and recovery process can differ depending on whether surgery is performed after severe cardiac impairment has developed or while the patient's overall condition is still relatively good.
Kim said, "It is not advisable to delay treatment as much as possible simply because surgery is frightening. Instead, it is important to receive appropriate treatment while you are still healthy, preserve cardiac function, and lead a more stable life afterward."

For CABG, median sternotomy, which involves opening the sternum, and minimally invasive approaches each have clear advantages and disadvantages. In complex surgeries requiring simultaneous bypasses around multiple vessels, median sternotomy can provide a sufficient surgical view, improving precision and safety. The procedure also takes less time and allows surgeons to respond quickly to unexpected emergencies. The most concerning complications of surgery involving the sternum are failure of the sternum to heal properly or infection after surgery. Recently, rigid sternal fixation plates have helped lower the risks of complications and infection by stabilizing the bone.
However, opening the sternum is not necessarily the best option for every patient. The surgical approach should be selected after considering the patient's age and overall health, as well as the location and extent of the lesions. For example, in younger patients, surgeons may consider the possibility that the chest could need to be reopened in the future because of another heart or thoracic condition. Depending on the location and extent of the lesions and the patient's condition, they may also perform minimally invasive direct coronary artery bypass grafting (MIDCABG), which uses an incision on the left side of the chest to bypass approximately one vessel.
Patients with symptoms such as angina or shortness of breath often notice that their symptoms improve and their exercise capacity increases after surgery as blood flow improves. By contrast, patients whose symptoms were not particularly severe or who had no notable symptoms may not feel a significant difference after surgery. Nevertheless, CABG is important not only for improving current symptoms but also for preventing future damage to the heart muscle and preserving cardiac function. Even if current symptoms are not severe, surgery may be the safer choice when the patient meets the indications, as it can help prevent future risks.
Kim said, "Coronary artery bypass surgery may be frightening from the patient's perspective, but I hope patients do not choose a treatment based on the size of the incision or which option seems less burdensome." He emphasized, "Rather than having a vague fear of the surgery itself, the priority is to accurately assess the current condition of your heart and blood vessels—to understand exactly what state your heart is in and which treatment is safest and most appropriate." He added, "It is important to discuss the options thoroughly with your medical team and decide which treatment can preserve cardiac function while providing stable long-term results."
 

[email protected] Jung Myung-jin, medical writer Reporter