Again please note that I am not a cardiologist, so take my comments with a grain of salt. I do work with stents in the rest of the body (anything below the neck and outside of the heart). I apologize that this will probably be long and rambling, since I’m not sure there was a specific question and haven’t seen the Widow Maker documentary. If there are any specific questions feel free to ask and I’m happy to answer (or defer if I simply don’t know).
I’m not up to date with all the literature regarding stents in the coronary arteries, but from what I remember, there was a lot of data initially suggesting that they are helpful, and more recently (in the past 5-10 years) more literature suggesting maybe they aren’t so helpful after all.
As a background, stents are used to keep open a blood vessel that is narrowed. Originally, they were developed in bigger vessels, and as an adjunct to angioplasty alone (using a small balloon to re-open a blood vessel that has been narrowed or occluded by clot, scar tissue, or calcium). Stents were originally made because after using a balloon, often there is a “recoil” effect where the vessel closes back down partially or completely, like rubber. Stents in general exert a radial force and hold open the vessel.
The problem is that stents are a foreign object and elicit an inflammatory response, which in the body means scar tissue and a chance of clotting. In big vessels this isn’t so much of a problem because it’s just small portion of the diameter (in a big pipe, a little gunk on the side doesn’t block it off). In the coronary arteries, which are only a few millimeters in size to begin with, this can be a big problem. And the biggest concern is that it causes a clot, which can cause a chain reaction, completely closing off the blood vessel. Instant, large or massive heart attack.
To combat this problem, patients are put on Aspirin and Plavix, which inhibit thrombosis (clotting). This puts them at risk for bleeding in any minor fall or trauma. Stents cost a lot more than balloons (and are reimbursed more). So you can see that while there are probably some real upsides (keeping a vital blood vessel open) there are also real downsides (cost of stent, risk of complication, cost of medication, risk of bleeding). Also add to the equation that we aren’t always sure the area stented is actually the problem in a heart attack or chest pain. Many doctors will put a stent in a vessel that looks bad on angiogram, even though there are no symptoms.
Bottom line, yes, in my opinion the value of stents is overrated and stents are probably overused. I personally use stents much less frequently than my cardiology and vascular surgery colleagues who perform similar procedures when working with vessels of that size (for me, mostly in the legs). But I do believe that PCI (percutaneous coronary intervention) has great value and is not going away until we have nanobots doing it for us.
ABMD does not make a stent. They make a device that assists the heart in supplying blood to the body during a heart attack, particularly during PCI when a stent might be placed. During a massive heart attack, the heart is often stunned and does not pump as well. This can be exacerbated during PCI when a balloon is used to open a vessel, during which time the vessel is completely blocked off. After the procedure, the Impella device can be left in to continue helping the heart as it recovers. In the past, this was accomplished with an intra-aortic balloon pump, which relied on expanding a balloon in the aorta (the outflow pipe of the heart) to fill space, then deflating the balloon to create a suction effect to suck out blood. This is relatively clunky and can be more traumatic to the aorta, and can block off other blood vessels during expansion and affect other organs, most commonly the kidneys. So whether stents are truly helpful or not it will take a major article clearly showing a detriment for it to stop being used, and even then cardiologists will still perform the same interventions, just not with stents (perhaps by sucking out clot or just ballooning). PCI is here to stay, and ABMD is an adjunct to PCI. I don’t think the risk of stents going defunct is even a question except that it might reduce potential buyouts if that seriously affects the big device makers.
@mauser, in general I believe physicians over-recommend screening tests like the stress echo, which on a population basis is probably not cost effective. But you are less likely to be sued if someone has an unnecessary procedure because of a screening test (hard to prove) than if someone drops dead but you didn’t screen for heart disease. If it were me or a family member, I would suggest that someone who is active and regularly stresses his or her heart and has no problems (chest pain or clearly decreasing tolerance) probably doesn’t need a stress echo. Someone who otherwise isn’t stressing the heart for physical or personal reasons probably should. Also, people with very high risk factors or other evidence of problems (for example calcium in the coronary arteries or carotid arteries on a CT for other reasons) might benefit as well. But please do speak with your doctor about it. I’m frequently asked to do procedures or tests on people who have no idea why they’re doing it, and I don’t think it really needs to be done. Also think about this, if there’s something you could recommend that could simultaneously reduce your chance of getting sued and increase your revenue, what might you be tempted to do?
I heard a rumor that a former president recently got a stress test for no reason other than being old when he was hospitalized for something unrelated. The test showed some questionable defect, resulting in a coronary angiogram, which led to stenting. In my opinion, the state of current medical malpractice lends itself to this kind of medicine.