Dear Dr Garner,
I have been hearing about President Clinton, and the stents he had placed. My husband is in his 60’s and was told last week that he would need a by-pass operation for clogged arteries of the heart. I am a little bit confused as to what the difference is between the two.
Why did the President need both? Does this mean that my husband wills need the stents later on? Couldn’t he just start with stents? I thank you for your help. The news that my husband needs heart surgery has everyone in the family on edge.
Anxious wife in Williamsburg

Dear Anxious,
Naturally, any time anyone has surgery, there are risks involved. . To keep the matter in perspective however, the risks are very small with heart surgery. As with any type of operation, it is critical to have it provided by doctors who perform it frequently.
I was just talking about the President’s situation with my good friend and loyal Tablet reader, Robert Ochs, from Howard Beach.
The body is truly amazing, and lets us know when something is wrong. When there is a narrowing of the arteries of the heart, the muscle of the heart doesn’t get enough oxygen one experiences chest pain, known as angina.
To correct this situation there are three ways to approach the problem.
One that should be tried first in most cases is a change in lifestyle. Often with control of blood pressure, and lowering of cholesterol, and exercise a person may avoid stents or by-pass surgery. Your doctor will decide how serious or acute your problem is to determine which approach is the correct one for you. The other two options are angioplasty and stents and open heart surgery.
Stents are very different from open heart by- pass surgery.
In the stent procedure an angiogram and angioplasty is first performed using a small catheter inserted into a blood vessel in the groin and advanced to the heart.
Dye is then injected and the arteries of the heart are examined. If there is significant narrowing of the vessel from clots known as plaque, the vessel is “ballooned out” using a small ballon at the end of the catheter. It mechanically opens up the vessel, widening the space for the blood to bring oxygen to the heart. This is known as angioplasty.
To help prevent the artery from collapsing after the angioplasty, a metal stent (a mesh wire tubing) is inserted. This is similar to what President Clinton had last week.
In open heart surgery, the chest is opened and the heart is examined to see which vessels are diseased. There are two ways to get to the heart- one is through an incision the length of the breast bone, and the other through a smaller incision. You should discuss with your doctor which approach is better for your husband.
Unlike a stent procedure, in which the patient is alert, general anesthesia is used.
A vein from the calf is usually cut out and used to bypass a narrowing in the “plumbing” or arteries bringing blood and oxygen to the heart muscle.
This procedure requires a lot more recuperation time than a stent.
Depending on the symptoms and the amount of narrowing, a doctor will decide which method to use.
Not every patient has lesions that are fixable by stents. . Some patients have more extensive areas of narrowing and will require surgery.
To answer your questions, it is not unusual for a person to return after by pass surgery, for an angioplasty and stent procedure. The reasons for the large plaque buildup originally causing the problem may not have diminished if related to a genetic or inherited problem. Over time accumulation of fats can build up at the by pass site, and it is a fairly routine to open up the vessles and put a stent in.
Many patients will require this between 5 and 10 years after the by-pass. It is quite possible your husband may require this. Your doctor should discuss with you and your husband a proper diet, and lifestyle, as well as what problems to look for, that might require return for angioplasty and stenting in the future.
In the stenting procedure, the patient stays overnight in the hospital and is usually sent home to follow light activity with no heavy lifting for a week or two.
In open heart surgery, there are several weeks of recuperation, and discomfort about the incision site.
To answer your questions, it is not unusual for a person to returne for angioplasty and stenting after having had by pass surgery. This usually occurs in the period of 5-10 years after the original surgery.
There may have been continued plaque build up after the surger, either due to genetics or inherited problems or due to build up of excess fat in the blood.
It is quite possible that your husband will need this “fine tuning” of his surgical procedure in the years to come. Your doctor will discuss with him the type of lifetwly and medications he will need to lessen the chances this will happen.
In any event, as you saw with President Clinton, the procedure is straight forward and minor as he returned home the next day.
Some patients cannot be treated with stents and require by pass surgery. Your doctor in reviewing ht situation can determine the number and severity of the lesions in your heart.
It is always a good idea to ask your doctor if surgery can be avoided and stenting used in stead.
I wish you and your husband well, and hope you understand that by pass surgery has become much more routine with very few complications.
Please talk to your doctor one more time, to ask about alternatives to surgery, so that you are absolutely assured that the procedure is necessary and that stents would not be preferable in his case.
Please let me know of his progress.

*Reprinted with permission of The Tablet