Coronary Artery Bypass Surgery

What is coronary artery bypass graft (CABG) surgery?

Coronary artery bypass graft surgery is a form of cardiac bypass surgery in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient's own arteries and veins located in the chest, leg, or arm. The graft goes around the clogged artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart.
The goals of the cardiac bypass surgery are to relieve symptoms of coronary artery disease (including angina), enable the patient to resume a normal lifestyle and to lower the risk of a heart attack or other heart problems.

Who is eligible to receive coronary artery bypass graft surgery?

The decision to prescribe medical treatment, invasive procedures or cardiac bypass surgery depends on several factors including the extent of cardiovascular disease, the severity of symptoms, your age and other medical conditions. The cardiologist (heart specialist) and surgeon will determine the best method of therapy for each patient.

What happens during the surgery?

The surgery generally lasts from three to five hours, depending on the number of arteries being bypassed.

Surgical Procedure

During traditional CABG surgery, a surgeon makes an incision down the center of the chest, cuts through the sternum (breastbone), and retracts the ribcage to get direct access to the heart. During surgery, the heart-lung bypass machine (called "on-pump" surgery) is used to take over for the heart and lungs during surgery, allowing the circulation of blood throughout the rest of the body. The heart's beating is stopped so the surgeon can perform the bypass procedure on a "still" heart.

Traditional coronary artery bypass graft (CABG) surgery

During traditional CABG, a surgeon will make an incision down the center of your sternum (breastbone), to get direct access to your heart. You are connected to the heart-lung bypass machine which allows the circulation of blood throughout the body during surgery. The heart is stopped and the surgeon then performs the bypass procedure. After surgery, the surgeon closes the breastbone with special sternal wires and the chest with special internal or traditional external stitches.

Minimally invasive coronary artery bypass (MIDCAB) surgery

Your surgeon will review your diagnostic tests prior to your surgery to see if you are a candidate for minimally invasive bypass surgery.
Minimally invasive bypass surgery can be performed through a small thoracotomy incision for patients that require a LIMA graft to the LAD.
Newer robotic techniques are allowing surgeons to perform bypass surgery through even smaller keyhole incisions.

The benefits to minimally invasive bypass surgery include

• Smaller incision - smaller scar
• Shorter hospital stay - in some cases, only 3 days are needed (instead of the average 5 - 6 days for traditional surgery)

Other benefits may include

• Shorter recovery time
• Less bleeding
• Less potential for infection
• Less pain and trauma

Off-pump or beating heart bypass surgery

Off-pump or beating heart bypass surgery allows surgeons to perform surgery on the heart while it is still beating. The heart-lung machine is not used. The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.

Bypass Grafts

There are several types of bypass grafts that can be used. These types of blood vessels can be used because there are other pathways that take blood to and from the tissues of your chest, arms, and legs. The surgeon decides which graft(s) to use depending on the location of blockage, the amount of blockage, and the size of your coronary arteries.

Internal mammary arteries (also called thoracic arteries, IMA grafts)

These are the most common bypass grafts used, as they have been shown to have the best long-term results. In most cases, these arteries can be kept intact at their origin, then sewn to the coronary artery below the site of blockage because they have their own oxygen-rich blood supply. If the surgeon removes the mammary artery from its origin, it is then called a "free" mammary artery. Over the last decade, more than 90% of all patients received at least one internal artery graft.

Surgeons use arteries more than veins to bypass narrowed coronary arteries. This is done because the arteries do not close nearly as quickly after surgery as do the veins, which have traditionally been used to bypass arteries of the heart.

Radial artery

The radial artery is the second most common type of arterial graft. There are two arteries in the arm, the ulnar and radial arteries. Most people receive blood to their arm from the ulnar artery and will not have any side effects if the radial artery is used. Careful preoperative and intraoperative tests determine if the radial artery can be used. If you have certain conditions (such as Raynaud's, carpal tunnel syndrome or painful fingers in cold air) you may not be a candidate for this type of bypass graft. The radial artery incision is in your forearm, about 2 inches from your elbow and ending about 1 inch from your wrist. After this type of bypass, patients are routinely placed on a medication called a "calcium channel blocker" for about 6 months after surgery to help keep the radial artery widely open.

The gastroepiploic artery to the stomach and the inferior epigastric artery to the abdominal wall are less commonly used for grafting.

After Surgery

If the procedure was done "on pump," electric shocks start the heart pumping again after the grafts have been completed. The heart-lung machine is turned off and the blood slowly returns to normal. Pacing wires and a chest tube to drain fluid are placed before the sternum is closed surgically with special sternal wires and the chest with special internal or traditional external stitches. Sometimes a temporary pacemaker is attached to the pacing wires to regulate the heart rhythm until your condition improves.

The patient is transferred to an intensive care unit for close monitoring for about one to two days after the surgery. The monitoring during recovery includes frequent checks of vital signs and other parameters, such as heart sounds and oxygen and carbon dioxide levels in arterial blood.

Once the patient is transferred to the nursing unit, the hospital stay is about 3 to 5 more days.

Recovery

Full recovery from coronary artery bypass graft surgery takes two to three months. Most patients are able to drive in about three to eight weeks after surgery. Sexual activity can be resumed in three to four weeks, depending on your rate of recovery. Most people with sedentary jobs can go back to work in four to six weeks after surgery; people with more physical jobs (such as construction workers or jobs requiring heavy lifting) may have to wait up to twelve weeks before returning to work. Your doctor will provide specific guidelines for your recovery and return to work, including specific instructions on how to care for your incision and general health after the surgery.

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