Coronary artery bypass surgery - Wikipedia

Coronary artery bypass surgery, also known as coronary artery bypass graft (CABG, pronounced "cabbage") surgery, and colloquially heart bypass or bypass ... Coronaryarterybypasssurgery FromWikipedia,thefreeencyclopedia Jumptonavigation Jumptosearch Surgicalproceduretorestorenormalbloodflowtoanobstructedcoronaryartery "Heartbypass"redirectshere.Forthetechniquetotakeoverthefunctionoftheheartandlungsduringsurgery,seeCardiopulmonarybypass. Thisarticlemaybetootechnicalformostreaderstounderstand.Pleasehelpimproveittomakeitunderstandabletonon-experts,withoutremovingthetechnicaldetails.(April2016)(Learnhowandwhentoremovethistemplatemessage) CoronaryarterybypasssurgeryEarlyinacoronaryarterybypassoperation,duringveinharvestingfromthelegs(leftofimage)andtheestablishmentofcardiopulmonarybypassbyplacementofanaorticcannula(bottomofimage).Theperfusionistandheart-lungmachineareontheupperright.Thepatient'shead(notseen)isatthebottom.OthernamesCoronaryarterybypassgraftICD-10-PCS021209WICD-9-CM36.1MeSHD001026MedlinePlus002946[editonWikidata] Coronaryarterybypasssurgery,alsoknownascoronaryarterybypassgraft(CABG,pronounced"cabbage")surgery,andcolloquiallyheartbypassorbypasssurgery,isasurgicalproceduretorestorenormalbloodflowtoanobstructedcoronaryartery.Anormalcoronaryarterytransportsbloodtotheheartmuscleitself,notthroughthemaincirculatorysystem. Therearetwomainapproaches.Inone,theleftinternalthoracicartery,LITA(alsocalledleftinternalmammaryartery,LIMA)isdivertedtotheleftanteriordescendingbranchoftheleftcoronaryartery.Inthismethod,thearteryis"pedicled"whichmeansitisnotdetachedfromtheorigin.Intheother,agreatsaphenousveinisremovedfromaleg;oneendisattachedtotheaortaoroneofitsmajorbranches,andtheotherendisattachedtotheobstructedarteryimmediatelyaftertheobstructiontorestorebloodflow. CABGisperformedtorelieveanginathatispoorlymanagedbymaximumtoleratedanti-ischemicmedication,preventorrelieveleftventriculardysfunction,and/orreducetheriskofdeath.CABGdoesnotpreventmyocardialinfarction(heartattack).Thissurgeryisusuallyperformedwiththeheartstopped,necessitatingtheusageofcardiopulmonarybypass.However,twoalternativetechniquesarealsoavailable,allowingCABGtobeperformedonabeatinghearteitherwithoutusingthecardiopulmonarybypass,aprocedurereferredtoas"off-pump"surgery,orperformingbeatingsurgeryusingpartialassistanceofthecardiopulmonarybypass,aprocedurereferredtoas"on-pumpbeating"surgery.Thelatterprocedureofferstheadvantagesoftheon-pumpstoppedandoff-pumpwhileminimizingtheirrespectiveside-effects. CABGisoftenindicatedwhencoronaryarterieshavea50to99percentobstruction.Theobstructionbeingbypassedistypicallyduetoarteriosclerosis,atherosclerosis,orboth.Arteriosclerosisischaracterizedbythickening,lossofelasticity,andcalcificationofthearterialwall,mostoftenresultinginageneralizednarrowingintheaffectedcoronaryartery.Atherosclerosisischaracterizedbyyellowishplaquesofcholesterol,lipids,andcellulardebrisdepositedintotheinnerlayerofthewallofalargeormedium-sizedcoronaryartery,mostoftenresultinginapartialobstructionintheaffectedartery.Eitherconditioncanlimitbloodflowifitcausesacross-sectionalnarrowingofatleast50%. Contents 1Terminology 1.1Numberofarteriesbypassed 2Efficacy 2.1Resultscomparedtostentplacement 3Complications 3.1CABGassociated 3.2Openheartsurgeryassociated 3.3Generalsurgeryassociated 4Procedure 4.1Minimallyinvasivetechnique 4.2Choiceofsourceofgrafts 4.3Followup 5Numberperformed 6History 7Cost 8Seealso 9References 10Externallinks Terminology[edit] RenéGerónimoFavalorowasanArgentinecardiacsurgeonandeducatorbestknownforhispioneeringworkoncoronaryarterybypasssurgeryusingthegreatsaphenousvein. Threecoronaryarterybypassgrafts,aLIMAtoLADandtwosaphenousveingrafts–onetotherightcoronaryarterysystemandonetotheobtusemarginalsystem. Therearemanyvariationsinterminology,inwhichoneormoreof"artery","bypass"or"graft"isleftout.ThemostfrequentlyusedacronymforthistypeofsurgeryisCABG(pronounced'cabbage'),[1]pluralizedasCABGs(pronounced'cabbages').Initiallythetermaortocoronarybypass(ACB)wasmorepopularlyusedtodescribethisprocedure.[2]CAGS(coronaryarterygraftsurgery,pronouncedphonetically)shouldnotbeconfusedwithcoronaryangiography(CAG). Numberofarteriesbypassed[edit] Thissectionneedsadditionalcitationsforverification.Pleasehelpimprovethisarticlebyaddingcitationstoreliablesources.Unsourcedmaterialmaybechallengedandremoved.Findsources: "Coronaryarterybypasssurgery" – news ·newspapers ·books ·scholar ·JSTOR(October2016)(Learnhowandwhentoremovethistemplatemessage) Thissectionneedstobeupdated.Pleasehelpupdatethisarticletoreflectrecenteventsornewlyavailableinformation.(October2016) Illustrationdepictingsingle,double,triple,andquadruplebypass Thetermssinglebypass,doublebypass,triplebypass,quadruplebypassandquintuplebypassrefertothenumberofcoronaryarteriesbypassedintheprocedure.Inotherwords,adoublebypassmeanstwocoronaryarteriesarebypassed(e.g.,theleftanteriordescending(LAD)coronaryarteryandrightcoronaryartery(RCA));atriplebypassmeansthreevesselsarebypassed(e.g.,LAD,RCAandleftcircumflexartery(LCX));aquadruplebypassmeansfourvesselsarebypassed(e.g.,LAD,RCA,LCXandfirstdiagonalarteryoftheLAD)whilequintuplemeansfive.Leftmaincoronaryarteryobstructionrequirestwobypasses,onetotheLADandonetotheLCX. Acoronaryarterymaybeunsuitableforbypassgraftingifitissmall(<1 mmor<1.5 mm),heavilycalcified,orlocatedwithintheheartmuscleratherthanonthesurface.Asingleobstructionoftheleftmaincoronaryarteryisassociatedwithahigherriskforacardiacdeathandusuallyreceivesadoublebypass.[3] Thesurgeonreviewsthecoronaryangiogrampriortosurgeryandidentifiesthenumberofobstructions,thepercentobstructionofeach,andthesuitabilityofthearteriesbeyondtheobstruction(s)astargets.Thepresumednumberofbypassgraftsneededaswellasthelocationforgraftattachmentisdeterminedinapreliminaryfashionpriortosurgery,butthefinaldecisionastonumberandlocationismadeduringsurgerybydirectexaminationoftheheart. Efficacy[edit] The2004ACC/AHACABGguidelinesstateCABGisthepreferredtreatmentfor:[4] Diseaseoftheleftmaincoronaryartery(LMCA). Diseaseofallthreecoronaryarteries(LAD,LCXandRCA). Diffusediseasenotamenabletotreatmentwithapercutaneouscoronaryintervention(PCI). The2005ACC/AHAguidelinesfurtherstatethatCABGisthepreferredtreatmentwithotherhigh-riskpatientssuchasthosewithsevereventriculardysfunction(i.e.lowejectionfraction),ordiabetesmellitus.[4] Bypasssurgerycanprovidereliefofanginawhenthelocationofpartialobstructionsprecludesimprovingbloodflowwithstents. Thereisnosurvivalbenefitwithbypasssurgeryvs.medicaltherapyinstableanginapatients.[citationneeded]However,thereisobviousbenefitofCABGsurgerywhencomparedtomedicaltherapy,asitprolongssurvivalnotonlyinpatientswith3-vesseldiseasebutalsowithleftmaindiseaseand1-or2-vesseldiseasewithproximalLADdisease.[5] Bypasssurgerydoesnotpreventfuturemyocardialinfarctions.[6] AgeperseisnotafactorindeterminingriskvsbenefitofCABG.[7] PrognosisfollowingCABGdependsonavarietyoffactors,andsuccessfulgraftstypicallylast8–15years.[citationneeded]Ingeneral,CABGimprovesthechancesofsurvivalofpatientswhoareathighrisk(generallytripleorhigherbypass),thoughstatisticallyafteraboutfiveyearsthedifferenceinsurvivalratebetweenthosewhohavehadsurgeryandthosetreatedbydrugtherapydiminishes.AgeatthetimeofCABGiscriticaltotheprognosis,youngerpatientswithnocomplicatingdiseasesdoingbetter,whileolderpatientscanusuallybeexpectedtosufferfurtherblockageofthecoronaryarteries.[8] Veinsthatareusedeitherhavetheirvalvesremovedorareturnedaroundsothatthevalvesinthemdonotoccludebloodflowinthegraft.Externalsupportmaybeplacedontheveinpriortograftingintothecoronarycirculationofthepatient.LITAgraftsarelonger-lastingthanveingrafts,bothbecausethearteryismorerobustthanaveinandbecause,beingalreadyconnectedtothearterialtree,theLITAneedonlybegraftedatoneend.TheLITAisusuallygraftedtotheleftanteriordescendingcoronaryartery(LAD)becauseofitssuperiorlong-termpatencywhencomparedtosaphenousveingrafts.[9][10] Resultscomparedtostentplacement[edit] CABGorstentplacementisindicatedwhenmedicalmanagement –anti-anginamedications,statins,antihypertensives,smokingcessation,and/ortightbloodsugarcontrolindiabetics –donotsatisfactorilyrelieveischemicsymptoms. BothPCIandCABGaremoreeffectivethanmedicalmanagementatrelievingsymptoms,[11](e.g.angina,dyspnea,fatigue). CABGissuperiortoPCIformostofthepatientswithmultivesselCAD[12][13]SYNTAXstudyfounda40%highermortalityinpatientwith3-vesselcoronaryarterydiseasetreatedwithPCIincomparisonwithCABG.[14] TheSurgeryorStent(SoS)trialwasarandomizedcontrolledtrialthatcomparedCABGtoPCIwithbare-metalstents.TheSoStrialdemonstratedCABGissuperiortoPCIinmultivesselcoronarydisease.[12] TheSYNTAXtrialwasarandomizedcontrolledtrialof1800patientswithmultivesselcoronarydisease,comparingCABGversusPCIusingdrug-elutingstents(DES).Thestudyfoundthatratesofmajoradversecardiacorcerebrovasculareventsat12monthsweresignificantlyhigherintheDESgroup(17.8%versus12.4%forCABG;P=0.002).[13]Thiswasprimarilydrivenbyhigherneedforrepeatrevascularizationproceduresandmorepost-proceduralmyocardialinfarctioninthePCIgroupwithnodifferenceinlong-termsurvival.[14]HigherratesofstrokeswereseenintheCABGgroup. TheFREEDOM(FutureRevascularizationEvaluationinPatientsWithDiabetesMellitus—OptimalManagementofMultivesselDisease)trialwillcompareCABGandDESinpatientswithdiabetes.Theregistriesofthenonrandomizedpatientsscreenedforthesetrialsmayprovideasmuchrobustdataregardingrevascularizationoutcomesastherandomizedanalysis.[15] AstudycomparingtheoutcomesofallpatientsinNewYorkstatetreatedwithCABGorpercutaneouscoronaryintervention(PCI)demonstratedCABGwassuperiortoPCIwithDESinmultivessel(morethanonediseasedartery)coronaryarterydisease(CAD).PatientstreatedwithCABGhadlowerratesofdeathandofdeathormyocardialinfarctionthantreatmentwithacoronarystent.PatientsundergoingCABGalsohadlowerratesofrepeatrevascularization.[16]TheNewYorkStateregistryincludedallpatientsundergoingrevascularizationforcoronaryarterydisease,butwasnotarandomizedtrial,andsomayhavereflectedotherfactorsbesidesthemethodofcoronaryrevascularization. Ameta-analysiswithover6000patientsshowedthatcoronaryarterybypasswasassociatedwithlowerriskformajoradversecardiaceventscomparedtodrug-elutingstenting.However,patientshadahigherriskofstrokeevents.[17] A2018meta-analysiswithover4000patientcasesfoundhybridcoronaryrevascularization(LIMA-to-LADanastomosiscombinedwithpercutaneousstentsatotheratheroscleroticsites)tohavesignificantadvantagescomparedwithconventionalCABG.Reducedincidenceofbloodtransfusion,reducedhospitalstaydurationandreducedintubationdurationwereallreported.Incontrast,HCRwasfoundtobesignificantlymoreexpensivecomparedtoCABG.[18] Complications[edit] Thissectionneedsadditionalcitationsforverification.Pleasehelpimprovethisarticlebyaddingcitationstoreliablesources.Unsourcedmaterialmaybechallengedandremoved.(May2013)(Learnhowandwhentoremovethistemplatemessage) CABGassociated[edit] Postperfusionsyndrome(pumphead),atransientneurocognitiveimpairmentassociatedwithcardiopulmonarybypass.Someresearchshowstheincidenceisinitiallydecreasedbyoff-pumpcoronaryarterybypass,butwithnodifferencebeyondthreemonthsaftersurgery.Aneurocognitivedeclineovertimehasbeendemonstratedinpeoplewithcoronaryarterydiseaseregardlessoftreatment(OPCAB,conventionalCABGormedicalmanagement).However,a2009researchstudysuggeststhatlongerterm(over5years)cognitivedeclineisnotcausedbyCABGbutisratheraconsequenceofvasculardisease.[19]Lossofmentalfunctionisacomplicationofbypasssurgeryinelderlypeople,andmightinfluenceprocedurecostbenefitconsiderations.[20]Severalfactorsmaycontributetoimmediatecognitivedecline.Theheart-lungbloodcirculationsystemandthesurgeryitselfreleaseavarietyofdebris,includingbitsofbloodcells,tubing,andplaques.Forexample,whensurgeonsclampandconnecttheaortatotubing,resultingemboliblockbloodflowandcauseministrokes.Otherheartsurgeryfactorsrelatedtomentaldamagemaybeeventsofhypoxia,highorlowbodytemperature,abnormalbloodpressure,irregularheartrhythms,andfeveraftersurgery.[21] Nonunionofthesternum;internalthoracicarteryharvestingincreasesthesternumdevascularizationrisk.[22] Myocardialinfarctionduetoembolism,hypoperfusion,orgraftfailure.Inmostcases,earlygraftfailurecanbesuccessfullytreatedinordertoimproveoutcomes.[23]Whileremoteischaemicpreconditioning(RIPC)reducesthecardiactroponinT(cTnT)releasemeasuredat72hoursaftersurgeryandcardiactroponinI(cTnI)releasemeasuredat48hoursand72hoursaftersurgery,itdoesnotreducereperfusioninjuryinpeopleundergoingcardiacsurgery.[24] Lategraftstenosis,particularlyofsaphenousveingraftsduetoatherosclerosiscausingrecurrentanginaormyocardialinfarction.[25] Acuterenalfailureduetoembolismorhypoperfusion.[26][27] Stroke,secondarytoembolismorhypoperfusion.[28] Vasoplegicsyndrome,secondarytocardiopulmonarybypassandhypothermia Pneumothorax:Anaircollectionaroundthelungthatcompressesthelung[27] Hemothorax:Bloodinthespacearoundthelungs Pericardialtamponade:Bloodcollectionaroundtheheartthatcompressestheheartandcausespoorbodyandbrainperfusion.Chesttubesareplacedaroundtheheartandlungtopreventthis.Ifthechesttubesbecomecloggedintheearlypostoperativeperiodwhenbleedingisongoingthiscanleadtopericardialtamponade,pneumothoraxorhemothorax. Pleuraleffusion:Fluidinthespacearoundthelungs.Thiscanleadtohypoxiawhichcanslowrecovery. Pericarditis Lowerextremityedema,extravasation,inflammation,andeccymosesfromveinharvest;entrapmentofupto9pounds(4.1 kg)offluidintheextremityiscommon.Thisismanagedwithathighlengthcompressionstocking,elevationofthelimb,andearlyandfrequentslowwalking;aswellasavoidanceofstandinginplace,sitting,andbendingthelegatthekneemorethanafewdegrees. Openheartsurgeryassociated[edit] Post-operativeatrialfibrillationandatrialflutter.[29] Anemia-secondarytobloodloss,plustheanemiaofinflammation,inflammationbeinginevitablewithopeningthechestplusharvestingoflegvein(s)forgrafting.Afallinthehemoglobinfromnormalpreoperativelevels(e.g.15)topostoperativelevelsof6to10areinevitable.Thereisnobenefitfromtransfusionsuntilthehemoglobinfallsbelow7.5.[30]Institutionsshouldestablishprotocolstoensuretransfusionsarenotgivenunlessthehemoglobinfallsbelow7.5withoutsomeadditionalcompellingreason(s).[31] Delayedhealingorrefractureofsternum-thesternumisbifurcatedlongitudinally(amediansternotomy)andretractedtoaccesstheheart.Failuretofollow"sternalprecautions"followingsurgerycouldresultindelayedhealingorrefractureofthesternumwhichwassuturedattheclosureofthechestwound: Holdapillowagainstthechestwhenevergettingoutoforintoachairorbed;orcoughing,sneezing,blowingnose,orlaughing,inordertoopposetheintrathoracicoutwardforcecreatedbytheseactivitiesonthehealingsternum. Avoidusingthepectoralmuscles,suchasbypushingonthechairarmstoassistone'sselfoutofachair,orbyusingthearmstoassistinsittingdown.Properstandingtechniqueistorockthreetimesinthechairandthenstandtoprovidemomentumformovingthecenterofgravityfromthesittingtothestandingposition.Propersittingtechniqueistoslowlylowerthebottomtowardthechairseatusinggluteusandquadricepsmuscles("legsonly")withoutgrabbingthechairarms.Second,patientsshouldavoidliftingobjectsutilizingthepectoralmuscles:carryinglightobjectswitharmsextendeddownatsides,andliftinglightobjectswiththeelbowspressedtothechestandusingthebiceps,areacceptable.Also,avoidusingthearmsoverhead. Avoidsittinginthecarfrontseat(nodriving)foratleastfourweeks:theexplosionofthedeploymentofanairbagcouldrefracturethesternalunion. Generalsurgeryassociated[edit] Infectionatincisionsites Sepsis Deepveinthrombosis Anestheticcomplicationssuchasmalignanthyperthermia Keloidscarring Chronicpainatincisionsites Chronicstressrelatedillnesses Procedure[edit] Illustrationofatypicalcoronaryarterybypasssurgery.Aveinfromthelegisremovedandgraftedtothecoronaryarterytobypassablockage. Coronaryarterybypasssurgeryduringmobilization(freeing)oftherightcoronaryarteryfromitssurroundingtissue,adiposetissue(yellow).Thetubevisibleatthebottomistheaorticcannula(returnsbloodfromtheHLM).Thetubeaboveit(obscuredbythesurgeonontheright)isthevenouscannula(receivesbloodfromthebody).Thepatient'sheartisstoppedandtheaortaiscross-clamped.Thepatient'shead(notseen)isatthebottom. Thissectiondoesnotciteanysources.Pleasehelpimprovethissectionbyaddingcitationstoreliablesources.Unsourcedmaterialmaybechallengedandremoved.(December2010)(Learnhowandwhentoremovethistemplatemessage) Thepatientisbroughttotheoperatingroomandmovedontotheoperatingtable. Ananaesthetistplacesintravenousandarteriallinesandinjectsananalgesic,usuallyfentanyl,intravenously,followedwithinminutesbyaninductionagent(usuallypropofoloretomidate)torenderthepatientunconscious. Anendotrachealtubeisinsertedandsecuredbytheanaesthetistandmechanicalventilationisstarted.Generalanaesthesiaismaintainedwithaninhaledvolatileanestheticagentsuchasisoflurane. Thechestisopenedviaamediansternotomyandtheheartisexaminedbythesurgeon. Thebypassgraftsareharvested–frequentvesselsaretheinternalthoracicarteries,radialarteriesandsaphenousveins.Whenharvestingisdone,thepatientisgivenheparintoinhibitbloodclotting. Inthecaseof"off-pump"surgery,thesurgeonplacesdevicestostabilizetheheart. Inthecaseof"on-pump"surgery,thesurgeonsuturescannulaeintotheheartandinstructstheperfusionisttostartcardiopulmonarybypass(CPB)normallyinstructingtheperfusionistto"Goonpump".OnceCPBisestablished,therearetwotechnicalapproaches:eitherthesurgeonplacestheaorticcross-clampacrosstheaortaandinstructstheperfusionisttodelivercardioplegiawithacooledpotassiummixturetostoptheheartandslowitsmetabolismorperformingbypassesonbeatingstate(on-pumpbeating). Oneendofeachveingraftissewnontothecoronaryarteriesbeyondtheobstructionandtheotherendisattachedtotheaortaoroneofitsbranches.Fortheinternalthoracicartery,thearteryisseveredandtheproximalintactarteryissewntotheLADbeyondtheobstruction.Asidethelatterclassicalapproach,thereareemergingtechniquesforconstructionofcompositegraftsastoavoidingconnectinggraftsontheascendingaorta(Un-Aortic)inviewofdecreasingneurologiccomplications. Theheartisrestartedbyremovingtheaorticcrossclamp;orin"off-pump"surgery,thestabilizingdevicesareremoved.IncaseswheretheaortaispartiallyoccludedbyaC-shapedclamp,theheartisrestartedandsuturingofthegraftstotheaortaisdoneinthispartiallyoccludedsectionoftheaortawhiletheheartisbeating. Oncethegraftsarecompleteddistallyandproximally,thepatientisrewarmedtoanormaltemperatureandtheheartandotherpressuresarenormaltosupportcomingoffthebypassmachine,weaningoffthebypassmachinebegins. Theperfusionistmakessuretheyhaveenoughvolumetocomeoffbypass,confirmsthatanesthesiaisventilatingthepatient,confirmsthatvacuumassistisoff(ifused),andvocalizeseachstepintheweaningprocesstothesurgeonandanesthesia.Volumecanbegiventothepatientthroughthearteriallineofthebypassmachinewhiletheaorticcannulaisstillin. Protamineisgiventoreversetheeffectsofheparin. Chesttubesareplacedinthemediastinalandpleuralspacetodrainbloodfromaroundtheheartandlungs. Thesternumiswiredtogetherandtheincisionsaresuturedclosed. Thepatientismovedtoanintensivecareunit(ICU)orcardiacuniversalbed(CUB)torecover.NursesintheICUmonitorbloodpressure,urineoutput,respiratorystatus,andchesttubesforexcessiveornodrainage. AfterawakeningandstabilizingintheICUfor18to24hours,thepersonistransferredtothecardiacsurgeryward.IfthepatientisinaCUB,equipmentandnursingis"steppeddown"appropriatetothepatient'sprogresswithouthavingtomovethepatient.Vitalsignmonitoring,remoterhythmmonitoring,earlyambulationwithassistance,breathingexercises,paincontrol,bloodsugarmonitoringwithintravenousinsulinadministrationbyprotocol,andanti-plateletagentsareallstandardsofcare. Thepatientwithoutcomplicationsisdischargedinfourorfivedays. Minimallyinvasivetechnique[edit] Alternatemethodsofminimallyinvasivecoronaryarterybypasssurgeryhavebeendeveloped.Off-pumpcoronaryarterybypass(OPCAB)isatechniqueofperformingbypasssurgerywithouttheuseofcardiopulmonarybypass(theheart-lungmachine).[32]Avoidanceofaorticmanipulationmaybeachievedthroughthe"anaortic"orno-touchOPCABtechnique,whichhasbeenshowntoreducestrokeandmortalitycomparedtoon-pumpCABG.[33]FurtherrefinementstoOPCABhaveresultedinminimallyinvasivedirectcoronaryarterybypasssurgery(MIDCAB),atechniqueofperformingbypasssurgerythrougha5to10 cmincision.[34] HybridCoronaryRevascualrisation,wheretheLIMA-to-LADanastomosisiscombinedwithpercutaneousstentsinotheratheroscleroticsites,hasbeenshowntohavesignificantadvantagescomparedtoconventionalCABG,includingadecreaseintheincidenceofbloodtransfusion,andareducedintubationtime.A2018meta-analysishashoweverdemonstratedagreaterfinancialcostwhencomparedtoconventionalCABG.[35] Choiceofsourceofgrafts[edit] Heartbypasspatientshowingalmostinvisibleresidualscarring.Left:daysafteroperation.Middle:chestscar,twoyearslater.Right:legscarfromharvestedvein,twoyearslater. Thechoiceofvessel(s)ishighlydependentupontheparticularsurgeonandinstitution.Typically,theleftinternalthoracicartery(LITA)(previouslyreferredtoasleftinternalmammaryarteryorLIMA)isgraftedtotheleftanteriordescendingarteryandacombinationofotherarteriesandveinsisusedforothercoronaryarteries.[36]Thegreatsaphenousveinfromthelegisusedapproximatelyin80%ofallgraftsforCABG.[37]Therightinternalthoracic(mammary)artery(RITAorRIMA)andtheradialartery-RAfromtheforearmarefrequentlyusedaswell;[38]intheU.S.,radialarteryandsaphenousveingraftareusuallyharvestedeitherendoscopically,usingatechniqueknownasendoscopicvesselharvesting(EVH),orwiththeopen-bridgingtechnique,employingtwoorthreesmallincisions.Therightgastroepiploicarteryfromthestomachisinfrequentlyusedgiventhedifficultmobilizationfromtheabdomen.However,analysispublishedin2015demonstratedanangiographicsuperiorityofRIMAandRAoverSVG,whiletheRIMAisexpectedtoachieveabetterpatencyratethantheRA.[39][40] Followup[edit] Acute-patientswithoutcomplicationsaretypicallyseen3–4weekspostoperatively,atwhichtimedrivingmayberesumedandformalcardiacrehabilitationbeguntoincreaseaerobicenduranceandmuscularstrength. Chronic- acardiacstresstestatfiveyearsisrecommended,evenintheabsenceofcardiacsymptoms.[41][42] anintensivemedicalregimenincludingstatins,aspirin,andaerobicexerciseisessentialtodelayingtheprogressionofplaqueformationinboththenativeandgraftedvessels. Illustrationdepictingcoronaryarterybypasssurgery(doublebypass) IllustrationofSinglebypass IllustrationofDoublebypass IllustrationofTriplebypass IllustrationofQuadruplebypass Numberperformed[edit] CABGisoneofthemostcommonproceduresperformedduringU.S.hospitalstays;itaccountedfor1.4%ofalloperatingroomproceduresperformedin2011.[43]Between2001and2011,however,itsvolumedecreasedby46%,from395,000operatingproceduresperformedin2001to213,700proceduresin2011.[44] Between2000and2012,thenumberofCABGprocedurescarriedoutdecreasedacrossthemajorityofOECDcountries.However,thereremainedsubstantialvariationintherateofprocedures,withtheU.S.carryingoutfourtimesasmanyCABGoperationsper100,000peopleasSpain.[45]Thesedifferencesdonotappeartobecloselyrelatedtotheincidenceofheartdisease,butmaybeduetovariationinfinancialresources,capacity,treatmentprotocolsandreportingmethods.[46] History[edit] ThefirstcoronaryarterybypasssurgerywasperformedintheUnitedStatesonMay2,1960,attheAlbertEinsteinCollegeofMedicine-BronxMunicipalHospitalCenterbyateamledbyRobertH.Goetzandthethoracicsurgeon,MichaelRohmanwiththeassistanceofJordanHallerandRonaldDee.[47][48]Inthistechniquethevesselsareheldtogetherwithcircumferentialligaturesoveraninsertedmetalring.Theinternalmammaryarterywasusedasthedonorvesselandwasanastomosedtotherightcoronaryartery.TheactualanastomosiswiththeRosenbachringtookfifteensecondsanddidnotrequirecardiopulmonarybypass.Thedisadvantageofusingtheinternalmammaryarterywasthat,atautopsyninemonthslater,theanastomosiswasopen,butanatheromatousplaquehadoccludedtheoriginoftheinternalmammarythatwasusedforthebypass.[citationneeded][verificationneeded] Sovietcardiacsurgeon,VasiliiKolesov,performedthefirstsuccessfulinternalmammaryartery–coronaryarteryanastomosisin1964.[49][50]However,Goetzhasbeencitedbyothers,includingKolesov,[51]asthefirstsuccessfulhumancoronaryarterybypass.[52][53][54][55][56][57]Goetz'scasehasfrequentlybeenoverlooked.Confusionhaspersistedforover40yearsandseemstobeduetotheabsenceofafullreportandtomisunderstandingaboutthetypeofanastomosisthatwascreated.Theanastomosiswasintima-to-intima,withthevesselsheldtogetherwithcircumferentialligaturesoveraspeciallydesignedmetalring.Kolesovdidthefirstsuccessfulcoronarybypassusingastandardsuturetechniquein1964,andoverthenextfiveyearsheperformed33suturedandmechanicallystapledanastomosesinLeningrad(nowSt.Petersburg),USSR.[58][59] RenéFavaloro,anArgentinesurgeon,achievedaphysiologicapproachinthesurgicalmanagementofcoronaryarterydisease—thebypassgraftingprocedure—attheClevelandClinicinMay1967.[50][60]Hisnewtechniqueusedasaphenousveinautografttoreplaceastenoticsegmentoftherightcoronaryartery.Later,hesuccessfullyusedthesaphenousveinasabypassingchannel,whichhasbecomethetypicalbypassgrafttechniqueweknowtoday;intheU.S.,thisvesselistypicallyharvestedendoscopically,usingatechniqueknownasendoscopicvesselharvesting(EVH). SoonDudleyJohnsonextendedthebypasstoincludeleftcoronaryarterialsystems.[50] In1968,doctorsCharlesBailey,TeruoHiroseandGeorgeGreenusedtheinternalmammaryarteryinsteadofthesaphenousveinforthegrafting.[50] Cost[edit] AccordingtotheCDC,theaveragecostofhospitalization(only)associatedwithacoronarybypassoperationintheUnitedStatesin2013was$38,707,foranaggregatehospitalizationcostof$6.4billion.[61]TheInternationalFederationofHealthcarePlans[62]hasestimatedtheaveragecostofhospitalizationandphysicianfeesforacoronarybypassoperationinvariouscountriesasshownintheTablebelow.[63] InAustralia,acoronarybypasssurgerycosts$2,268.75.[64]However,thoseenlistedintheMedicarehealthcarescheme[65]aregranteda75%rebate,withthebenefitcomingto$1,701.60. Country Cost UnitedStates $75,345 NewZealand $40,368 Switzerland $36,509 Argentina $16,492 Spain $16,247 Netherlands $15,742 India $1,583[66] Australia $567.15[64] Seealso[edit] Angioplasty Cardiothoracicsurgery Dressler'ssyndrome Hybridcoronaryrevascularization Totallyendoscopiccoronaryarterybypasssurgery Chesttube References[edit] ^"BypassSurgery,CoronaryArtery".AmericanHeartAssociation.RetrievedMarch26,2010. ^"Resultsfor"aortocoronarybypass,coronaryarterybypassgraft"between1960and2008".GoogleNgramViewer.Retrieved8January2015. ^Ramadan,Ronnie(April2018)."ManagementofLeftMainCoronaryArteryDisease".JAmHeartAssoc.7(7):e008151.doi:10.1161/JAHA.117.008151.PMC 5907594.PMID 29605817. 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Externallinks[edit] ABBCfilmshowingapatientundergoingadoublebypassoperation. ClevelandClinicpageoncoronaryarterybypasssurgery vteTestsandproceduresinvolvingtheheartCardiacsurgery ·Interventionalcardiology ·Cardiologydiagnostictestsandprocedures ·CardiacimagingSurgeryHeartvalvesandsepta Valverepair Valvulotomy Mitralvalverepair Valvuloplasty aortic mitral Valvereplacement Aorticvalverepair Aorticvalvereplacement Rossprocedure Percutaneousaorticvalvereplacement Mitralvalvereplacement Percutaneouspulmonaryvalveimplantation productionofseptaldefectinheart enlargementofexistingseptaldefect Atrialseptostomy Balloonseptostomy creationofseptaldefectinheart Blalock–Hanlonprocedure shuntfromheartchambertobloodvessel atriumtopulmonaryartery Fontanprocedure leftventricletoaorta Rastelliprocedure rightventricletopulmonaryartery Sanoshunt compoundprocedures fortranspositionofthegreatvessels Arterialswitchoperation Mustardprocedure Senningprocedure foruniventriculardefect Norwoodprocedure Kawashimaprocedure shuntfrombloodvesseltobloodvessel systemiccirculationtopulmonaryarteryshunt Blalock–Taussigshunt SVCtotherightPA Glennprocedure Cardiacvessels CHD Angioplasty Bypass/Coronaryarterybypass MIDCAB Off-pumpCAB TECAB Coronarystent Bare-metalstent Drug-elutingstent Bentallprocedure Valve-sparingaorticrootreplacement LeComptemaneuver Other Pericardium Pericardiocentesis Pericardialwindow Pericardiectomy Myocardium Cardiomyoplasty Dorprocedure Septalmyectomy Ventricularreduction Alcoholseptalablation Conductionsystem Mazeprocedure Coxmazeandminimaze Catheterablation Cryoablation Radiofrequencyablation Pacemakerinsertion S-ICDimplantation ICDimplantation Cardiacresynchronizationtherapydeviceimplantation Leftatrialappendageocclusion Cardiotomy Hearttransplantation Tests Electrophysiology Electrocardiography Vectorcardiography Holtermonitor Implantablelooprecorder Cardiacstresstest Bruceprotocol Electrophysiologystudy Cardiacimaging Angiocardiography Echocardiography TTE TEE Myocardialperfusionimaging CardiovascularMRI Ventriculography Radionuclideventriculography Cardiaccatheterization/Coronarycatheterization CardiacCT CardiacPET sound Phonocardiogram Functiontests Impedancecardiography Ballistocardiography Cardiotocography Pacing Cardioversion Transcutaneouspacing Category Retrievedfrom"https://en.wikipedia.org/w/index.php?title=Coronary_artery_bypass_surgery&oldid=1080363916" Categories:CardiacsurgeryHiddencategories:CS1Japanese-languagesources(ja)CS1Russian-languagesources(ru)CS1errors:externallinksArticleswithshortdescriptionShortdescriptionmatchesWikidataWikipediaarticlesthataretootechnicalfromApril2016AllarticlesthataretootechnicalArticlesneedingadditionalreferencesfromOctober2016AllarticlesneedingadditionalreferencesWikipediaarticlesinneedofupdatingfromOctober2016AllWikipediaarticlesinneedofupdatingAllarticleswithunsourcedstatementsArticleswithunsourcedstatementsfromJanuary2019ArticleswithunsourcedstatementsfromMarch2015ArticlesneedingadditionalreferencesfromMay2013ArticlesneedingadditionalreferencesfromDecember2010ArticleswithunsourcedstatementsfromJune2010AllpagesneedingfactualverificationWikipediaarticlesneedingfactualverificationfromJune2010 Navigationmenu Personaltools NotloggedinTalkContributionsCreateaccountLogin Namespaces ArticleTalk English Views ReadEditViewhistory More Search Navigation MainpageContentsCurrenteventsRandomarticleAboutWikipediaContactusDonate Contribute HelpLearntoeditCommunityportalRecentchangesUploadfile Tools WhatlinkshereRelatedchangesUploadfileSpecialpagesPermanentlinkPageinformationCitethispageWikidataitem Print/export DownloadasPDFPrintableversion Inotherprojects WikimediaCommons Languages العربيةCatalàČeštinaDeutschΕλληνικάEspañolفارسیFrançais한국어Հայերենहिन्दीBahasaIndonesiaÍslenskaItalianoעבריתLatviešuМакедонскиNederlands日本語NorskbokmålOʻzbekcha/ўзбекчаPolskiPortuguêsРусскийSimpleEnglishSlovenčinaСрпски/srpskiSrpskohrvatski/српскохрватскиSuomiSvenskaTürkçeУкраїнська粵語中文 Editlinks