Coronary artery bypass grafting - Knowledge @ AMBOSS

There are no absolute contraindications for CABG. Relative contraindications include: Asymptomatic patients with a low risk of myocardial ... ExpandallsectionsRegisterLoginCoronaryarterybypassgraftingLastupdated:May5,2021SummaryCoronaryarterybypassgrafting(orCABG)isacardiacrevascularizationtechniqueusedtotreatpatientswithsignificant,symptomaticstenosisofthecoronaryartery(oritsbranches).Thestenosedsegmentisbypassedusinganarterial(e.g.,internalthoracicartery)orvenous(e.g.,greatsaphenousvein)autograft,re-establishingbloodflowtotheischemicareasofthemyocardium.Thismaybeperformedeitherwiththehelpofaheart-lungbypassmachine(traditionalCABG,performedviaathoracotomy),oronabeatingheart(off-pumpCABG,andminimallyinvasivedirectCABG).Inadditiontogeneralsurgicalrisks,themaincomplicationsassociatedwithbypassgraftingarebypassocclusionandpostpericardiotomysyndrome.TheprocedureprovidesmoreeffectivesymptomreliefthanmedicalmanagementandissuperiortoPCIinmultivesselcoronarydisease. IndicationsIndicationforCABGisestablishedaftercarefulconsiderationoftheclinicalfeatures,coronarycatheterizationfindings,cardiacfunction,andthepatient'sgeneralcondition. High-gradeleftmainstemcoronaryarterystenosisSignificantstenosis(>70%)oftheproximalleftanteriordescendingartery,with2-vesselor3-vesseldiseaseSymptomatic2-vesselor3-vesseldiseaseDisablinganginadespitemaximalmedicaltherapyPoorleftventricularfunctionwithmyocardiumthatcanreturntofunctiononrevascularization Postinfarctangina IndicationsforemergencyCABG Non-STsegmentelevationmyocardialinfarctionwithongoingischemiathatisunresponsivetomedicaltherapy/PCI STEMIwithinadequateresponsetoallnonsurgicaltherapySignificantongoingischemia,traumaticcomplications,orthreatenedocclusioninSTEMI,afterafailedPCIorpreviousCABG ContraindicationsTherearenoabsolutecontraindicationsforCABG.Relativecontraindicationsinclude: Asymptomaticpatientswithalowriskofmyocardialinfarctionordeath Comorbidities(e.g.,COPD,pulmonaryhypertension,systemicdiseases)Advancedage[1] Welistthemostimportantcontraindications.Theselectionisnotexhaustive.Procedure/application Overviewofsteps Thoracotomyviaamidlinesternotomy→cardiopulmonarybypass;(heart-lungmachine)→cardioplegicarrestoftheheart→anastomosisofthebypassvesselsdistaltothecoronaryarterystenosisusingautologousvessels Typesofgrafts Arterialgraft Internalthoracicartery(internalmammaryartery) Goodaccessibility,closeproximitytotheheart Leftthoracicarteryissuitableforbridgingstenosesintheleftanteriordescendingarteryduetotheirclosespatialproximity. Radialartery:performancemodifiedAllentestbeforeCABG Venousgraft(aortocoronarysaphenousveinbypass,orACVB) Greatsaphenousvein(firstchoiceinveinbypassgraftsbecauseofgoodsurgicalaccesstothelong,superficiallegveinwithsuitablevesselcross-section) Smallsaphenousvein TypesofCABG TraditionalCABG Off-pumpcoronaryarterybypass(OPCAB)surgeryMinimallyinvasivedirect,ortotallyendoscopicCABG Alternateprocedure:percutaneouscoronaryintervention(PCI) Advantages:decreasedperiproceduralmorbidity,decreasedcost,decreasedhospitalstayDisadvantages:higherrateofpatientsrequiringreintervention CABGisproventobeasuperiorlong-termformofrevascularizationinhigh-riskmultivesseldisease(diabeticsorlowLVfunction),certaincasesofseveretwo-vesselCAD,andinallpatientswiththree-vesselCAD. PCIispreferredincaseswithsymptomaticlow-riskobstruction(singlevessel,milddoublevesselobstruction). Postoperativelong-termtreatmentwithantiplateletdrugs(e.g.,100mgaspirin1-0-0)isrequiredtoreducetheriskofsubsequentmyocardialischemia. ComplicationsCardiaccomplications Myocardialdysfunction Postpericardiotomysyndrome:autoimmunefebrilepericarditisorpleuritisthatmayoccur1–6weeksfollowingcardiacsurgery Features Fever,malaise Chestpain,withorwithoutassociateddyspnea TachycardiaPericardialfrictionrub Treatment Anti-inflammatorydrugs:nonsteroidalanti-inflammatorydrugs(NSAIDs)orprednisonePericardialdrainage Surgery:formationofapericardialwindowthroughthoracotomyorbymeansofaballooncatheter Postoperativecardiactamponadewithcardiogenicshock BypassocclusionArrhythmias Mediastinalcomplications Postoperativeacutemediastinitis Nasalcolonizationwithmethicillin-susceptibleStaphylococcusaureuspriortosurgeryisassociatedwithahigherincidenceofpostoperativemediastinitis Features:fever,chestpain,↑WBC,chestx-rayshowsmediastinalwidening Treatment:surgical(drainageanddebridement),long-termantibiotics(minimumof4–6weeks) Mediastinalhemorrhage Features:excessiveblood(>100–200mLperhour)inchesttubedrainage;decreasedcardiacoutput,hemoglobin,bloodpressure,orurineoutput;chestx-rayshowsmediastinalwidening Treatment:raisingtheairwaypressureforartificialventilation;surgicalexplorationofthemediastinum Other Complicationsresultingfromsternotomy(woundinfection,sternaldehiscence,sternalosteomyelitis,etc.)Postoperativerenalfailure Neurologicdeficitsandcoma References:[2] Welistthemostimportantcomplications.Theselectionisnotexhaustive.Outcomeandprognosis PrognosisfollowingCABGdependsonavarietyoffactors,suchasanatomicallocationandseverityofthestenoses,presenceofcomorbidities,patientage,andpreoperativelevelsofactivity.Successfulgraftstypicallylast8–15yearsandprovideanimprovedchanceofsurvival(decreased5-yearmortality,especiallyinpatientswithtriplevesseldisease).FurtherprogressionofarteriosclerosismaystilloccurafterCABG. References ShanL,SaxenaA,McmahonR,NewcombA.Coronaryarterybypassgraftsurgeryintheelderly:areviewofpostoperativequalityoflife.Circulation.2013;128 (21):p.2333-2343. doi:10.1161/CIRCULATIONAHA.112.000729.|OpeninReadbyQxMD CoronaryArteryBypassGrafting(CABG). http://www.merckmanuals.com/professional/cardiovascular-disorders/cardiovascular-tests-and-procedures/coronary-artery-bypass-grafting-cabg. Updated:February1,2016. Accessed:April10,2017. HeroldG.InternalMedicine. HeroldG ;2014 3freearticlesremainingYouhave3freemember-onlyarticlesleftthismonth.Signupandgetunlimitedaccess.SignupHaveanaccount?LogIn Evidence-basedcontent,createdandpeer-reviewedbyphysicians.Readthedisclaimer