April 2019 digital edition

is going to become important.
When a plaque happens, it is not one
plaque in one artery. There will be multiple
plaques in one artery or there will be
multiple vessels affected. How do you
make the choice between one long stent
and two short ones, particularly if the
plaque is in a bifurcation of arteries?
Initially, we had to depend on simple
angiography. You got black and white
shadows on a background; it’s what we call
a luminogram and you judge visually and
say it looks to be about 20 mm, you don’t
measure. So, let’s put a 20 mm device.
Today, it is much more precise and critical,
so you have techniques like IVUS and OCT,
and then you see the inside of the vessel,
and you see where the vessel is more or less
healthy. And that’s your landing zone, and
defines the length of the stent very precisely
in mm. So, there is a lot of precision
introduced by the imaging techniques.
treatment. But in the last 15 years, we realised that we should
treat the lesions that really need to be treated. So, you have
to do pressure wire studies and prove that this is the lesion
which is ischemic. That has slowed down the use and misuse
of the stent. That’s one thing.
In countries like India and China, naturally, the people
propose the PCI (percutaneous coronary intervention) and
stenting and the patient often agrees because it is less
invasive. In Europe, we have a dialogue with the patient, and
we say, surgery may be more invasive but in the long term, it
will be better. That debate is still very, very active and will take
a few more years, or a decade, because in the meantime,
pharma is coming back. What you have in pharma is PCSK-9,
monoclonal antibodies against PCSK-9. And for the first time,
not only can you block the progression of the disease, but you
can also cause regression. So, I think that is something which
Dr Patrick Serruys
PHOTO: UMESH GOSWAMI
Now for the patient, who has to pay for
the procedure, the charges often depend
on the number of stents that are put. So,
the government will say you cannot charge
more than Rs 8,000 or 10,000 per stent.
But if the patient needs three stents, then
that’s three times the number. How much
does that play on a cardiologist’s mind
when he takes the decision?
It’s a very important question. Obviously,
surgery is expensive, certainly in western
countries where a surgeon can easily charge
$10,000 to 20,000 for surgery. Then, there
is the heart-lung machine, the perfusionist,
the anaesthetist, three, four, five days in the
hospital and so on. With angioplasty, there is
no need for anaesthesia, no perfusionist, no
heart-lung machine. We may need to sedate
the patient a little bit. And you could put
many stents in one session. So, in terms of
cost-effectiveness, we are already more costeffective
than the surgeon. Also, in Europe,
mass production and purchase by large
healthcare organisations have brought the
stent prices down to about 250 Euros. Now
the Indian government has also decided to
put a price cap, which is a good thing.
If I could take you in another direction,
internal carotid artery stenting must have
April 2019 / FUTURE MEDICINE / 45