CORONARY ARTERY BYPASS GRAFT (CABG) SURGERY
The objective of CABG is complete revascularization of the myocardium
Arteries with severe stenoses (> 50% diameter reduction) are bypassed, except those of small caliber (<
1mm in diameter)
Indications
class 3 or 4 chronic stable angina, either to improve prognosis and/or relieve symptoms
Unstable angina refractory to medical management
Acute ischemia or hemodynamic instability post-PTCA (rate of emergency surgery post-PTCA is 3-4%,
with 5-6% operative mortality)
Post-MI angina
Acute evolving infarction within 4-6 hours of onset
Ventricular arrhythmias with coronary disease
Markedly positive stress test before major intra-abdominal or vascular surgery
Ischemic pulmonary edema
Usually left main or triple vessel disease, impaired LV function (70% 2 year mortality managed
medically)
To improve survival in patients (even if asymptomatic)
1. Left main stenosis > 50% (annual mortality 10-15%)
2. Left main equivalent: > 70% stenosis of proximal left anterior descending (LAD) and proximal
circumflex artery (PCA)
3. Three vessel disease with ejection fraction (EF)< 50%
4. Three vessel disease with EF> 50% but significant inducible ischemia
5. One and two vessel disease with extensive myocardium at risk but lesions not amendable to
PTCA
Other
Significant coronary lesions accompanying other cardiac lesions requiring surgical correction
Congenital coronary anomalies
Approach to reading coronary angiograms
see selected angiograms in Colour Atlas (see Colour Atlas CS1-CS3)
Angiographic atherosclerotic stenoses are expressed as a percent reduction of the lumen diameter
compared to an area of adjacent normal vessel
The catheter usually is a size 6 French catheter (1.8 mm in diameter) -comparing the size of vessels to
the size of the catheter can help distinguish graftable from non-graftable (< 1 mm) vessels
Right coronary artery divides to posterior interventricular (PIV) artery (also known as posterior
descending artery) and posterolateral branches (PIV can be identified by the presence of septal
perforating branches)
Left main coronary artery divides to the LAD and circumflex (LAD can be identified by the presence of
septal perforating branches and its approach towards the apex)
Left ventriculogram assesses the global and regional contractile performance of the heart, and
presence and degree of MR
Surgical approach (see Figure 2)
Right coronary artery - common site of distal anastomosis is just before the bifurcation at the crux, or
directly to the posterior descending artery if the bifurcartion is diseased
left main coronary artery - not directly grafted because it is inaccessible without dividing the aorta and
pulmonary artery (therefore graft LAD and obtuse marginals of circumflex for left main stenosis)
left anterior descending (LAD) -distal anastomosis is usually placed from midpoint on; diagonal
branches > 1-1.5 mm in diameter are also bypassed especially if they are diseased
circumflex coronary artery - difficult to approach since located below great cardiac vein, therefore
bypass circumflex artery system by grafting to obtuse marginalbranches
Conduits for coronary bypass surgery
Saphenous vein grafts
At 10 years, 50% occluded, 25% stenotic, 25% angiographically normal
Internal thoracic (mammary) artery - anastomosed to LAD
At 10 years, 90-95% patency
increased 10-year patient survival
improved event-free survival (angina, MI)
No increase in operative risk
Contraindications: inadequate mammary blood flow, occluded abdominal aorta, chest wall irradiation,
avoid bilateral internal thoracic arteries in diabetics or obese patients.
Right gastroepiploic artery
Good long term patency
Usually long enough to bypass any of the 3 vessels
Concerns: cannot use as free graft, laparotomy incision (increased morbidity), arterial graft (therefore
vasoactive postoperatively)
Radial artery
Time consuming to harvest
Approximately 90% patency at 5 years
Prone to severe vasospasm postoperatively ("no touch" technique during harvest of the radial
artery pedicle) - avoid with CCB (Adalat XL 20 mg PO OD) for 6 months.
Redo bypass grafting
Operative mortality 2-3 times higher than first operation
10% perioperative MI rate
Reoperation undertaken only in symtomatic patients who have failed medical therapy and in
whom angiography has documented progression of the disease
increased risk with redo-sternotomy
Adhesions may result in laceration to aorta, RV, LITA and other bypass grafts (consider preop CT chest)
Myocardial protection is very important
Cardioplegia should be given through the aortic root through the new bypass grafts as
constructed and retrograde via the coronary sinus to protect ischemic areas
Distal and proximal incision of old atherosclerotic grafts should be undertaken as early as possible on
CPB to prevent atherosclerotic emboli down these grafts
consider using right or left IMA's, lesser or greater saphenous veins if available, or right gastroepiploic
artery
Only arteries that are > 1.5 mm in diameter should be grafted at the second operation
