Coronary Artery Bypass Graft (CABG) Surgery
OVERVIEW
- most common cardiothoracic surgical case seen in ICU
- Depending on number of vessels (RCA, LAD or LCx) involved patient is described as having
- Single-vessel disease
- Double-vessel disease
- Triple-vessel disease
- Prognosis depends on
- Number of vessels involved
- Left ventricular function
- can be performed off pump or on pump
INDICATIONS
- Usually requires severe stenosis (>70%) with left main stem or triple vessel disease
- No improved survival seen in patients with single or double-vessel disease
- Improved survival seen in those with poor left ventricular function
- Similar survival seen in patients undergoing angioplasty for multi-vessel disease
DESCRIPTION OF SURGERY
- Chest is entered via a median sternotomy
- Left internal mammary artery (LIMA) is dissected
- Long saphenous vein can be harvested and prepared by second surgeon
- Heart is cannulated and patient is placed on bypass
- Aorta is cross clamped
- Injury to heart reduced by cardioplegic solutions
- Cardioplegia can be either warm (37 degrees) or cold (4 degrees)
- Recent advances include
- Off-pump coronary artery surgery
- Minimally invasive direct coronary artery surgery
- Both can avoid either bypass or median sternotomy
CHOICE OF CONDUIT
- Conduits can be either venous or arterial
- LIMA and long saphenous vein are most common
Long saphenous vein
- Long saphenous vein is easy to harvest by a second surgeon
- Allows multiple grafts to be fashioned
- Patency rate of 60% at 10 years
LIMA
- Left internal mammary artery (LIMA) can be used to graft the left anterior descending (LAD) – only need to divide one end (remains attached to LSCA)
- Patency rate of 90% at 10 years
- see Factors determining LIMA Flow
COMPLICATIONS
- Bleeding
- Pericardial tamponade
- Graft failure (e.g. kinking, disconnection)
- Atrial fibrillation
- Wound infection
- Poor cardiac function
- Stroke
- subclavian-coronary steal (if LIMA graft and proxinal left subclavian artery stenosis)
References and Links
LITFL
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC