11/7/2014

Coronary Artery Bypass Grafting

CoronaryArteryBypassGrafting
Author:RHBilal,MBBS,MRCSChiefEditor:RichardALange,MDmore...
Updated:Apr4,2014

PracticeEssentials
Coronaryarterybypassgrafting(CABG)isperformedforpatientswithcoronaryarterydisease(CAD)toimprove
qualityoflifeandreducecardiacrelatedmortality.

Indications
ClassIindicationsforCABGfromtheAmericanCollegeofCardiology(ACC)andtheAmericanHeartAssociation
(AHA)areasfollows[1,2]:
Leftmaincoronaryarterystenosis>50%
StenosisofproximalLADandproximalcircumflex>70%
3vesseldiseaseinasymptomaticpatientsorthosewithmildorstableangina
3vesseldiseasewithproximalLADstenosisinpatientswithpoorleftventricular(LV)function
1or2vesseldiseaseandalargeareaofviablemyocardiuminhighriskareainpatientswithstableangina
>70%proximalLADstenosiswitheitherejectionfraction<50%ordemonstrableischemiaonnoninvasive
testing
OtherindicationsforCABGincludethefollowing:
Disablingangina(ClassI)
OngoingischemiainthesettingofanonSTsegmentelevationMIthatisunresponsivetomedicaltherapy
(ClassI)
Poorleftventricularfunctionbutwithviable,nonfunctioningmyocardiumabovetheanatomicdefectthatcan
berevascularized
CABGmaybeperformedasanemergencyprocedureinthecontextofanSTsegmentelevationMI(STEMI)in
caseswhereithasnotbeenpossibletoperformpercutaneouscoronaryintervention(PCI)orwherePCIhasfailed
andthereispersistentpainandischemiathreateningasignificantareaofmyocardiumdespitemedicaltherapy.

Contraindications
CABGisnotconsideredappropriateinasymptomaticpatientswhoareatalowriskofMIordeath.Patientswhowill
experiencelittlebenefitfromcoronaryrevascularizationarealsoexcluded.
Althoughadvancedageisnotacontraindication,CABGislesscommonlyperformedintheelderly.Becauseelderly
patientshaveashorterlifeexpectancy,CABGmaynotnecessarilyprolongsurvival.Thesepatientsarealsomore
likelytoexperienceperioperativecomplicationsafterCABG.

Preproceduralevaluation
BeforeCABG,thepatientsmedicalhistoryshouldbecarefullyexaminedforfactorsthatmightpredisposeto
complications,suchasthefollowing:
RecentMI
Previouscardiacsurgeryorchestradiation
Conditionspredisposingtobleeding
Renaldysfunction
CerebrovasculardiseaseincludingcarotidbruitsandTIA
Electrolytedisturbancesthatmightpredisposethepatienttodysrhythmias
Infection,includingurinarytractinfectionanddentalabscesses
Respiratoryfunction,includingthepresenceofCOPDorinfection[3]
Routinepreoperativeinvestigationsincludethefollowing[3]:
Fullbloodcount(abnormalitiescorrected)
Clottingscreen
Creatinineandelectrolytes(abnormalitiescorrectedanddiscussedwiththeanesthetist)
Liverfunctiontests
ScreeningformethicillinresistantStaphylococcusaureus
Chestradiography
ECG
Echocardiographyorventriculography(toassessLVfunction)
Coronaryangiography(todefinetheextentandlocationofCAD)

Premedication
Theaimsofpremedicationaretominimizemyocardialoxygendemandsbyreducingheartrateandsystemicarterial
pressureandtoimprovemyocardialbloodflowwithvasodilators.Drugsthatshouldbecontinueduptothetimeof
surgeryareasfollows:
Betablockers,calciumchannelblockers,andnitrates
Aspirin

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Agentsgivenareasfollows:
Temazepamimmediatelypreoperatively
Midazolam,asmallIVdoseintheoperatingroombeforearteriallineinsertion
Eachpatientshouldbecrossmatchedwith2unitsofblood(forsimplecases)or6unitsofblood,freshfrozen
plasma,andplatelets(forcomplexcases).[3,4,5]Tranexamicacid(bolus1gbeforesurgicalincisionfollowedbyan
infusionof400mg/hrduringsurgery)maybeconsideredtoreducepostoperativemediastinalbleedingandblood
product(ie,redbloodcellandfreshfrozenplasma)use[6]

Anesthesia
Cardiacsurgerymakesuseofthefollowing2formsofneuraxialblockade:
Intrathecalopioidinfusion
Thoracicepiduralanesthesia(generallyalowdoselocalanesthetic/opioidinfusion)

Monitoring
Inadditiontothestandardanestheticmonitoring(ECG,pulseoximetry,nasopharyngealtemperature,urineoutput,
gasanalysis),specificmonitoringrequirementsforcardiacsurgeryincludethefollowing:
Invasivebloodpressure
Centralvenousaccess
Transesophagealechocardiography(TEE)
Neurologicmonitoring

Technique
Sitesfromwhichtheconduitcanbeharvestedincludethefollowing:
Saphenousvein
Radialartery
Leftinternalthoracic(mammary)artery(LITA)
Rightinternalthoracic(mammary)artery(RITA)
Rightgastroepiploicartery
Inferiorepigastricartery
Splenicartery
TheusualincisionforCABGisamidlinesternotomy,althoughananteriorthoracotomyforbypassoftheLADor
lateralthoracotomyformarginalvesselsmaybeusedwhenanoffpumpprocedureisbeingperformed.
Cardiopulmonarybypass,cardioplegicarrest,andplacementofgraftfollows.
AlternativeapproachestoCABGincludethefollowing:
OffpumpCABG
TotallyendoscopicCABG
Hybridtechnique(bypassplusstenting

Imagelibrary

Mediansternotomy

Background
Coronaryarterybypassgrafting(CABG)isperformedforpatientswithcoronaryarterydisease(CAD)toimprove
qualityoflifeandreducecardiacrelatedmortality.CADistheleadingcauseofmortalityintheUnitedStates,
Europe,andAustralia.[7]Additionally,itisthemostcommoncauseofheartfailure.[8]
CABGwasintroducedinthe1960swiththeaimofofferingsymptomaticrelief,improvedqualityoflife,andincreased
lifeexpectancytopatientswithCAD.[9,10]Bythe1970s,CABGwasfoundtoincreasesurvivalratesinpatientswith
multivesseldiseaseandleftmaindiseasewhencomparedwithmedicaltherapy.[11]
Despitetheseinitialpositiveresults,theEuropeanCoronarySurgeryStudyconductedinthe1970sindicatedthatthe
significantimprovementin5yearsurvivalrateswithCABGwasnotapparentinthesubsequent5years.[12]
Nonetheless,CABGbecamearoutineoperationinpatientswithCAD.

Indications
CABGisperformedforbothsymptomaticandprognosticreasons.IndicationsforCABGhavebeenclassifiedbythe
AmericanCollegeofCardiology(ACC)andtheAmericanHeartAssociation(AHA)accordingtothelevelofevidence
supportingtheusefulnessandefficacyoftheprocedure[1,2]:

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ClassIConditionsforwhichthereisevidenceand/orgeneralagreementthatagivenprocedureortreatment
isusefulandeffective
ClassIIConditionsforwhichthereisconflictingevidenceand/oradivergenceofopinionaboutthe
usefulnessorefficacyofaprocedureortreatment
ClassIIaWeightofevidenceoropinionisinfavorofusefulnessorefficacy
ClassIIbUsefulnessorefficacyislesswellestablishedbyevidenceoropinion
ClassIIIConditionsforwhichthereisevidenceand/orgeneralagreementthattheprocedure/treatmentis
notusefuloreffective,andinsomecasesitmaybeharmful
IndicationsforCABGasdetailedbytheACCandtheAHA[1,2]arelistedinTable1below.
Table1.ACC/AHAIndicationsforCoronaryArteryBypassGrafting(OpenTableinanewwindow)

Indication

Asymptomatic
orMild
Angina

StableAngina

Unstable
Angina/
NSTEMI

PoorLeft
Ventricular
Function

Leftmainstenosis>50% ClassI

ClassI

ClassI

ClassI

StenosisofproximalLAD ClassI
andproximalcircumflex
>70%

ClassI

ClassI

ClassI

3vesseldisease

ClassI

ClassI

2vesseldisease

ClassIifthereislargeareaofviable
myocardiuminhighriskarea

ClassI,with
proximalLAD
stenosis
ClassIIb

ClassIIaifthereismoderateviablearea
andischemia

With>70%proximalLAD ClassIIa
stenosis
InvolvingproximalLAD

ClassIwitheitherejectionfraction<
50%ordemonstrableischemiaon
noninvasivetesting

ClassIIa

ClassIifthereislargeareaofviable
myocardiuminhighriskarea

ClassIIb

ClassI

ClassIIb

1vesseldisease

ClassIIa,ifthereisviablemoderatearea
andischemia

With>70%proximalLAD ClassIIa
stenosis
InvolvingproximalLAD

ClassIIa

ClassIIa

ClassIIb

ACC=AmericanCollegeofCardiologyAHA=AmericanHeartAssociationLAD=leftanteriordescending
(artery)NSTEMI=nonSTsegmentelevationmyocardialinfarction.
OtherindicationsforCABGincludethefollowing:
Disablingangina(ClassI)
OngoingischemiainthesettingofanonSTsegmentelevationmyocardialinfarctionthatisunresponsiveto
medicaltherapy(ClassI)
Poorleftventricularfunctionbutwithviable,nonfunctioningmyocardiumabovetheanatomicaldefectthatcan
berevascularized
CABGmaybeperformedasanemergencyprocedureinthecontextofanSTsegmentelevationmyocardial
infarction(STEMI)incaseswhereithasnotbeenpossibletoperformpercutaneouscoronaryintervention(PCI)or
wherethisprocedurehasfailedandthereispersistentpainandischemiathreateningasignificantareaof
myocardiumdespitemedicaltherapy.
OtherindicationsforCABGinthesettingofSTEMIareventricularseptaldefectrelatedtomyocardialinfarction,
papillarymusclerupture,freewallrupture,ventricularpseudoaneurysm,lifethreateningventriculararrhythmias,and
cardiogenicshock.
Table2belowshowstherecommendationsfortreatmentofpatientswithacuteheartfailureinthesettingofacute
myocardialinfarction(AMI).
Table2.TreatmentRecommendationsforPatientswithAcuteHeartFailureinSettingofAcuteMyocardialInfarction
(OpenTableinanewwindow)
Classof
levelof
Recommendation Evidence
PatientswithNSTEACSorSTEMIandunstablehemodynamicsshould
immediatelybetransferredforinvasiveevaluationandtargetvessel
revascularization

ClassI

Immediatereperfusionisindicatedinacuteheartfailurewithongoingischemia

ClassI

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EchocardiographyshouldbeperformedtoassessLVfunctionandexclude
mechanicalcomplications

ClassI

Emergencyangiographyandrevascularizationofallcriticallynarrowedarteriesby
PCI/CABGasappropriateisindicatedinpatientsincardiogenicshock

ClassI

IABPinsertionisrecommendedinpatientswithhemodynamicinstability
(particularlythoseincardiogenicshockandwithmechanicalcomplications)

ClassI

SurgeryformechanicalcomplicationsofAMIshouldbeperformedassoonas
possiblewithpersistenthemodynamicdeteriorationdespiteIABP

ClassI

EmergencysurgeryafterfailureofPCIorfibrinolysisisindicatedonlyinpatients
withpersistenthemodynamicinstabilityorlifethreateningventriculararrhythmia
duetoextensiveischemia(leftmainorsevere3vesseldisease)

ClassI

Ifpatientcontinuestodeterioratewithoutadequatecardiacoutputtopreventend
organfailure,temporarymechanicalassistance(surgicalimplantationof
LVAD/BiVAD)shouldbeconsidered

ClassIIa

Routineuseofpercutaneouscentrifugalpumpsisnotrecommended

ClassIII

AMI=acutemyocardialinfarctionBiVAD=biventricularassistdeviceCABG=coronaryarterybypassgrafting
IABP=intraaorticballoonpumpLV=leftventricleLVAD=leftventricularassistdeviceNSTEACS=nonST
segmentelevationacutecoronarysyndromePCI=percutaneouscoronaryinterventionSTEMI=STsegment
elevationmyocardialinfarction.
Specialrecommendationsinpatientswithcomorbiditiesarepresentedinthetablesbelow.
Table3.SpecificTreatmentRecommendationsforCoronaryArteryDiseaseinPatientswithMildtoModerate
ChronicKidneyDisease(OpenTableinanewwindow)
Recommendation

levelof
Evidence

CABGshouldbeconsidered,ratherthanPCI,whenextentofCADjustifiessurgical ClassIIa
approach,patientsriskprofileisacceptable,andlifeexpectancyisreasonable

OffpumpCABGmaybeconsideredratherthanonpumpCABG

ClassIIb

ForPCI,diseaseelutingstentmaybeconsidered,ratherthanbaremetalstent

ClassIIb

CABG=coronaryarterybypassgraftingCAD=coronaryarterydiseasePCI=percutaneouscoronary
intervention.
Table4.SpecificTreatmentRecommendationsforCoronaryArteryDiseaseinDiabeticPatients(OpenTableina
newwindow)
Recommendation

levelof
Evidence

InpatientspresentingwithSTEMI,primaryPCIispreferredoverfibrinolysisifitcan ClassI
beperformedwithinrecommendedtimelimits

InstablepatientswithextensiveCAD,revascularizationisindicatedtoimprove
MACCEfreesurvival

ClassI

Useofdrugelutingstentisrecommendedinordertoreducerestenosisandrepeat ClassI
targetvesselrevascularization

Inpatientsonmetformin,renalfunctionshouldbecarefullymonitoredafter
coronaryangiography/PCI

ClassI

CABGshouldbeconsidered,ratherthanPCI,whenextentofCADjustifiessurgical ClassIIa
approach(especiallymultivesseldisease)andpatientsriskprofileisacceptable

InpatientswithknownrenalfailureundergoingPCI,metforminmaybestopped48
hoursbeforeprocedure

ClassIIb

Systematicuseofglucoseinsulinpotassiumindiabeticpatientsundergoing
revascularizationisnotindicated

ClassIII

CABG=coronaryarterybypassgraftingCAD=coronaryarterydiseaseGIK=glucoseinsulinpotassium
MACCE=majoradversecardiacandcerebraleventPCI=percutaneouscoronaryinterventionSTEMI=ST
segmentelevationmyocardialinfarction.
Table5.RecommendationsforCombiningValveSurgeryandCoronaryArteryBypassGrafting(OpenTableina
newwindow)
Recommendation

levelof
Evidence

CABGisrecommendedinpatientswithprimaryindicationforaortic/mitralvalve
surgeryandcoronaryarterystenosis=70%

ClassI

CABGshouldbeconsideredinpatientswithprimaryindicationforaortic/mitral
valvesurgeryandcoronaryarterystenosis5070%

ClassIIa

MitralvalvesurgeryisindicatedinpatientswithprimaryindicationforCABGand
severeischemicmitralregurgitationandEF>30%a

ClassI

Mitralvalvesurgeryshouldbeconsideredinpatientswithprimaryindicationfor
CABGandmoderateischemicmitralregurgitation,providedthatvalverepairis
feasibleandperformedbyexperiencedoperators

ClassIIa

Aorticvalvesurgeryshouldbeconsideredinpatientswithprimaryindicationfor

ClassIIa

Incombinationwithvalvesurgery:

IncombinationwithCABG:

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CABGandmoderateaorticstenosis(meangradient3050mmHg,Dopplervelocity
34m/sec,orheavilycalcifiedaorticvalveevenwithDopplervelocity2.53m/sec)
aDefinitionofseveremitralregurgitationisathttp://www.escardio.org/guidelines.

CABG=coronaryarterybypassgraftingEF=ejectionfraction.

Table6.CarotidRevascularizationinPatientsScheduledforCoronaryArteryBypassGrafting(OpenTableinanew
window)
Recommendation

levelof
Evidence

CEAorCASshouldbeperformedonlybyteamswithdemonstrated30day
combineddeathstrokeratesof<3%inpatientswithoutpreviousneurologic
symptomsand<6%inpatientswithpreviousneurologicsymptoms

ClassI

Indicationforcarotidrevascularizationshouldbeindividualizedafterdiscussionby
multidisciplinaryteam,includingneurologist

ClassI

Timingofprocedures(synchronousorstaged)shouldbedictatedbylocalexpertise ClassI
andclinicalpresentation,withmostsymptomaticterritorytargetedfirst

InpatientswithpreviousTIA/nondisablingstroke:
Carotidrevascularizationisrecommendedfor7099%carotidstenosis

ClassI

Carotidrevascularizationmaybeconsideredfor5069%carotidstenosisinmen
withsymptoms<6months

ClassIIb

Carotidrevascularizationisnotrecommendedifcarotidstenosis<50%inmenand ClassIII
<70%inwomen

InpatientswithnopreviousTIA/stroke:
Carotidrevascularizationmaybeconsideredinmenwithbilateral7099%carotid
stenosisor7099%carotidstenosisandcontralateralocclusion

ClassIIb

Carotidrevascularizationisnotrecommendedinwomenorpatientswithlife
expectancy<5years

ClassIII

CAS=carotidarterystentingCEA=carotidendarterectomyTIA=transientischemicattack.
Table7.ManagementofPatientswithAssociatedCoronaryandPeripheralArterialDisease(OpenTableinanew
window)
Recommendation

levelof
Evidence

InpatientswithunstableCAD,vascularsurgeryispostponedandCADtreatedfirst, ClassI
exceptwhenvascularsurgerycannotbedelayedbecauseoflifethreatening
condition

Betablockersandstatinsareindicatedpreoperativelyandcontinued
postoperativelyinpatientswithknownCADwhoarescheduledforhighrisk
vascularsurgery.

ClassI

ChoicebetweenCABGandPCIshouldbeindividualizedandassessedbyheart
teaminlightofpatternsofCAD,PAD,comorbidity,andclinicalpresentation

ClassI

Prophylacticmyocardialrevascularizationbeforehighriskvascularsurgerymaybe ClassIIb
consideredinstablepatientsiftheyhavepersistentsignsofextensiveischemicor
highcardiacrisk

CABG=coronaryarterybypassgraftingCAD=coronaryarterydiseasePAD=peripheralarterialdiseasePCI=
percutaneouscoronaryintervention.
Table8.ManagementofPatientswithRenalArteryStenosis(OpenTableinanewwindow)
Recommendation

levelof
Evidence

Functionalassessmentofrenalarterystenosisseverityusingpressuregradient
measurementsmaybeusefulinselectinghypertensivepatientswhobenefitfrom
renalarterystenting

ClassIIb

Routinerenalarterystentingtopreventdeteriorationofrenalfunctionisnot
recommended

ClassIII

Table9.RecommendationsforPatientswithChronicHeartFailureandSystolicLeftVentricularDysfunction
(EjectionFraction=35%),PresentingPredominantlywithAnginaSymptoms(OpenTableinanewwindow)

CABGisrecommendedforthefollowing:

Recommendation

levelof
Evidence

ClassI

Significantleftmainstenosis
Leftmainequivalent(proximalstenosisofbothleftanteriordescendingand
leftcircumflex)
Proximalleftanteriordescendingstenosiswith2or3vesseldisease

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CABGwithsurgicalventricularreconstructionmaybeconsideredinpatientswith
LVESVindex=60mL/m2andscarredleftanteriordescendingterritory

ClassIIb

PCImaybeconsideredinpresenceofviablemyocardiumifanatomyissuitable

ClassIIb

CABG=coronaryarterybypassgraftingLVESV=leftventricularendsystolicvolumePCI=percutaneous
coronaryintervention.
Table10.RecommendationsforPatientswithChronicHeartFailureandSystolicLeftVentricularDysfunction
(EjectionFraction=35%),PresentingPredominantlywithHeartFailureSymptoms(NoorMildAngina:Canadian
CardiovascularSociety12)(OpenTableinanewwindow)
levelof
Evidence

Recommendation
LVaneurysmectomyduringCABGisindicatedinpatientswithlargeLV
aneurysm

ClassI

CABGshouldbeconsideredinpresenceofviablemyocardium,irrespectiveof ClassIIa
LVESV

CABGwithSVRmaybeconsideredinpatientswithscarredLADterritory

ClassIIb

PCImaybeconsideredinpresenceofviablemyocardiumifanatomyis
suitable

ClassIIb

Revascularizationinabsenceofevidenceofmyocardialviabilityisnot
recommended

ClassIII

CABG=coronaryarterybypassgraftingLAD=leftanteriordescending(artery)LV=leftventricleLVESV=left
ventricularendsystolicvolumePCI=percutaneouscoronaryinterventionSVR=surgicalventricular
reconstruction.

Contraindications
CABGcarriesariskofmorbidityandmortalityandisthereforenotconsideredappropriateinasymptomaticpatients
whoareatalowriskofmyocardialinfarctionordeath.Patientswhowillexperiencelittlebenefitfromcoronary
revascularizationarealsoexcluded.
CABGisperformedinelderlypatientsforsymptomaticrelief.However,althoughageisnotacontraindication,CABG
islesscommonlyperformedinthisgroupofpatients.Becauseelderlypatientshaveashorterlifeexpectancy,CABG
maynotnecessarilyprolongsurvival.Thesepatientsarealsomorelikelytoexperienceperioperativecomplications
afterCABG.

TechnicalConsiderations
Bestpractices
EitherveinsorarteriesmaybeusedasconduitsforCABG.Thegreatandsmallsaphenousveinsarethemost
commonlyusedveingrafts,andtheinternalthoracic(mammary)arteryisthemostcommonlyusedartery.
Thedisadvantageofsaphenousveingraftsistheirdecliningpatencywithtime:1020%areoccluded1yearafter
surgerybecauseoftechnicalerrors,thrombosis,andintimalhyperplasia.Another12%ofveingraftsoccludeevery
yearfrom15yearsaftersurgery,and45%occludeeveryyearfrom610yearsaftersurgery.Veingraftocclusion
thatoccurs1ormoreyearsafterCABGisduetoveingraftatherosclerosis.At10yearsaftersurgery,only5060%
ofsaphenousveingraftsarepatent,andonlyhalfofthesearefreeofangiographicatherosclerosis.
Unlikesaphenousveingrafts,internalthoracicarterygraftsexhibitstablepatencyovertime.At10years,morethan
90%ofinternalthoracicarterygraftsarepatent.Theleftinternalthoracicarteryshouldbetheconduitusedwhenthe
leftanteriorcoronaryarteryisbypassed.
TechnicalrecommendationsforCABGarepresentedinTable11below.
Table11.TechnicalRecommendationsforCoronaryArteryBypassGrafting(OpenTableinanewwindow)
Recommendation

levelof
Evidence

Proceduresshouldbeperformedinhospitalstructureandbyteamspecializedin
cardiacsurgery,usingwrittenprotocols

ClassI

ArterialgraftingtoLADsystemisindicated

ClassI

CompleterevascularizationwitharterialgraftingtononLADcoronarysystemis
indicatedinpatientswithreasonablelifeexpectancy

ClassI

Minimizationofaorticmanipulationisrecommended

ClassI

Graftevaluationisrecommendedbeforedeparturefromoperatingtheater

ClassI

LAD=leftanteriordescending(artery).

Procedureplanning
Theformationofaheartteamenablesabalancedmultidisciplinarydecisionmakingprocess(seeTable12below).
Theinformedconsentprocessshouldbeseenasanopportunitytoenhanceobjectivedecisionmakingratherthan
solelyasalegalrequirement.Itisvitaltobeawarethatfactorssuchassex,race,availability,technicalskills,local
results,referralpatterns,andpatientpreferencemayaffectthedecisionmakingprocessindependentofclinical
findings.
Table12.MultidisciplinaryDecisionPathways,PatientInformedConsent,andTimingofIntervention(OpenTablein
anewwindow)

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AcuteCoronarySyndrome
Shock

Stable
Multivessel
Disease

Stable
with
Indication
forAdHoc
PCI

STEMI

NSTEACS

OtherACS

Multidisciplinary Not
decisionmaking mandatory

Notmandatory

Notrequired
forculprit
lesionbut
requiredfor
nonculprit
vessel(s)

Required

Required

According
to
predefined
protocols

Informed
consent

Oralwitnessed
informedconsent
maybesufficient
unlesswritten
consentislegally
required

Written
informed
consenta(if
timepermits)

Written
informed
consenta

Written
informed
consenta

Written
informed
consenta

Timeto
Emergency: Emergency:No
revascularization Nodelay
delay

Urgency:
Within24hif
possibleand
nolaterthan
72h

Urgency:Time Elective:No
constraints
time
apply
constraints

Elective:
Notime
constraints

Procedure

Proceedwith
interventionon
basisofbest
evidence/
availability
nonculprit
lesionstreated
accordingto
institutional
protocol

Proceedwith
interventionon
basisofbest
evidence/
availability
nonculprit
lesionstreated
accordingto
institutional
protocol

Proceed
with
intervention
according
to
institutional
protocol
definedby
localheart
team

Oral
witnessed
informed
consentor
family
consentif
possible
without
delay

Proceed
with
intervention
onbasisof
best
evidence/
availability

Proceedwith
interventionon
basisofbest
evidence/availability

Planmost
appropriate
intervention,
allowing
enoughtime
from
diagnostic
catheterization
tointervention

aMaynotapplytocountriesthatlegallydonotaskforwritteninformedconsent,althoughEuropeanSocietyof

CardiologyandEuropeanAssociationforCardiothoracicSurgerystronglyadvocatedocumentationofpatient
consentforallrevascularizationprocedures.

ACS=acutecoronarysyndromeNSTEACS=nonSTsegmentelevationacutecoronarysyndromePCI=
percutaneouscoronaryinterventionSTEMI=STsegmentelevationmyocardialinfarction.

Additionalinputfromgeneralpractitioners,anesthesiologists,geriatricians,andintensivistsmaybeneeded.
Hospitalswithoutasurgicalcardiacunitorwithinterventionalcardiologistsworkinginanambulatorysettingshould
refertostandardevidencebasedprotocolsdevisedincollaborationwithexpertinterventioncardiologistsorcardiac
surgeonsorshouldseektheopinionsofthesephysiciansforcomplexcases.Consensusonthebest
revascularizationtreatmentshouldbedocumented.Standardprotocolsthatareinaccordancewithcurrent
guidelinesmaybeusedtoobviateindividualcasereviewofeachdiagnosticangiogram.
AdhocPCIisatherapeuticinterventionalprocedurethatisperformeddirectlyafterthediagnosticprocedurerather
thanduringadifferentsession.Althoughitisconvenientandoftencosteffective,itisnotdesirableforallcases
somepatientsmaybeincategoriesforwhichCABGisthemostsuitablechoice.Theanatomiccriteriaandclinical
factorsthatdeterminewhetherapatientcanorcannotbetreatedbymeansofadhocPCIshouldbedefinedby
institutionalprotocolsdesignedbytheheartteam.

Complicationprevention
CerebrovascularcomplicationsareamajorcauseofmorbidityafterCABG.Themaincausesofthesecomplications
arehypoperfusionorembolicevents.Accordingly,itisimportanttomaintainadequatemeanarterialpressuresasa
prophylacticmeasureagainsthypoperfusion,althoughthereislittlethatcanbedonetoprotectthepatientfrom
embolicevents.

Outcomes
Inametaanalysisof8randomizedstudiesthatincludedatotalof3612adultpatientswithdiabetesandmultivessel
CAD,treatmentwithCABGsignificantlyreducedtheriskofallcausemortalityby33%at5years,ascomparedwith
PCI.ThisrelativeriskreductiondidnotdiffersignificantlywhenpatientswhounderwentCABGwerecomparedwith
subgroupsofpatientswhoreceivedeitherbaremetalstentsordrugelutingstents.[13,14]

ContributorInformationandDisclosures
Author
RHBilal,MBBS,MRCSSpecialistRegistrarinCardiothoracicSurgery,NorthWestCardiothoracicRotation,UK
RHBilal,MBBS,MRCSisamemberofthefollowingmedicalsocieties:BritishMedicalAssociation
Disclosure:Nothingtodisclose.

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Coauthor(s)
SarahMahmoodUniversityofLiverpoolFacultyofMedicine,UK
Disclosure:Nothingtodisclose.
MahvashZamanUniversityofLiverpoolFacultyofMedicine,UK
Disclosure:Nothingtodisclose.
BridieRO'NeillUniversityofManchester,UK
Disclosure:Nothingtodisclose.
DumborLaatehNgaage,MBBS,MS,FRCSED,FWACS,FETCS,FRCS(CTh)ConsultantCardiothoracic
Surgeon,BlackpoolVictoriaHospital,UK
Disclosure:Nothingtodisclose.
AndrewJDuncan,MBChB,FRCS(CTh)ConsultantCardiothoracicSurgeon,LancashireCardiacCentre,
VictoriaHospital,UK
Disclosure:Nothingtodisclose.
ChiefEditor
RichardALange,MDProfessorandExecutiveViceChairman,DepartmentofMedicine,Director,Officeof
EducationalPrograms,UniversityofTexasHealthScienceCenteratSanAntonio
RichardALange,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
Cardiology,AmericanHeartAssociation,andAssociationofSubspecialtyProfessors
Disclosure:Nothingtodisclose.
AdditionalContributors
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.
Acknowledgments
MedscapeReferencethanksDaleKMueller,MD,forassistancewiththevideocontributiontothisarticle.Dr
MuellerisClinicalAssociateProfessorofSurgery,SectionChief,DepartmentofSurgery,UniversityofIllinois
CollegeofMedicineCoMedicalDirector,ThoracicCenterofExcellence,ViceChair,Departmentof
CardiovascularMedicineandSurgery,OSFStFrancisMedicalCenterandDirector,AdultECMO,Cardiovascular
andThoracicSurgeon,HeartCareMidwest,SC.

References
1. [BestEvidence][Guideline]HillisLD,SmithPK,AndersonJL,BittlJA,BridgesCR,ByrneJG,etal.2011
ACCF/AHAGuidelineforCoronaryArteryBypassGraftSurgery:AReportoftheAmericanCollegeof
CardiologyFoundation/AmericanHeartAssociationTaskForceonPracticeGuidelines.Circulation.Nov7
2011[Medline].
2. EagleKA,GuytonRA,DavidoffR,EdwardsFH,EwyGA,GardnerTJ.ACC/AHA2004guidelineupdatefor
coronaryarterybypassgraftsurgery:summaryarticle:areportoftheAmericanCollegeof
Cardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines(CommitteetoUpdatethe1999
GuidelinesforCoronaryArteryBypassGraftSurgery).Circulation.Aug312004110(9):116876.[Medline].
3. ChikweJ,BeddowE,GlenvilleB.CardiothoracicSurgery.Oxford:OxfordUniversityPress2006.
4. MackayJH,ArrowsmithJE.CoreTopicsinCardiacAnaesthesia.Cambridge:CambridgeUniversityPress
2007.
5. GothardJ,KelleherA,HaxbyE.Cardiovascularandthoracicanaesthesia.Edinburgh:Butterworth
Heinemann2004.
6. WangG,XieG,JiangT,WangY,WangW,JiH,etal.TranexamicAcidreducesbloodlossafteroffpump
coronarysurgery:aprospective,randomized,doubleblind,placebocontrolledstudy.AnesthAnalg.Aug
2012115(2):23943.[Medline].
7. WorldHealthOrganisation.WHOGlobalInfobase.Availableathttps://apps.who.int/infobase/Mortality.aspx.
Accessed10/03/2011.
8. GheorghiadeM,BonowRO.ChronicheartfailureintheUnitedStates:amanifestationofcoronaryartery
disease.Circulation.Jan27199897(3):2829.[Medline].
9. vanDomburgRT,KappeteinAP,BogersAJ.Theclinicaloutcomeaftercoronarybypasssurgery:a30year
followupstudy.EurHeartJ.Feb200930(4):4538.[Medline].
10. KonstantinovIE.Thefirstcoronaryarterybypassoperationandforgottenpioneers.AnnThoracSurg.Nov
199764(5):15223.[Medline].
11. ElevenyearsurvivalintheVeteransAdministrationrandomizedtrialofcoronarybypasssurgeryforstable
angina.TheVeteransAdministrationCoronaryArteryBypassSurgeryCooperativeStudyGroup.NEnglJ
Med.Nov221984311(21):13339.[Medline].
12. VarnauskasE.TwelveyearfollowupofsurvivalintherandomizedEuropeanCoronarySurgeryStudy.N
EnglJMed.Aug111988319(6):3327.[Medline].

http://emedicine.medscape.com/article/1893992-overview

8/9

11/7/2014

Coronary Artery Bypass Grafting

13. VermaS,FarkouhME,YanagawaB,etal.Comparisonofcoronaryarterybypasssurgeryand
percutaneouscoronaryinterventioninpatientswithdiabetes:Ametaanalysisofrandomizedcontrolled
trials.TheLancet.Availableathttp://www.thelancet.com/journals/landia/article/PIIS22138587(13)70089
5/abstract.AccessedSeptember13,2013.
14. O'RiordanM.CABGReducesRiskofDeathvsPCIinDiabeticPatients.Medscape[serialonline].Available
athttp://www.medscape.com/viewarticle/810953.AccessedSeptember23,2013.
15. EuroscoreScoringSystem.Availableathttp://www.euroscore.org/euroscore_scoring.htm.AccessedMarch
24,2011.
16. WardHB,KellyRF.OPCABvsCABG:who,what,when,where?.Chest.Mar2004125(3):8156.[Medline].
17. DeweyTM,MackMJ.MyocardialRevascularizationwithoutCardiopulmonaryBypass.In:CohnL.Cardiac
SurgeryintheAdult.NewYork:McGrawHill2008:633654.
18. ChocronS,VandelP,DurstC,LalucF,KailiD,ChocronM,etal.Antidepressanttherapyinpatients
undergoingcoronaryarterybypassgrafting:theMOTIVCABGtrial.AnnThoracSurg.May
201395(5):160918.[Medline].
19. BrooksM.AntidepressantPriortoBypassMayReducePostopPain.MedscapeMedicalNews.Availableat
http://www.medscape.com/viewarticle/805336.AccessedJune11,2013.
20. ZohrehK,FarahAE,MehrabM,AbbasSO,AlirezaH,SorayaM.Comparisonofcompressionstockingwith
elasticbandageinreducingpostoperativeedemaincoronaryarterybypassgraftpatient.JVascNurs.Dec
200927(4):1036.[Medline].
21. ParolariA,AlamanniF,CannataA,NaliatoM,BonatiL,RubiniP.Offpumpversusonpumpcoronaryartery
bypass:metaanalysisofcurrentlyavailablerandomizedtrials.AnnThoracSurg.Jul200376(1):3740.
[Medline].
22. SongHK,PuskasJD.OffPumpCoronaryArteryBypassSurgery.In:KaiserLR,KronIL,SprayTL.Mastery
ofCardiothoracicSurgery.2nd.Philadelphia:LippincottWilliams&Wilkins.
23. MllerCH,PenningaL,WetterslevJ,SteinbrchelDA,GluudC.Offpumpversusonpumpcoronaryartery
bypassgraftingforischaemicheartdisease.CochraneDatabaseSystRev.Mar1420123:CD007224.
[Medline].
24. BonattiJ,SchachnerT,BonarosN,OhlingerA,DanzmayrM,JonetzkoP.Technicalchallengesintotally
endoscopicroboticcoronaryarterybypassgrafting.JThoracCardiovascSurg.Jan2006131(1):14653.
[Medline].
25. MishraYK,WasirH,SharmaKK,MehtaY,TrehanN.TotallyEndoscopicCoronaryArteryBypassSurgery.
AsianCardiovascThoracAnn.200614:447451.
26. GngoraE,SundtTMIII.MyocardialRevascularizationwithCardiopulmonaryBypass.In:CohnLh.Cardiac
SurgeryintheAdult.3rd.NewYork:McGrawHill2008:599632.[FullText].
27. RoachGW,KanchugerM,ManganoCM,NewmanM,NussmeierN,WolmanR,etal.Adversecerebral
outcomesaftercoronarybypasssurgery.MulticenterStudyofPerioperativeIschemiaResearchGroupand
theIschemiaResearchandEducationFoundationInvestigators.NEnglJMed.Dec191996335(25):1857
63.[Medline].
28. HigginsR,PerezTamayoRA.CoronaryArteryBypassGraftingUsingCardiopulmoaryBypass.In:Kaiser
LR,KronIL,SprayTL.MasteryofCardiothoracicSurgery.2nd.Philadelphia:LippincottWilliams&Wilkins
2007.
29. BuskoM.CABGtrumpsPCIforsurvivalinCADevenwithoutdiabetes.MedscapeMedicalNews[serial
online].December2,2013AccessedDecember17,2013.Availableat
http://www.medscape.com/viewarticle/815245.
30. KatzMH.EvolvingTreatmentOptionsinCoronaryArteryDisease.JAMAInternMed.Dec22013[Medline].
31. SipahiI,AkayMH,DagdelenS,BlitzA,AlhanC.CoronaryArteryBypassGraftingvsPercutaneous
CoronaryInterventionandLongtermMortalityandMorbidityinMultivesselDisease:Metaanalysisof
RandomizedClinicalTrialsoftheArterialGraftingandStentingEra.JAMAInternMed.Dec22013
[Medline].
MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/1893992-overview

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