The most publicized form of treatment for atherosclerosis is surgery, the usual form involving surgical excision or stripping of the atheromatous intimal lining of some of the larger arteries, such as the carotid arteries in the neck. Bypass surgery can sometimes be performed on the heart by creating a new vascular blood supply in order to circumvent a constricted or blocked coronary artery. A similar type procedure has been used in the femoral arteries in the legs.

This operation involves bypassing the occluded portions of the three major coronary arteries with grafts made out of a vein that had been taken from the patient's leg. The operation is a temporary measure that treats symptoms for a limited time and cannot cure arteriosclerosis, which is a chronic, progressive disease.

Due to its great success in helping the chest pains, the operation has had a very enthusiastic response. It has become so popular that some physicians recommend surgery after diagnostic tests on patients who are really in no discomfort, but show slight irregularities in electrocardiogram readings and the x-ray reveals narrowing of the coronary arteries. This surgery is a temporary measure, which is most certainly not recommended by a great many physicians.

At first there were hopes that bypass surgery would not only relieve chest pain (angina pectoris) of heart disease and allow the patient more activity, plus prevent future heart attacks and deterioration of the heart muscle, but would also prolong the patient's life. There have not been any studies that demonstrate the operation prolongs life. In fact, there is a good deal of evidence to the contrary, of significant damage to the heart that involves long-term risk and actually accelerates the progression of coronary artery disease.

It is estimated this year that over 125,000 Americans will have the bypass operation, As far as fatalities connected with this type of operation are concerned, it is very difficult to arrive at accurate figures. This is mainly because hospitals are not required to report the figures, so consequently, all tabulations are derived only from sources who cooperate.

Because of this, it could be assumed that it is probable many hospitals with high rates of fatalities would not voluntarily report. Nor do the hospitals report the deaths that occur after the surgeries when the patients go home, within weeks of the discharge. The actual numbers are hard to net. The hospitals that perform operations as a more or less prophylactic measure, where the patient is in exceptionally good health and not a critical state, thus having a far better chance of surviving and recovering from the operation, are more prone to report.

It is estimated the expenditure for bypass surgery in 1979 was well over 3 billion dollars. In 1986 it was about a 100 billion dollar a year industry, in 1995 about 300 billion dollars or more. Who knows what the numbers are today.

In some controlled studies, comparing patients treated surgically versus those treated with drugs, there is shown no evidence of increased survival or lowered risk of heart attack as a result of surgery.

Most such studies show the main benefit of surgery is the relief of chest pain and increased tolerance of exercise and activity. One report shows up to.

• 12 percent of the patients undergoing bypass surgery die during the operation, or shortly thereafter

• 10 percent die within one year of the surgery

• Within two years of the surgery, another 18 percent have died.

• Of the remaining survivors, some 25 percent of the patients develop complications such as pulmonary embolism, pericarditis., pleuritis and hemorrhage.

• An additional 25 percent find their arteries reclogging within a year and this, of course, means another bypass operation.

According to this report, about 40 percent of the patients who have had the by-pass operation have died within two years and 50 percent of the survivors have developed further problems. Some of the remaining survivors are unable to have an additional bypass operation because clogged portions of critical arteries, such as the carotid (which supplies blood to the brain) are too critical for another bypass surgery.

A study released by the Veterans Administration Hospital of Little Rock, Arkansas, has probably caused the most uproar. This study stated the survival rate after 3 years for comparable patients treated with surgery was identical to those treated medically. A number of surgeons retaliated to this claim by stating that the low survival rate was due to the poor quality of open heart surgery that is performed in many hospitals; another comment was that even if the comparison is true, after the surgery patients have a much better "quality of life."

There are a number of hazards to the operation. Some patients die or have heart attacks at the time of surgery, and others suffer accelerated deterioration of the arteries being bypassed. Another hazard is a high rate of graft occlusions; this leads to heart attacks and the re-appearance of severe chest pains a few years later because of the progressive nature of the disease which could be and sometimes is accelerated due to the surgery. It is estimated that anywhere from 5 to 40 percent of the patients experience a heart attack during or after the surgery.

It is further estimated that 15 to 30 percent of vein grafts become occluded within one year of surgery. If the grafts become occluded, the patient is in a worse situation than before surgery, because he/she has now lost whatever arterial opening he/she had before, so consequently faces a greater risk of heart attack. Pathology reviews show that the grafts used in bypass block up about 10 times faster than normal arteries.

Mortality rates or death during surgery, or soon afterwards, are reported at about 2 to 12 percent. Some centers have reported the lower rates, but it seems safe to say the mortality rates are between 7 and 12 percent, this figure being dependent upon just where the surgery was performed. Most reports indicate that a hospital doing 200 or more operations a year has a lower fatality rate than a hospital doing less operations. In other words, the experience of the surgeon and his staff has a great deal to do with the overall success.