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Early noncardiac complications of coronary artery bypass

graft surgery
Authors: Sary Aranki, MD, Rakesh M Suri, MD, DPhil
Section Editors: Gabriel S Aldea, MD, Donald Cutlip, MD
Deputy Editor: Gordon M Saperia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature rev iew current through: Apr 2020. | This topic last updated: Jan 31, 2019.
INTRODUCTION
The treatment of coronary heart disease has evolved significantly over the past several years
due in part to improvement in both surgical and percutaneous revascularization techniques. The
majority of patients with chronic stable angina are still treated with medical therapy; however,
revascularization with either coronary artery bypass graft surgery (CABG) or percutaneous
coronary intervention should be considered in several subgroups. (See "Chronic coronary
syndrome: Indications for revascularization".)
The major complications associated with CABG are death, myocardial infarction, stroke, wound
infection, prolonged requirement for mechanical ventilation, acute kidney injury, and bleeding
requiring transfusion or reoperation [1-4]. The short-term, particularly perioperative, noncardiac
complications that can occur following conventional CABG (using cardiopulmonary bypass) will
be reviewed here. Cardiac complications and perioperative mortality after CABG are discussed
separately. (See "Early cardiac complications of coronary artery bypass graft surgery" and
"Operative mortality after coronary artery bypass graft surgery".)
Off-pump and minimally invasive CABG are discussed separately. (See "Minimally invasive
coronary artery bypass graft surgery: Definitions and technical issues" and "Off-pump and
minimally invasive direct coronary artery bypass graft surgery: Clinical use".)
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PREVENTION OF COMPLICATIONS
Mechanisms — Many complications related to traditional techniques of cardiac surgery are

primarily the result of cardiopulmonary bypass (CPB). An important factor is aortic
instrumentation and manipulation, including cannulation, decannulation, and partial or complete
clamping and unclamping, which can result in embolization of atherosclerotic debris. Technical
errors in bypass graft construction that can lead to graft occlusion, primarily in saphenous vein
grafts, also may be important [5,6]. (See "Embolism from aortic plaque: Thromboembolism".)
Other factors that contribute to complications include:
● Global cardiac arrest

● Hypothermia
● Nonpulsatile bypass and artificial perfusion
● An intense "inflammatory" response to perfusion with artificial (nonendothelialized) surfaces
● The reintroduction of fat and particulate debris as well as procoagulant and proinflammatory
factors from the pericardial surgical field into the systemic circulation via the use of
cardiotomy (field) suction [7,8].
● The sternotomy and skin incision
● Conduit harvest
Minimal extracorporeal CPB — Off-pump coronary artery bypass graft surgery (OP CABG)
procedures are considered to be less invasive than full CPB. Data from randomized trials and
observational studies are conflicting as to whether or not there is an improvement in clinical
outcomes such as mortality and stroke with OP CABG. (See "Off-pump and minimally invasive
direct coronary artery bypass graft surgery: Clinical use", section on 'Off-pump CABG'.)
CPB systems designed to decrease the rates of the complications discussed above (particularly
stroke) have also been evaluated. One such device, the mini-extracorporeal circulation (MECC),
is a heparin bonded CPB circuit that requires a relatively small prime for the centrifugal pump,
and does not include either an open venous reservoir (which minimizes blood-air contact) or
direct reinfusion of cardiotomy suction from the pericardial space. This design has the potential
to limit the systemic inflammatory response seen with traditional CPB.
In an initial prospective trial, 300 CABG patients were randomly assigned to MECC or OP CABG
[9]. There were no differences between the two groups in operative mortality and morbidity,
transfusion rates, hospital stay, or serum levels of creatine kinase and inflammatory markers
including interleukin-6. In a study of 40 consecutive patients undergoing CABG who were
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randomly assigned to either MECC or standard CPB, the former was shown to be a safe
alternative [10].
Improvements in surgical technique — Improvements in surgical technique have led to a

steady reduction in morbidity after CABG, despite the fact that patients currently undergoing
CABG have higher-risk profiles. This was illustrated in a report that compared 5051 patients
undergoing CABG from 1986 to 1988 with 2793 patients undergoing CABG from 1993 to 1994
[1]. Although the patients in the latter period were at higher cardiovascular risk, the risk-adjusted
morbidity rate decreased from 14.5 to 8.8 percent with no change in risk-adjusted hospital
mortality (2.8 versus 2.9 percent). A later report that evaluated over 37,000 patients undergoing
CABG for multivessel disease in New York state between 1997 and 2000 found an in-hospital
mortality of only 1.8 percent [11].
The following are some of the improvements in technique that have reduced postoperative
complications:
● Complications related to aortic manipulation can be limited by routine, careful evaluation of

the ascending aorta using intraoperative transesophageal and epiaortic echocardiography
to identify mobile and intramural atheromatous disease, and to help define safe areas for
cannulation. Aortic manipulation also can be decreased using a "single-clamp" technique.
By avoiding the application of an additional partial occlusion clamp to construct proximal
anastomoses, neurologic complications can be reduced, although not eliminated [12].
● Advances have been made in the composition of cardioplegia fluid (eg, blood versus
crystalloid) as well as substrate enhancement with aspartate and glutamate and
superoxide radical scavengers. These advances, used in conjunction with integration of
different routes of cardioplegia administration (antegrade, retrograde, and down the newly
constructed grafts) to effect homogeneous delivery to all parts of the heart beyond coronary
artery blockages, have resulted in more optimal myocardial protection. As a result, the heart
can be safely arrested for as long as two hours with minimal cardiac dysfunction, allowing
precise repair of complex problems [13].
● Normothermic or near normothermic systemic perfusion is now routinely used. Avoiding

systemic hypothermia decreases coagulation abnormalities and organ dysfunction.
● Many of the complications of CABG are related to the biologic response of the body to
artificial perfusion and gas exchange through the nonendothelialized CPB circuit. Within
seconds of CPB, formed and unformed blood elements come into contact with the large
surface area of the CPB circuit. Despite anticoagulation with heparin, this interaction results
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in extensive activation of platelets, neutrophils, complement, cytokines, and the fibrinolytic

system, producing a complex and intense "inflammatory" response. Although these
responses are usually short-lived and leave no residual deficits, they can lead to long-
lasting cardiac, pulmonary, renal, and neurologic dysfunction in a subset of patients.
● Advances in perfusion technology and techniques and research in biomaterial sciences

have resulted in the application of more biocompatible CPB circuits, such as heparin-
bonded circuits. The use of these circuits has reduced the need for homologous
transfusion and decreased neutrophil and complement activation, resulting in reductions in
thromboembolic complications (including neurologic dysfunction), myocardial and
pulmonary dysfunction, and cost [14-19]. Elimination of cardiotomy suction is an important
adjunct by minimizing inflammation, thrombin and platelet activation, and the increase in
markers of neuronal injury [8].
● Active leukocyte depletion of transfused blood during CPB and of autologous saved blood
prior to reinfusion can reduce perioperative morbidity, particularly when more than three
blood transfusions are required [20]. (See "Leukoreduction to prevent complications of
blood transfusion".)
● Additional pharmacologic interventions and perfusion surface modifications to further

attenuate platelet, neutrophil, and complement activation and cytokine release are being
actively investigated. As an example, direct C5 inhibition with a recombinant, humanized
antibody during CPB blunts complement activation, proinflammatory byproducts, and
leukocyte activation, and may result in decreased myocardial injury, blood loss, and new
cognitive deficits [21]. (See "Regulators and receptors of the complement system".)
● Technical errors in bypass graft construction can lead to graft occlusion [5,6]. Such patients
should undergo emergency surgical re-exploration/revision or coronary angiography. Hybrid
operating room catheterization laboratories have been used to perform "completion
angiography" of bypass grafts, and fluorescent angiographic techniques can be performed
without angiography.
In a report of a novel technique, intraoperative angiography using fluorescent indocyanine

green dye resulted in graft revision (all but one saphenous vein grafts) for technical
problems in 4.2 percent of patients that would otherwise have gone unrecognized [5]. The
test took 2.2 minutes to perform. Further studies are required.
Medical therapy — The 2004 American College of Cardiology/American Heart Association

guidelines on bypass surgery issued general recommendations for preventive measures to
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minimize the risk of some of these complications [22]:
● Prophylactic antimicrobials to prevent surgical site infection
● Strict glycemic control (using an insulin infusion) during the perioperative period, which also
may reduce sternal wound infection.
● An antifibrinolytic agent is used in most CABG procedures to minimize bleeding
● Beta blockers, aspirin, and statins are indicated in many patients
The evidence supporting the efficacy of these therapies is presented separately. (See "Medical
therapy to prevent complications after coronary artery bypass graft surgery" and "Atrial fibrillation
and flutter after cardiac surgery", section on 'Prevention of atrial fibrillation and complications'
and 'Sternal wound infection and mediastinitis' below and 'Antifibrinolytic agents' below.)
In addition to these medical therapies, carotid duplex ultrasound may be performed to identify
severe carotid stenosis in patients with an audible bruit, severe peripheral artery disease, or a
previous stroke or transient ischemic attack. (See "Neurologic complications of cardiac surgery",
section on 'Risk factors'.)
Minimally invasive CABG — The preceding discussion applied to conventional CABG using
CPB. OP CABG has been evaluated as a minimally invasive approach. Clinical trials comparing
the two approaches have suggested that OP CABG may reduce morbidity but there is concern
about long-term graft patency. These issues, as well as patient selection for OP CABG, are
discussed elsewhere. (See "Off-pump and minimally invasive direct coronary artery bypass graft
surgery: Clinical use", section on 'Off-pump CABG'.)
BLEEDING
Approximately 30 percent of patients require a blood transfusion after coronary artery bypass
graft surgery (CABG) [23]. In addition, bleeding requiring reoperation is associated with large
increases in transfusion requirements and intensive care unit and hospital stays. Rates of
reoperation have ranged from 4 to 6 percent [24], although one study found that, during 1995 to
1997, there was a reduction in the rate of reoperation to 2 percent [25]. Although reoperation is
usually performed in the operating room, reoperation in the intensive care unit is feasible [26].
Risk factors — In order to preoperatively identify patients at high risk for requiring blood, one
study of 1007 patients undergoing a first CABG developed a prediction rule based upon data
from two-thirds of the sample and prospectively applied it to the remaining one-third [23].
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Independent factors predicting the need of transfusion were lower preoperative hemoglobin,
lower weight, older age, and female gender.
Additional risk factors for perioperative transfusion include preoperative use of antiplatelet or
antithrombotic drugs, reoperation, acquired or congenital clotting/coagulation abnormalities,
complex procedures, and emergency operations [27].
Antiplatelet agents — Antiplatelet agents have a variable effect on bleeding risk.
● Aspirin – Evidence suggests that late (less than five days prior to surgery) discontinuation of
aspirin did not decrease adverse cardiovascular events but did increase the risk of
perioperative blood transfusion [28]. It is generally recommended that aspirin be started in
the early postoperative period to reduce both mortality and morbidity [29]. However, with
increasing experience, some surgeons recommend continuation of aspirin throughout the
preoperative period. The possible risk of aspirin therapy in patients undergoing CABG,
including recommendations for the timing of aspirin therapy, is discussed separately. (See
"Medical therapy to prevent complications after coronary artery bypass graft surgery", section
on 'Aspirin' and "Perioperative medication management", section on 'Aspirin'.)
● Clopidogrel – Clopidogrel therapy within five days of CABG is associated with an increased
bleeding risk. Two reports comparing the bleeding risk with or without recent clopidogrel
use in (mostly) stable patients undergoing CABG are available [30,31]. The larger of the two
is a retrospective observational study of 1572 consecutive patients who underwent
nonemergent off-pump CABG; 281 (18 percent) had either received a 300 mg loading dose
before PCI or had been on oral clopidogrel within seven days of surgery [31]. Patients with,
compared to those without, recent clopidogrel use had a significantly increased need for
packed red blood transfusion and of reoperation for bleeding (6.4 versus 1.4 percent, odds
ratio 5.1 on multivariable analysis). There was no difference in operative mortality between
the two groups (1.4 percent). (See "Off-pump and minimally invasive direct coronary artery
bypass graft surgery: Clinical use".)
However, among those patients who receive clopidogrel within five to seven days of surgery,
the risk of bleeding is more likely related to the residual antiplatelet effect of the drug than
the number of days since the last dose. In a prospective study of 100 patients who received
clopidogrel within five days of off pump CABG, blood loss (and transfusion requirement)
was significantly greater in patients in the third tertile of the percentage of platelet inhibitory
response to clopidogrel (greatest residual clopidogrel effect), as assessed by
thromboelastography, compared to those in the first and second tertiles (914 versus 623
and 683 mL, respectively) [32]. In multivariate analysis, discontinuation date did not
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significantly predict either the degree of blood loss or transfusion requirement. (See
"Platelet function testing", section on 'Thromboelastography (TEG) and ROTEM'.)
● Patients taking clopidogrel referred for CABG have generally been placed on it either for
prevention of cardiovascular events after an acute coronary syndrome or for the prevention of
stent thrombosis after stent placement. In these settings, discontinuation of clopidogrel
prior to the recommended duration places the patient at increased risk. Thus, the timing of
discontinuation of clopidogrel requires consideration of both the benefit (less bleeding) and
risk (increased rate of ischemic events) of its discontinuation. The 2004 American College
of Cardiology/American Heart Association guidelines on CABG and the 2008 American
College of Chest Physicians guidelines on the primary and secondary prevention of
coronary heart disease recommend five (preferably seven) days off clopidogrel before CABG
[33,34]. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients"
and "Antiplatelet agents in acute non-ST elevation acute coronary syndromes", section on
'Bleeding risk'.)
The decision whether to perform CABG within five days of clopidogrel use in an individual
patient requires an analysis of the risks and benefits. Local institutional and surgeon
preferences need to be taken into account.
● Potent P2Y12 receptor blockers – Bleeding at the time of CABG is also a concern for patients
receiving prasugrel and ticagrelor, both of which are potent P2Y12 receptor blockers. In the
major randomized trials comparing these agents to clopidogrel, the rates of major bleeding
were similar to or higher with the more potent agent [35,36].
● Glycoprotein (GP) IIb/IIIa inhibitors – The effect of GP IIb/IIIa antagonists on bleeding risk is
less clear. One report evaluated surgical outcomes in 85 patients in the EPILOG and
EPISTENT trials who required emergency CABG after abciximab therapy for percutaneous
coronary intervention [37]. These patients, compared to those not treated with abciximab,
had no significant increase in major blood loss or red cell transfusion and no reduction in
the use of optimal internal mammary artery grafts. However, abciximab-treated patients
were more likely to require surgical re-exploration for bleeding (12 versus 3 percent).
Stopping and restarting P2Y12 receptor blocker — The decision as to when to

discontinue platelet P2Y12 receptor blocker therapy prior to CABG must balance the perioperative
risks of bleeding (discussed above) while on and acute ischemic events while off dual
antiplatelet therapy.
The possible role of bridging therapy with cangrelor, an intravenous P2Y12 receptor blocker with
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a half-life of three to six minutes, was evaluated in the BRIDGE trial [38]. In BRIDGE, 210 patients
awaiting CABG with an acute coronary syndrome or treated with a coronary stent and receiving
either clopidogrel or prasugrel were randomly assigned to either cangrelor or placebo after
discontinuation of the thienopyridine. Study drug was continued for at least 48 hours and was
then discontinued one to six hours before CABG. As expected, cangrelor, compared to placebo,
was associated with a significantly lower level of platelet reactivity (platelet reactivity units <240,
98.8 versus 19.0 percent). However, it was not associated with any significant difference in
CABG surgery-related bleeding (11.8 versus 10. 4 percent, respectively). As BRIDGE did not test
the hypothesis that bridging therapy would improve outcomes compared to either early
discontinuation or continuation of P2Y12 receptor blocker therapy, we do not recommend such an
approach (cangrelor is not commercially available).
There is no good evidence upon which a recommendation can be made as to when to restart
P2Y12 receptor blocker therapy after CABG. Our reviewers generally wait until the risk of major
bleeding has significantly fallen, perhaps 12 to 24 hours after uncomplicated surgery.
Prevention — The use of intraoperative activated clotting time-guided heparin dosing is

appropriate in patients undergoing CABG [37]. Although some have suggested benefit from the
selective use of platelet transfusions [39], a prospective report of over 5000 patients undergoing
CABG noted increases in mortality and ischemic complications with platelet transfusions [29].
The latter observation and the benefit of postoperative aspirin therapy are consistent with a
central role for platelet activation in the ischemic response to reperfusion injury.
Similar to recommendations made in the 2014 clinical practice guideline from the American
Association of Blood Banks, we do not recommend prophylactic platelet transfusion for patients
without thrombocytopenia who are scheduled to undergo cardiopulmonary bypass [40]. Patients
with perioperative bleeding and thrombocytopenia are candidates for platelet transfusion.
Antifibrinolytic agents — The ability of the antifibrinolytic agents (aminocaproic acid,

tranexamic acid, and aprotinin) to prevent bleeding following both on- and off-pump CABG is well
established [41-45]. We use either aminocaproic acid or tranexamic acid in most cases. The
relative efficacy and safety of these three antifibrinolytic drugs were addressed in a meta-
analysis of 128 mostly small randomized controlled trials (published prior to August 2006) that
compared the efficacy and safety of the three agents to placebo and to each other in patients
undergoing CABG [41]. Compared to placebo, all agents were effective at reducing blood loss by
226 to 348 mL and at lowering the proportion of patients transfused with packed red blood cells.
High-dose aprotinin was more effective at reducing blood loss than either aminocaproic acid or
tranexamic acid. The meta-analysis found no statistically important worsening of the outcomes
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of mortality, stroke, myocardial infarction, or dialysis-dependent renal failure.
Tranexamic acid was evaluated in the more contemporary ATACAS trial [45]. (See "Medical
therapy to prevent complications after coronary artery bypass graft surgery", section on 'Aspirin'.)
In ATACAS, 4631 patients undergoing coronary artery surgery, with or without valve surgery, were
randomly assigned to tranexamic acid or placebo. There was no difference in the rate of the
primary outcome, a composite of death and thrombotic complications (myocardial infarction,
stroke, pulmonary embolism, renal failure, or bowel infarction [16.7 versus 18.1 percent; relative
risk 0.92. 95% CI 0.81-1.05]) within 30 days after surgery. However, the use of the antifibrinolytic
agent significantly decreased the total number of units of blood products that were transfused
(4331 versus 7994). Major hemorrhage or cardiac tamponade leading to reoperation occurred in
1.4 and 2.8 percent (p = 0.001) of the two groups and seizures occurred in 0.7 and 0.1 percent (p
= 0.002) of the two groups, respectively. At one year, there was no significant difference in the
rate of death or disability, the primary one-year outcome, or the composite rate of myocardial
infarction, stroke, and death [46].
Safety concerns exist with the use of aprotinin. In the meta-analysis discussed above, high-dose
aprotinin significantly increased the risk of temporary kidney injury compared with the other
agents, defined as an increase in serum creatinine (relative risk 1.47, 95% CI 1.12-1.94). An
increased likelihood of acute kidney injury with aprotinin was also seen in observational studies
[47-49]. A randomized trial and two large observational studies published after the meta-
analysis provided evidence for an increase in both short- and long-term mortality in patients who
received aprotinin compared to aminocaproic acid, tranexamic acid, or placebo [50-52]. The
BART trial (Blood conservation using Antifibrinolytics in a Randomized Trial) was designed to
further evaluate the safety of aprotinin [52]. After enrollment of 2331 of 3000 patients scheduled
to be randomly assigned to either aprotinin, aminocaproic acid, or tranexamic acid, the trial was
terminated early because of a significantly higher death rate in patients receiving aprotinin.
Similar findings were noted in a retrospective analysis of data from over 33,000 aprotinin
recipients and over 44,000 aminocaproic acid recipients in which the unadjusted risk of death
within the first seven days after CABG was 4.5 and 2.5 percent, respectively [50]. After adjustment
for 41 patient and hospital characteristics, the relative risk of death was significantly increased in
the aprotinin group (relative risk 1.64, 95% CI 1.50-1.78). Another retrospective analysis found
that the mortality risk with aprotinin remained significantly increased at one year [51]. Aprotinin is
not available for routine use in the United States is used in Europe.
Glucocorticoids — A 2008 meta-analysis of 11 trials (436 patients) that evaluated the effects
of prophylactic glucocorticoids found that their use resulted in a small but significant decrease in
the rate of postoperative bleeding [53]. However, we do not recommend prophylactic
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glucocorticoid use for this purpose, as the results of the individual trials in the meta-analysis
were heterogeneous, and only four studies reported transfusion rates.
Fresh frozen plasma — A 2015 meta-analysis of 15 randomized trials (755 patients) that
principally compared the prophylactic use of fresh frozen plasma (FFP) with no FFP found no
evidence to support its routine use to prevent blood loss [54].
Blood transfusion — For most patients with anemia during or after cardiac surgery, we
transfuse red blood cells (RBCs) to maintain the hemoglobin level above 8 g/dL (hematocrit >24
percent). However, this threshold for transfusion should be individualized and should take into
account clinical factors such as patient age, whether the person is entering the diuretic phase
after surgery, and the presence and rate of active bleeding.
While anemia is an independent risk factor for morbidity and mortality after cardiac surgery, RBC
transfusion used for the purpose of correcting anemia has been associated with increased
rates of infection, ischemic complications, and death in observational studies [55,56]. In
addition, RBC transfusion leads to increased financial cost, the consumption of limited
resources, and risks such as infection or transfusion reaction. (See "Immunologic transfusion
reactions" and "Transfusion-transmitted bacterial infection" and "The approach to the patient
who declines blood transfusion" and "Hemolytic transfusion reactions" and "Transfusion-related
acute lung injury (TRALI)" and "Risk of HIV from blood transfusion".)
Thus, the issue of the optimal transfusion strategy is important for a variety of reasons,
particularly as rates of transfusion between 25 and 75 percent (and as low as 8 or as high as 93
percent) have been reported [55,57-59]. Three randomized trials with more than 500 patients
undergoing cardiac surgery have addressed the issue of whether a restrictive perioperative RBC
transfusion strategy is as safe as liberal strategy:
● In the TITRe2 trial, 2007 patients who underwent cardiac surgery (60 percent CABG or
CABG/valve) and had a postoperative hemoglobin level of <9 g/dL were randomly assigned
to a restrictive transfusion threshold (hemoglobin <7.5 g/dL) or a liberal threshold (<9 g/dL)
[58]. The rate of transfusion after randomization was 53.4 and 92.2 percent and the median
number of units transfused was one and two, respectively. There was no difference in the
rate of the primary outcome of serious infection or an ischemic event (permanent stroke,
myocardial infarction, gut infarction, or acute kidney injury) within three months between two
groups, respectively (35.1 and 33.0 percent, respectively; odds ratio 1.11, 95% CI 0.91-1.34).
All-cause mortality at 90 days, a secondary outcome, was observed more frequently in the
restrictive group (4.2 versus 2.6 percent; hazard ratio 1.64, 95% CI 1.00-2.67).
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● In the TRACS non-inferiority trial, 502 patients who underwent cardiac surgery were
randomly assigned to a restrictive (hematocrit ≥24 percent) or a liberal (hematocrit ≥30
percent) strategy of blood transfusion [55]. Patients were transfused, at any time from the
start of surgery until discharge, if the hematocrit was less than 24 percent in the restrictive
group or less than 30 percent in the liberal group. The rates of transfusion were 47 and 78
percent in the two groups, respectively. There was no difference in the rate of the primary
composite end point of all-cause mortality and severe morbidity (cardiogenic shock, acute
respiratory distress syndrome, or acute renal injury requiring dialysis or hemofiltration) at 30
days (11 versus 10 percent). Hemoglobin concentrations were 9.1 and 10.5 g/dL. As pointed
out by the authors, the absence of blood leukodepletion in this study may limit its
generalizability. (See 'Leukoreduced blood' below.)
● In the TRICS III trial, 5243 high-risk (of death) adults undergoing cardiac surgery with
cardiopulmonary bypass (45 percent CABG or CABG/valve) with a EuroSCORE I value of 6
or more (table 1) were randomly assigned to a restrictive red cell transfusion threshold
(transfuse if hemoglobin <7.5 g/dL deciliter) or a liberal red cell transfusion threshold
(transfuse if hemoglobin <9.5 g/dL in the operating room or intensive care unit [ICU] or <8.5
in the non-ICU ward) [59]. The following findings were noted:
● At day 28 or hospital discharge, whichever came first, the primary composite outcome
(death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis)
occurred at a similar rate in both groups (11.4 versus 12.5 percent, respectively; absolute
risk difference -1.11 percentage points, 95% CI -2.93 to 0.72; odds ratio 0.90, 95% CI
0.76-1.07). There was no significant difference in mortality (3.0 and 3.6 percent, respectively)
and red cell transfusion occurred in 52.3 and 72.6 percent of the two groups, respectively.
● At six months, the primary composite outcome occurred at a similar rate in both groups
(17.4 versus 17.1 percent, respectively; absolute risk difference before rounding, 0.22
percentage points, 95% CI -1.95 to 2.39; odds ratio 1.02, 95% CI 0.87-1.18) [60]. Mortality
was similar in the two groups.
Leukoreduced blood — Among patients who required blood transfusion, leukoreduced blood
may improve outcomes. The need for multiple blood transfusions and the infusion of allogeneic
leukocytes is associated with an increase in complications including antigen-antibody
formation, transmission of viruses, febrile reactions, and possibly impaired wound healing and
postoperative infections.
The potential efficacy of leukoreduced blood was illustrated in a trial that randomly assigned 944
patients undergoing cardiac surgery to receive packed cells or blood that was leukocyte
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depleted by filtration if transfusion was required [20]. Those receiving leukocyte-depleted blood
had a reduced incidence of infection compared to patients receiving packed cells and a
significant reduction in mortality at 60 days. This was particularly evident when more than three
units of blood were required. (See "Leukoreduction to prevent complications of blood
transfusion".)
Duration of red cell storage and outcome — Longer RBC storage times are associated with
structural and functional changes that may worsen outcomes in the recipient [61]. In a
retrospective study of over 6000 patients who underwent open heart surgery and were
transfused, those who received blood stored for more than 14 days had significantly worse
outcomes (intubation beyond 72 hours, renal failure, sepsis or septicemia, and in-hospital and
one-year mortality) compared to those with shorter storage times [62].
However, other studies have not demonstrated an independent effect of red cell storage time on
outcomes after CABG and any potential benefits of using blood stored for two weeks or less
must be weighed against the difficulty of maintaining the blood supply if only fresher units are
used for transfusion. These issues are discussed in detail separately. (See "Practical aspects of
red blood cell transfusion in adults: Storage, processing, modifications, and infusion", section
on 'Storage duration'.)
NEUROLOGIC COMPLICATIONS
Neurologic complications are an important source of morbidity and mortality after coronary artery
bypass graft surgery (CABG). The major neurologic problems are stroke, neuropsychiatric
abnormalities such as cognitive dysfunction, and peripheral neuropathy. The risk increases with
patient age (figure 1) [63].
The mechanisms, risk factors, and possible therapies and preventive measures for neurologic
complications after CABG, and issues related to CABG in patients with known carotid artery
disease are discussed in detail elsewhere. (See "Neurologic complications of cardiac surgery"
and "Coronary artery bypass grafting in patients with cerebrovascular disease".)
INFECTION
Sternal wound infection and mediastinitis — Issues related to postoperative sternal wound
infection with mediastinitis are discussed in detail separately. The following discussion will be
limited to issues related to coronary artery bypass graft surgery (CABG). (See "Postoperative
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mediastinitis after cardiac surgery" and "Surgical management of sternal wound

complications".)
Mediastinitis after CABG has been reported in 0.9 to 1.3 percent of patients [64-67]. It is usually
detected within the first two weeks (median about seven days), but the onset is delayed for more
than one month in occasional patients. Virtually all patients have fever, tachycardia, chest pain or
sternal instability, signs of sternal wound infection, and purulent discharge from the mediastinal
area. Fever and systemic symptoms appear first in most patients. Streptococcus and
Staphylococcus are the most frequent organisms.
A number of risk factors have been identified for the development of mediastinitis after CABG,
although the same risk factors were not noted in all studies. (See "Surgical management of
sternal wound complications", section on 'Risk factors for sternal wound complications'.)
These include:
● Obesity [65,67,68]
● Diabetes mellitus [64,65,69,70]
● Bilateral internal mammary artery grafts [64,65], a relationship that has not been confirmed
in some studies [67,71].
● Prolonged duration of surgery [65,67]
● Prior cardiac surgery [67]
● Use of staples for skin closure [69]
● Underlying obstructive airways disease [68]
● Dual antiplatelet therapy with aspirin and clopidogrel (compared with aspirin alone) within
five days of surgery [72].
Among patients with diabetes, strict perioperative glycemic control appears to reduce the risk of
sternal wound infection [70].
Mediastinitis after CABG is associated with increases in both short- and long-term mortality. This
was illustrated in a report of 6459 consecutive patients, 83 (1.3 percent) of whom developed
mediastinitis [67]. The patients with mediastinitis compared to those without this complication
had increased mortality at 90 days (11.8 versus 5.5 percent); the interval mortality remained high
between one and two years after surgery (8.1 versus 2.3 percent).
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The prevention and management of mediastinitis is discussed elsewhere. (See "Postoperative

mediastinitis after cardiac surgery" and "Surgical management of sternal wound
complications".)
Leg wound complications — The reported incidence of leg wound complications after
saphenous vein graft (SVG) harvesting has varied widely, ranging from around 1 to 24 percent in
older reports [73-78] and 18 percent in a 2004 report [79]. The most common manifestations are
usually minor and do not require surgical intervention. These include dermatitis, cellulitis,
greater saphenous neuropathy, chronic nonhealing ulcers, and lymphocele.
Major complications are rare. In a retrospective review of 3525 CABG procedures, lower
extremity wound complications occurred in 4 percent of patients; however, only 0.65 percent
required additional surgical intervention, including wound debridement, skin grafting, vascular
procedure, amputation, or fasciotomy [75]. Significant predictors of major wound complications
were female gender, peripheral artery disease, and postoperative intraaortic balloon pump.
For patients in whom a conventional (open) harvesting has been used, the wound may be
closed with either staples or sutures. A 2010 Cochrane systemic review (updated in 2012) of
three trials including over 300 patients found no significant difference in the rates of leg wound
infection (10.8 versus 8.0 percent, respectively) or dehiscence (9.3 versus 8.8 percent) between
these two techniques [80]. However, all included studies were felt to be of sub-optimal
methodological quality and at risk of bias.
Endoscopic SVG harvesting was developed in the mid-1990s as a way to improve postoperative
discomfort and to potentially reduce wound infection. It is estimated that nearly 90 percent of all
procedures performed in the United States use the endoscopic technique [81]. Most studies
have shown that the rate of leg wound complications is significantly reduced [76-78,82]. In
REGROUP, a randomized trial comparing open to endoscopic vein-graft harvesting, there was a
trend toward a higher rate of leg wound complications in the former group (3.1 versus 1.4
percent; relative risk 2.26, 95% CI 0.99-5.15) [83]. Other outcomes with these two approaches
are discussed separately. (See "Coronary artery bypass graft surgery: Long-term clinical
outcomes", section on 'Endoscopic vein-graft harvesting'.)
Post-venectomy cellulitis — The syndrome of post-venectomy lower extremity cellulitis can be a

late complication of coronary artery bypass grafting, but is infrequent, particularly with the
increased use of minimally invasive vein harvesting. If it occurs, it tends to present months to
years after saphenous venectomy and recurrent episodes occur in most patients. Classically,
patients present with the acute onset of high fever, often greater than 40ºC, systemic toxicity, and
erythema and swelling of the lower extremity [84]. Erythema of the lower extremity usually begins
14 of 37 5/7/2020, 11:05 AM
along the medial aspect of the mid-tibial region at the saphenous venectomy site (picture 1). It
then spreads posteriorly and anteriorly and can involve the dorsal aspect of the ankle and foot,
and can extend proximally to involve the medial thigh. Many patients have maceration and
erythema of interdigital spaces indicative of tinea pedis infection (athlete's foot), which may
represent the source of the infection. Deep vein thrombosis and infections of underlying medical
devices (eg, a prosthetic vascular graft) are the two major differential diagnoses of post-
venectomy cellulitis.
The diagnosis is made clinically, based on the presence of lower extremity erythema and fever.
Cultures of blood, skin biopsies, and lesion aspirates usually do not identify a pathogen. Toe
web cultures may be useful in establishing a probable pathogen in patients with active cellulitis
and tinea pedis. When pathogens are recovered, non-group A beta-hemolytic streptococci have
been the most commonly isolated [85]. Other beta-hemolytic streptococci and Staphylococcus
aureus (including methicillin-resistant S. aureus) are also possible pathogens. In the acute
setting, antimicrobial therapy is directed against these organisms and usually results in the
prompt resolution of systemic complaints and slower resolution of the lower extremity changes.
Patients who are hospitalized for this syndrome should initially receive antibiotics intravenously.
For patients with recurrent cellulitis, chronic suppressive antibiotic therapy and pre-emptive,
patient-initiated therapy are options to prevent or manage additional episodes of cellulitis [86].
Treatment of tinea pedis, if present, in an effort to decrease the risk of recurrent episodes, is
also thought to be an important element in the prevention of recurrent lower extremity cellulitis.
These treatment issues are the same as those for cellulitis in general and are discussed in
detail elsewhere. (See "Cellulitis and skin abscess in adults: Treatment" and "Suspected
Staphylococcus aureus and streptococcal skin and soft tissue infections in children >28 days:
Evaluation and management".)
Bloodstream infection — Bloodstream infection (BSI), defined as ≥1 positive blood culture for a
known pathogen with additional criteria for positive cultures caused by potential skin
contaminants, occurred in 3 percent of patients within 90 days of undergoing CABG [87].
Individuals with BSI had a significantly increased risk of death (HR 4.2), and the risk was highest
among those with BSI due to gram-negative bacteria or Staphylococcus aureus.
ACUTE KIDNEY INJURY
Pathogenesis — Acute kidney injury (AKI, previously called acute renal failure) is a potential
complication of coronary artery bypass graft surgery (CABG) that can arise from a variety of
causes, including intraoperative hypotension, postoperative cardiac complications that impair
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renal perfusion, hemolysis, atheroemboli, and exposure to contrast media [88,89]. Reduced
renal function due to transient hypoperfusion or contrast nephropathy usually resolves within a
few days, but some patients develop more severe and persistent kidney injury with a
requirement for dialysis. (See "Pathogenesis and etiology of ischemic acute tubular necrosis",
section on 'Pathology and pathogenesis' and "Contrast-associated and contrast-induced acute
kidney injury: Clinical features, diagnosis, and management".)
Incidence — One problem with the available data on the incidence of AKI after CABG is the
variable definitions used [90]. The incidence is higher with smaller compared to larger
reductions in estimated glomerular filtration rate (eg, 25 percent increase in serum creatinine
compared to a 100 percent increase or the requirement for dialysis). In two studies of 843 and
649 patients undergoing cardiac surgery (mostly CABG), the incidence of AKI (defined as a rise
in the serum creatinine of only 25 percent) was 17 and 24 percent [91,92]. Using this definition, a
patient whose serum creatinine rose from 1.0 to 1.3 mg/dL (88 to 115 mmol/L) would be
considered to have AKI.
Other contemporary studies that used a more restrictive definition noted a much lower rate of
AKI. Two large series (one involving over 51,000 CABG procedures and a 2006 report from the
Society of Thoracic Surgery [STS]) defined AKI as either an increase of serum creatinine to >2
mg/dL (177 mmol/L) with a minimum doubling of the preoperative value or a new requirement
for dialysis [93,94]. The overall rate of AKI ranged from 3.6 to 5 percent and did not vary over time.
In the STS report, a higher rate of 7.5 and 12.9 percent was noted when CABG was combined
with aortic or mitral valve replacement, respectively [94].
A lower proportion of patients (0.9 to 1.7 percent in different large series) develops AKI severe
enough to require dialysis [95-98] and a reduced estimated creatinine clearance is a major risk
factor for the development of AKI requiring dialysis [95-97]. The magnitude of this effect was
illustrated in a study using the Society of Thoracic Surgeons National Adult Cardiac Database of
over 480,000 patients who underwent isolated CABG from 2000 to 2003 [95]. The rate of
requirement of new dialysis was 0.2 percent in the 23 percent of patients with normal baseline
renal function (estimated creatinine clearance ≥90 mL/min) compared to 0.5, 1.8, and 10.9
percent in patients with an estimated creatinine clearance of 60 to 89, 30 to 59, and less than 30
mL/min per 1.73 m 2 (adjusted odds ratio 1.7, 4.7, and 20.4, respectively). (See "Assessment of
kidney function", section on 'Assessment of GFR'.)
A study of over 2400 patients undergoing CABG after catheterization study found that the risk of
AKI was highest in those undergoing preoperative coronary angiography within one day (24
percent) of CABG surgery compared to those having the test performed at least five days prior to
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surgery (15.8 percent) [99].
Risk factors — In addition to baseline kidney dysfunction, preoperative risk factors for AKI
include New York Heart Association functional class IV (table 2), valve surgery, peripheral artery
disease, emergent or urgent surgery, obesity, and the need for preoperative intraaortic balloon
pump [96,97,100,101]. Perioperative factors such as anemia, red blood cell transfusions,
prolonged cardiopulmonary bypass, and surgical reexploration are also associated with the
development of AKI [100]. On the other hand, atherosclerotic renal artery stenosis does not
appear to be a risk factor for a postoperative decrease in the glomerular filtration rate, need for
renal replacement therapy, longer length of stay, or long-term mortality [102].
Multivariable risk models to predict cardiac surgery-associated AKI using either presurgical
[97,103] or presurgical and intrasurgical clinical information have been developed [104]. We do
not routinely use these risk prediction models.
Mortality — There is a strong relationship between the development of perioperative AKI and
both short- and long-term mortality after CABG. This issue is discussed in detail elsewhere.
(See "Operative mortality after coronary artery bypass graft surgery", section on 'Acute kidney
injury'.)
Prevention — The methods that may prevent AKI, including the possible benefit with an off-
pump approach in patients undergoing CABG, are discussed separately. (See "Possible
prevention and therapy of ischemic acute tubular necrosis", section on 'Prevention'.)
OTHER COMPLICATIONS
Venous thromboembolism — Deep venous thrombosis (DVT) and pulmonary embolism (PE)
may be difficult to recognize after coronary artery bypass graft surgery (CABG) and are therefore
likely to be underdiagnosed [105]. In a series of 330 patients who underwent venous
ultrasonography four to six days after CABG, DVT was present in 20 percent, and two patients
had symptomatic PE [106]. Most such patients remain asymptomatic. This was illustrated in a
review of hospital discharge records for 66,180 patients undergoing CABG in which only 736
(1.1 percent) were diagnosed with symptomatic DVT or PE within three months of surgery [107].
(See "Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected
acute pulmonary embolism" and "Clinical presentation and diagnosis of the nonpregnant adult
with suspected deep vein thrombosis of the lower extremity".)
Prophylactic measures, such as graduated compression stockings and anticoagulation, can
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reduce the incidence of venous thromboembolism after surgical procedures.

Recommendations for thromboembolism prophylaxis are presented in detail separately. (See
"Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
Pulmonary — Pulmonary complications after cardiac surgery are discussed elsewhere. (See
"Strategies to reduce postoperative pulmonary complications in adults" and "Postoperative
complications among patients undergoing cardiac surgery", section on 'Pulmonary dysfunction'.)
Pleural effusions are common postoperatively occurring in up to 90 percent of patients who have
undergone CABG. The effusions are usually small, left-sided, and do not require treatment. Early
effusions (within 30 days of CABG) tend to be bloody, while late effusions are yellow exudates
[108]. (See "Pleural effusions following cardiac surgery".)
Aortic dissection — Ascending aortic dissection is a rare complication of CABG, occurring with
both conventional on-pump CABG and, perhaps more often, with minimally invasive off-pump
CABG (OP CABG) [109-112]. In a review from a single institution, ascending aortic dissection
occurred in 1 of 2723 patients (0.04 percent) treated with conventional CABG and 3 of 308
undergoing OP CABG (1 percent) [111]. (See "Minimally invasive coronary artery bypass graft
surgery: Definitions and technical issues".)
Dissection can occur intraoperatively or weeks to months after surgery. The site of aortic
dissection is usually related to the partial occlusion clamp site, proximal vein graft anastomosis,
and the site of cardioplegia delivery. Patients at increased risk are older adults and those with
long-standing hypertension, severe atherosclerotic involvement of the ascending aorta, or
ectasia of aorta. (See "Clinical features and diagnosis of acute aortic dissection".)
Protamine reactions — Protamine is administered intravenously to reverse the effect of heparin

but may be associated with severe systemic reactions, including hypotension that may require
inotropic support, an increase in pulmonary artery pressure, noncardiogenic pulmonary edema,
and bronchospasm. In a series of 2069 patients, 2.6 percent had an adverse reaction within 10
minutes of protamine administration [113]. Independent risk factors for an adverse event were
NPH insulin use, fish allergy, and a history of nonprotamine medication allergy.
Thrombocytopenia — Thrombocytopenia is common after CABG. The causes and

management of this problem are presented elsewhere. (See "Management of heparin-induced
thrombocytopenia (HIT) during cardiac or vascular surgery" and "Approach to the adult with
unexplained thrombocytopenia".)
Gastrointestinal — Single center reports have found serious gastrointestinal (GI) complications
in 0.3 to 3 percent of patients undergoing cardiac surgery, primarily CABG [114,115]. Mortality in
18 of 37 5/7/2020, 11:05 AM
these patients has been as high as 33 percent.
The largest reported experience comes from the United States Agency for Healthcare Research
and Quality, which assessed the incidence and impact of GI complications after 2.7 million
CABG operations performed from 1998 to 2002 [116]. The most frequently reported
complications were abscess, ileus, gastrointestinal ulcer (perforation/bleeding), and bleeding
diverticulosis or diverticulitis in the colon. The following observations were noted:
● The incidence of GI complications was 4.1 percent. The largest increase in relative risk was
seen in patients over age 65 and those on hemodialysis. In contrast, use of an internal
mammary graft was associated with lower risk.
● The inpatient mortality was significantly increased in those with GI complications compared
to those without (12.0 versus 2.5 percent). (See "Operative mortality after coronary artery
bypass graft surgery".)
EARLY READMISSION
Rates of readmission within 30 days varied between 8.3 to 21.1 percent following coronary artery
bypass graft surgery in an analysis of the New York State Registry. The most common reasons
were postoperative infection (16.9 percent), heart failure (12.8 percent), and "other
complications" (9.8 percent). The authors found that the following variables were independently
associated with increased readmission risk: older age, female sex, African-American race,
higher body mass index, comorbidities, renal failure, unplanned cardiac reoperation, United
States Medicare or Medicaid status, discharge to a skilled nursing facility, saphenous vein grafts,
and longer length of stay. Readmission was not found to correlate with mortality [117]. Other
studies report that rates of readmission range between 13 to 16 percent at four to six weeks
[118-121].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Coronary artery bypass
graft surgery".)
INFORMATION FOR PATIENTS
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UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.”
The Basics patient education pieces are written in plain language, at the 5 th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10 th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on “patient info” and the keyword(s) of interest.)
● Beyond the Basics topics (see "Patient education: Coronary artery bypass graft surgery
(Beyond the Basics)" and "Patient education: Recovery after coronary artery bypass graft
surgery (CABG) (Beyond the Basics)")
● Basics topic (see "Patient education: Coronary artery bypass graft surgery (The Basics)")
SUMMARY
● Many of the noncardiac complications related to coronary artery bypass graft (CABG) surgery
are the result of either cardiopulmonary bypass or aortic instrumentation and manipulation.
Preventative strategies are available. (See 'Prevention of complications' above.)
● Bleeding, neurologic complications, infection, and acute kidney injury are four of the most
important adverse outcomes after CABG.
• Approximately 30 percent of patients require a blood transfusion after CABG. Risk

factors include lower preoperative hemoglobin, lower weight, older age, and female
gender. Additional risk factors for perioperative transfusion include preoperative use of
antiplatelet or antithrombotic drugs, reoperation, acquired or congenital
clotting/coagulation abnormalities, complex procedures, and emergency operations.
(See 'Bleeding' above.)
• The major neurologic problems are stroke, neuropsychiatric abnormalities such as

cognitive dysfunction, and peripheral neuropathy. (See 'Neurologic complications'
above.)
• Sternal wound infection and mediastinitis after CABG occur in approximately 1 percent
20 of 37 5/7/2020, 11:05 AM
of patients. (See 'Sternal wound infection and mediastinitis' above.)
• Acute kidney injury is a potential complication of CABG that can arise from a variety of
causes, including intraoperative hypotension, postoperative cardiac complications that
impair renal perfusion, hemolysis, atheroemboli, and exposure to contrast media.
Approximately 1 to 2 percent of patients require dialysis. (See 'Acute kidney injury'
above.)
ACKNOWLEDGMENT
The UpToDate editorial staff would like to thank Dr. Julian M. Aroesty for his past contributions as
an author to prior versions of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
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vein harvest for coronary revascularization. Ann Thorac Surg 2000; 70:492.
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77. Schurr UP, Lachat ML, Reuthebuch O, et al. Endoscopic saphenous vein harvesting for
CABG -- a randomized, prospective trial. Thorac Cardiovasc Surg 2002; 50:160.
78. Dacey LJ, Braxton JH Jr, Kramer RS, et al. Long-term outcomes of endoscopic vein
harvesting after coronary artery bypass grafting. Circulation 2011; 123:147.
79. Swenne CL, Lindholm C, Borowiec J, Carlsson M. Surgical-site infections within 60 days of
coronary artery by-pass graft surgery. J Hosp Infect 2004; 57:14.
80. Biancari F, Tiozzo V. Staples versus sutures for closing leg wounds after vein graft
harvesting for coronary artery bypass surgery. Cochrane Database Syst Rev 2010;
:CD008057.
81. https://www.sts.org/registries-research-center/sts-national-database/sts-adult-cardiac-sur
gery-database (Accessed on November 19, 2018).
82. Williams JB, Peterson ED, Brennan JM, et al. Association between endoscopic vs open
vein-graft harvesting and mortality, wound complications, and cardiovascular events in
patients undergoing CABG surgery. JAMA 2012; 308:475.
83. Zenati MA, Bhatt DL, Bakaeen FG, et al. Randomized Trial of Endoscopic or Open Vein-
Graft Harvesting for Coronary-Artery Bypass. N Engl J Med 2019; 380:132.
84. Baddour LM, Bisno AL. Recurrent cellulitis after saphenous venectomy for coronary bypass
surgery. Ann Intern Med 1982; 97:493.
85. Baddour LM, Bisno AL. Non-group A beta-hemolytic streptococcal cellulitis. Association
with venous and lymphatic compromise. Am J Med 1985; 79:155.
86. Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J
Med 2013; 368:1695.
87. Olsen MA, Krauss M, Agniel D, et al. Mortality associated with bloodstream infection after
coronary artery bypass surgery. Clin Infect Dis 2008; 46:1537.
88. Rosner MH, Okusa MD. Acute kidney injury associated with cardiac surgery. Clin J Am Soc
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89. Vermeulen Windsant IC, Snoeijs MG, Hanssen SJ, et al. Hemolysis is associated with
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acute kidney injury during major aortic surgery. Kidney Int 2010; 77:913.
90. Palevsky PM. Epidemiology of acute renal failure: the tip of the iceberg. Clin J Am Soc
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91. Loef BG, Epema AH, Smilde TD, et al. Immediate postoperative renal function deterioration
in cardiac surgical patients predicts in-hospital mortality and long-term survival. J Am Soc
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92. Del Duca D, Iqbal S, Rahme E, et al. Renal failure after cardiac surgery: timing of cardiac
catheterization and other perioperative risk factors. Ann Thorac Surg 2007; 84:1264.
93. Mack MJ, Brown PP, Kugelmass AD, et al. Current status and outcomes of coronary
revascularization 1999 to 2002: 148,396 surgical and percutaneous procedures. Ann
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94. 2006 Data analysis report of the National Adult Cardiac Surgery Database of the Society of
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95. Cooper WA, O'Brien SM, Thourani VH, et al. Impact of renal dysfunction on outcomes of
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96. Chertow GM, Lazarus JM, Christiansen CL, et al. Preoperative renal risk stratification.
97. Thakar CV, Arrigain S, Worley S, et al. A clinical score to predict acute renal failure after
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revascularization: risk factors, adverse outcomes, and hospital resource utilization. The
Multicenter Study of Perioperative Ischemia Research Group. Ann Intern Med 1998;
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99. Mehta RH, Honeycutt E, Patel UD, et al. Relationship of the time interval between cardiac
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kidney injury. Circulation 2011; 124:S149.
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105. Goldhaber SZ, Schoepf UJ. Pulmonary embolism after coronary artery bypass grafting.
106. Goldhaber SZ, Hirsch DR, MacDougall RC, et al. Prevention of venous thrombosis after
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different elective or urgent surgical procedures. Thromb Haemost 2003; 90:446.
108. Sadikot RT, Rogers JT, Cheng DS, et al. Pleural fluid characteristics of patients with
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2000; 160:2665.
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bypass surgery. Am J Cardiol 1978; 41:103.
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implications for evolving techniques of revascularization. J Card Surg 2000; 15:362.
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dissection with off-pump aortocoronary bypass surgery? Ann Thorac Surg 2001; 71:117.
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after protamine administration following cardiopulmonary bypass. J Am Coll Cardiol 1998;

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coronary artery bypass graft surgery. JAMA 2003; 290:773.
Topic 1585 Version 46.0
31 of 37 5/7/2020, 11:05 AM
GRAPHICS
EuroSCORE risk prediction algorithm for cardiac surgical mortality
Risk
Predictor Definition
points*
Age Per 5 years or part thereof over 60 years 1
Sex Female 1
Chronic pulmonary Long-term use of bronchodilators or steroids for lung disease 1

disease
Extracardiac arteriopathy Any one or more of the following: 2
claudication
carotid occlusion or >50% stenosis
previous or planned intervention on the abdominal aorta, limb arteries, or

carotids
Neurological dysfunction Disease severely affecting ambulation or day-to-day functioning 2
Previous cardiac surgery Requiring opening of the pericardium 3
Serum creatinine >200 micromol/L (2.3 mg/dL) preoperatively 2
Active endocarditis Patient still under antibiotic treatment for endocarditis at the time of 3
surgery
Critical preoperative Any one or more of the following: 3

state
ventricular tachycardia or fibrillation or aborted sudden death
preoperative cardiac massage
preoperative ventilation before arrival in the anesthetic room
preoperative inotropic support
intraaortic balloon counterpulsation
preoperative acute renal failure (anuria or oliguria <10 mL/hour)
Unstable angina Rest angina requiring IV nitrates until arrival in the anesthetic room 2
LV dysfunction Moderate or LV ejection fraction 30 to 50% 1
Poor or LV ejection fraction <30% 3
Recent myocardial infarct <90 days 2
Pulmonary hypertension Systolic pulmonary artery pressure >60 mmHg 2
Emergency operation Carried out on referral before the beginning of the next working day 2
Other than isolated CABG Major cardiac procedure other than or in addition to CABG 2
Surgery on thoracic aorta For disorder of ascending, arch or descending aorta 3
Postinfarct septal rupture 4
IV: intravenous; LV: left ventricle; CABG: coronary artery bypass grafting.
* To calculate the estimated perioperative mortality risk, the sum of the risk points is determined. Scores are stratified into
low risk (0 to 2 points; estimated mortality 1.3 percent), medium risk (3 to 5 points; estimated mortality 2.9 percent) and
high risk (≥6 points; estimated mortality 10.9 to 11.5 percent).
Reproduced with permission from: Nashef SA, Roques F, Michel P, et al. European system for cardiac operative risk
evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999; 16:9. Copyright © 1999 Elsevier.
Graphic 82521 Version 6.0
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Impact of age on adverse cerebral outcomes after

coronary bypass surgery
T he inc idenc e of adv ers e c erebral ev ents after c oronary artery by pas s
s urgery is 6 .1 perc ent, of whic h half are ty pe I (foc al injury, c oma, or
s tupor at dis c harge) and half are ty pe I I (deterioration in intellec tual
func tion, memory defec t, or s eizures ). T he inc idenc e of both ty pe I and
I I ev ents inc reas e with age.
Data from Roach GW, Kanchuger M, Mangano M, et al, and the Ischemia Research
and Education Foundation Investigators. N Engl J Med 1996; 335:1857.
33 of 37 5/7/2020, 11:05 AM
Postvenectomy cellulitis
C ellulitis oc c urring after s aphenous v enec tomy. T he inflammation

begins along the medial as pec t of the mid- tibial region at the
s aphenous v enec tomy s ite.
Courtesy of Larry M Baddour, MD.
34 of 37 5/7/2020, 11:05 AM
NYHA and other classifications of cardiovascular disability
Canadian
NYHA functional Cardiovascular Specific activity
Class
classification [1] Society functional scale [3]
classification [2]
I Patients with cardiac Ordinary physical activity, Patients can perform to

disease but without such as walking and completion any activity
resulting limitations of climbing stairs, does not requiring ≥7 metabolic
physical activity. Ordinary cause angina. Angina with equivalents (ie, can carry
physical activity does not strenuous or rapid 24 lb up 8 steps; do
cause undue fatigue, prolonged exertion at work outdoor work [shovel
palpitation, dyspnea, or or recreation. snow, spade soil]; do
anginal pain. recreational activities
[skiing, basketball, squash,
handball, jog/walk 5
mph]).
II Patients with cardiac Slight limitation of ordinary Patients can perform to

disease resulting in slight activity. Walking or completion any activity
limitation of physical climbing stairs rapidly, requiring ≥5 metabolic
activity. They are walking uphill, walking or equivalents (eg, have
comfortable at rest. stair-climbing after meals, sexual intercourse without
Ordinary physical activity in cold, in wind, or when stopping, garden, rake,
results in fatigue, under emotional stress, or weed, roller skate, dance
palpitation, dyspnea, or only during the few hours fox trot, walk at 4 mph on
anginal pain. after awakening. Walking level ground), but cannot
more than 2 blocks on the and do not perform to
level and climbing more completion activities
than 1 flight of ordinary requiring ≥7 metabolic
stairs at a normal pace and equivalents.
in normal conditions.
III Patients with cardiac Marked limitation of Patients can perform to

disease resulting in marked ordinary physical activity. completion any activity
limitation of physical Walking 1 to 2 blocks on requiring ≥2 metabolic
activity. They are the level and climbing 1 equivalents (eg, shower
comfortable at rest. Less- flight in normal conditions. without stopping, strip and
than-ordinary physical make bed, clean windows,
activity causes fatigue, walk 2.5 mph, bowl, play
palpitation, dyspnea, or golf, dress without
anginal pain. stopping) but cannot and
do not perform to
completion any activities
requiring >5 metabolic
equivalents.
IV Patients with cardiac Inability to carry on any Patients cannot or do not

disease resulting in inability physical activity without perform to completion
to carry on any physical discomfort. Anginal activities requiring >2
activity without discomfort. syndrome may be present metabolic equivalents.
Symptoms of cardiac at rest. Cannot carry out activities
insufficiency or of the listed above (specific
anginal syndrome may be activity scale III).
present even at rest. If
any physical activity is
undertaken, discomfort is
increased.
35 of 37 5/7/2020, 11:05 AM
NYHA: New York Heart Association.
References:
1. The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of
the Heart and Great Vessels, 9 th ed, Little, Brown & Co, Boston, 1994. p.253.
2. Campeau L. Grading of angina pectoris. Circulation 1976; 54:522.
3. Goldman L, Hashimoto B, Cook EF, Loscalzo A. Comparative reproducibility and validity of systems for assessing
cardiovascular functional class: Advantages of a new specific activity scale. Circulation 1981; 64:1227.
36 of 37 5/7/2020, 11:05 AM
Contributor Disclosures
Sary Aranki, MD Nothing to disclose Rakesh M Suri, MD, DPhil Consultant/Advisory Boards: Unpaid
President of Heart Valve Society 2019-2020. Gabriel S Aldea, MD Nothing to disclose Donald Cutlip,
MD Consultant/Advisory Boards: CeloNova [Coronary artery stent]. Gordon M Saperia, MD Nothing to
disclose
Contributor disclosures are review ed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy
37 of 37 5/7/2020, 11:05 AM

Early Noncardiac Complications of Coronary Artery Bypass Graft Surgery - UpToDate

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Early noncardiac complications of coronary artery bypass

Mechanisms — Many complications related to traditional techniques of cardiac surgery are

Other factors that contribute to complications include:

● Global cardiac arrest

Improvements in surgical technique — Improvements in surgical technique have led to a

● Complications related to aortic manipulation can be limited by routine, careful evaluation of

● Normothermic or near normothermic systemic perfusion is now routinely used. Avoiding

in extensive activation of platelets, neutrophils, complement, cytokines, and the fibrinolytic

● Advances in perfusion technology and techniques and research in biomaterial sciences

● Additional pharmacologic interventions and perfusion surface modifications to further

In a report of a novel technique, intraoperative angiography using fluorescent indocyanine

Medical therapy — The 2004 American College of Cardiology/American Heart Association

minimize the risk of some of these complications [22]:

● Prophylactic antimicrobials to prevent surgical site infection

● An antifibrinolytic agent is used in most CABG procedures to minimize bleeding

● Beta blockers, aspirin, and statins are indicated in many patients

Antiplatelet agents — Antiplatelet agents have a variable effect on bleeding risk.

Stopping and restarting P2Y12 receptor blocker — The decision as to when to

Prevention — The use of intraoperative activated clotting time-guided heparin dosing is

Antifibrinolytic agents — The ability of the antifibrinolytic agents (aminocaproic acid,

of mortality, stroke, myocardial infarction, or dialysis-dependent renal failure.

mediastinitis after cardiac surgery" and "Surgical management of sternal wound

● Diabetes mellitus [64,65,69,70]

● Prolonged duration of surgery [65,67]

● Prior cardiac surgery [67]

● Use of staples for skin closure [69]

● Underlying obstructive airways disease [68]

The prevention and management of mediastinitis is discussed elsewhere. (See "Postoperative

Post-venectomy cellulitis — The syndrome of post-venectomy lower extremity cellulitis can be a

ACUTE KIDNEY INJURY

surgery (15.8 percent) [99].

Prophylactic measures, such as graduated compression stockings and anticoagulation, can

reduce the incidence of venous thromboembolism after surgical procedures.

Protamine reactions — Protamine is administered intravenously to reverse the effect of heparin

Thrombocytopenia — Thrombocytopenia is common after CABG. The causes and

these patients has been as high as 33 percent.

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

• Approximately 30 percent of patients require a blood transfusion after CABG. Risk

• The major neurologic problems are stroke, neuropsychiatric abnormalities such as

of patients. (See 'Sternal wound infection and mediastinitis' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

2. Hammermeister KE, Burchfiel C, Johnson R, Grover FL. Identification of patients at

7. Reents W, Babin-Ebell J, Misoph MR, et al. Influence of different autotransfusion devices on

the quality of salvaged blood. Ann Thorac Surg 1999; 68:58.

9. Mazzei V, Nasso G, Salamone G, et al. Prospective randomized comparison of coronary

patients undergoing CABG with heparin-bonded cardiopulmonary bypass circuits. Ann

42. Sedrakyan A, Treasure T, Elefteriades JA. Effect of aprotinin on clinical outcomes in

outcomes. Ann Thorac Surg 1998; 65:1050.

Cardiovasc Surg 2002; 123:204.

after protamine administration following cardiopulmonary bypass. J Am Coll Cardiol 1998;

Topic 1585 Version 46.0

EuroSCORE risk prediction algorithm for cardiac surgical mortality

Age Per 5 years or part thereof over 60 years 1

Chronic pulmonary Long-term use of bronchodilators or steroids for lung disease 1

Extracardiac arteriopathy Any one or more of the following: 2

carotid occlusion or >50% stenosis

previous or planned intervention on the abdominal aorta, limb arteries, or

Neurological dysfunction Disease severely affecting ambulation or day-to-day functioning 2

Previous cardiac surgery Requiring opening of the pericardium 3

Serum creatinine >200 micromol/L (2.3 mg/dL) preoperatively 2