Why Bypass Is Often Favored For Diabetics

The reality of coronary artery disease in diabetics is that it is harder to control. Repairing one lesion in one coronary artery and then relying on statins, ACE receptor blockers, and beta-blockers to keep more lesions in more arteries from occurring simply doesn't work for most diabetics.

And when they receive five or six stents, which are metal implanted into the lining of an artery to keep it open, future surgical options are limited as doctors run out of places they could place a bypass graft. If a stent fails, the option is usually putting a stent inside a stent, which permanently reduces the flow through the vessel.

Even worse, choosing the wrong kind of stent can have disastrous consequences for a diabetic patient. Older coronary artery stents are made with bare metal, a coil with tiny pores holding a blood vessel open. New coronary artery stents are drug eluting, releasing a medication to prevent the formation of scar tissue.

Diabetics, as you probably know, recover from wounds more slowly than people who do not have diabetes. This is also true of wounds inside their arteries. When artery wall around the stent does not heal quickly enough, sometimes clots can form at the ends of of and along the stent, causing a pseudoaneurysm, a "blowout" of the stent that results in sudden death.

But of that 1%, about 50% die, usually an hour to a week after the operation. When the doctor chooses the wrong anticoagulant, or the patient fails to take anticoagulants as prescribed, clotting and death may also occur.

For all of these reasons, bypass surgery tends to be favored for diabetics. However, bypass surgery carries a great risk of stroke--which is also profoundly disabling and can result in death. There would be tremendous advantage in finding the right kind of stent that doesn't have the risk of clot formation that kills a significant, although small number of diabetics who receive stents every year.

The kind of stent that makes a difference for diabetics, the FREEDOM study at New York University has found, is a cobalt–chromium everolimus-eluting stent, cobalt and chromium the alloy used to make the stent, and everolimus the drug with which it is coated. In their study of 24,015 diabetic patients who received either bypass surgery or stents, they found that:

• Coronary artery bypass surgery is more less likely to result in death of the patient than percutaenous intervention with bare metal stents, or with paclitaxel-eluting stents (Taxus Express, Taxus Liberté, Boston Scientific), which are not widely available in the US, or with sirolimus-eluting stents (Cypher, Cypher Select, Cypher Select Plus, Cordis), not all of which are always available.
• Stent procedures are not more likely to result in death when the surgeon uses the previously mentioned cobalt–chromium everolimus-eluting stent or a the zotarolimus-eluting stents (Endeavor, Endeavor Resolute, Endeavor Sprint, Medtronic), or the platinum–chromium everolimus-eluting stents (Promus, Promus Element, Boston Scientific). 

See Also: DIGAMi 1: New Study Says Diabetics Need Insulin, Not Pills, To Recover From Heart Attacks

You don't want to be lying on the surgical table when your doctor tells the surgical nurse, give me the cheap one--which is exactly what happened to me, and I had a cardiac arrest in the recovery room. If you have diabetes, ask your doctor whether or not receiving drug-eluting stents, and ask for a second opinion if the answer is no.