Coronary Artery Bypass Grafting - Medscape Reference

Contraindications. CABG is not considered appropriate in asymptomatic patients who are at a low risk of MI or death. Patients who will ... ForYou News&Perspective Drugs&Diseases CME&Education Academy Video DecisionPoint Edition: English Medscape English Deutsch Español Français Português UKNew Univadis LogIn SignUpIt'sFree! EnglishEdition Medscape English Deutsch Español Français Português UKNew Univadis X UnivadisfromMedscape Register LogIn NoResults NoResults ForYou News&Perspective Drugs&Diseases CME&Education Academy Video DecisionPoint close PleaseconfirmthatyouwouldliketologoutofMedscape. Ifyoulogout,youwillberequiredtoenteryourusernameandpasswordthenexttimeyouvisit. Logout Cancel https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTg5Mzk5Mi1vdmVydmlldw== processing.... Drugs&Diseases > ClinicalProcedures CoronaryArteryBypassGrafting Updated:Mar28,2022 Author:RohitShahani,MD,MCh,FACC,FACS;ChiefEditor:KarlheinzPeter,MD,PhD more... Share Email Print Feedback Close Facebook Twitter LinkedIn WhatsApp Sections CoronaryArteryBypassGrafting Sections CoronaryArteryBypassGrafting Overview PracticeEssentials Background Indications Contraindications TechnicalConsiderations Outcomes FutureDirections ShowAll PeriproceduralCare PreproceduralEvaluation PatientPreparation MonitoringandFollow-up ShowAll Technique ApproachConsiderations HarvestingoftheConduit CoronaryArteryBypass AlternativeApproachestoCoronaryArteryBypassGrafting Complications Guidelines ShowAll Medication MedicationSummary Anxiolytics,Benzodiazepines OpioidAnalgesics AnestheticAgents NeuromuscularBlockers,Nondepolarizing Anticoagulants,Hematologic ShowAll Questions&Answers MediaGallery Tables References Overview PracticeEssentials Coronaryarterybypassgrafting(CABG)isperformedforpatientswithcoronaryarterydisease(CAD)toimprovequalityoflifeandreducecardiac-relatedmortality. Indications IndividualsunderconsiderationforCABGshouldundergoSocietyofThoracicSurgeons(STS)riskstratification. [1] EvaluationofCADcomplexityinpatientswithmultivesselCADusingtoolssuchastheSYNTAX (SynergyBetweenPCIWithTAXUSandCardiacSurgery)scoremaybeusefulinguidingrevacularization. [1] ClassIindicationsforCABGfromtheAmericanCollegeofCardiology(ACC)andtheAmericanHeartAssociation(AHA)areasfollows [2,3]: Over50%leftmaincoronaryarterystenosis Over70%stenosisoftheproximalleftanteriordescending(LAD)andproximalcircumflexarteries Three-vesseldiseaseinasymptomaticpatientsorthosewithmildorstableangina Three-vesseldiseasewithproximalLADstenosisinpatientswithpoorleftventricular(LV)function One-ortwo-vesseldiseaseandalargeareaofviablemyocardiuminhigh-riskareainpatientswithstableangina Over70%proximalLADstenosiswitheitheranejectionfraction(EF)below50%ordemonstrableischemiaonnoninvasivetesting OtherindicationsforCABGincludethefollowing: Disablingangina(classI) Ongoingischemiainthesettingofanon–STsegmentelevationmyocardialinfarction(MI)thatisunresponsivetomedicaltherapy(classI) PoorLVfunctionbutwithviable,nonfunctioningmyocardiumabovetheanatomicdefectthatcanberevascularized CABGmaybeperformedasanemergencyprocedureinthecontextofanST-segmentelevationMI(STEMI)incaseswhereithasnotbeenpossibletoperformpercutaneouscoronaryintervention(PCI)orwherePCIhasfailedandthereispersistentpainandischemiathreateningasignificantareaofmyocardiumdespitemedicaltherapy. [1,2] Contraindications CABGisnotconsideredappropriateinasymptomaticpatientswhoareatalowriskofMIordeath.Patientswhowillexperiencelittlebenefitfromcoronaryrevascularizationarealsoexcluded. Althoughadvancedageisnotacontraindication,CABGshouldbecarefullyconsideredintheelderly,especiallythoseolderthan85years.ThesepatientsarealsomorelikelytoexperienceperioperativecomplicationsafterCABG. AmultidisciplinaryheartteamapproachthatemphasizesshareddecisionmakinginpatientswithcomplexCADisessentialtoofferthepatientthebestchanceofasuccessfulrevascularizationstrategy. Preproceduralevaluation BeforeperformingCABG,cliniciansshouldcarefullyexaminethepatient’smedicalhistoryforfactorsthatmightpredisposetocomplications,suchasthefollowing: RecentMI Previouscardiacsurgeryorchestradiation Conditionspredisposingtobleeding Renaldysfunction Cerebrovasculardiseaseincludingcarotidbruitsandtransientischemicattack(TIA) Electrolytedisturbancesthatmightpredisposethepatienttodysrhythmias Infection,includingurinarytractinfectionanddentalabscesses Respiratoryfunction,includingthepresenceofchronicobstructivepulmonarydisease(COPD)orinfection [4] Routinepreoperativeinvestigationsincludethefollowing [4]: Fullbloodcount(abnormalitiescorrected) Clottingscreen Creatinineandelectrolytelevels(abnormalitiescorrectedanddiscussedwiththeanesthetist) Liverfunctiontests Screeningformethicillin-resistantStaphylococcusaureus(MRSA) Chestradiography Electrocardiography(ECG) Echocardiographyorventriculography(toassessLVfunction) Coronaryangiography(todefinetheextentandlocationofCAD) AssessmentofRisk Riskmodelstopredict30-daymortalityfollowingisolatedCABGisanactiveareaofresearch.RiskmodelssuchastheEuroscoresystem, [5] andtheSocietyofThoracicSurgeons(STS)2008CardiacSurgeryRiskModel, [6] arethemostcommonlyused predictorsincardiacsurgery.Sharedvariablesinthesetwoimpressivemodelsincludeage,previousMI,peripheralvasculardisease(PVD),renalfailure,hemodynamicstateandEF.IntheSTSmodel,78%ofthevarianceisexplainedbyeightofthemostimportantvariables,whichincludeage,surgicalacuity,reoperativestatus,creatininelevel,dialysis,shock,chroniclungdisease,andEF. Premedication Theaimsofpremedicationaretominimizemyocardialoxygendemandsbyreducingheartrateandsystemicarterialpressureandtoimprovemyocardialbloodflowwithvasodilators.Drugsthatshouldbecontinueduptothetimeofsurgeryareasfollows: Beta-blockers,calciumchannelblockers,andnitrates Aspirin Administeredagentsareasfollows: Temazepamimmediatelypreoperatively Midazolam,asmallintravenous(IV)doseintheoperatingroombeforearteriallineinsertion Eachpatientshouldbecross-matchedwith2unitsofblood(forsimplecases)or6unitsofblood,freshfrozenplasma,andplatelets(forcomplexcases). [4,7,8]Tranexamicacid(1-gbolus beforesurgicalincisionfollowedbyaninfusionof400mg/hrduringsurgery)maybeconsideredtoreducetheamountofpostoperativemediastinalbleedingandthequantityofbloodproductsused(ie,redbloodcellandfreshfrozenplasma) [9] Anesthesia Cardiacsurgeryismostcommonlyperformedunderdeepgeneralendotrachealanesthesia. Rarelyusedadjunctsmakeuseofthefollowingtwoformsofneuraxialblockade: Intrathecalopioidinfusion Thoracicepiduralanesthesia(generallyalow-doselocalanesthetic/opioidinfusion) Monitoring Inadditiontothestandardanestheticmonitoring(ECG,pulseoximetry,nasopharyngealtemperature,urineoutput,gasanalysis),specificmonitoringrequirementsforcardiacsurgeryincludethefollowing: Invasivebloodpressure Centralvenousaccess Transesophagealechocardiography(TEE) Neurologicmonitoring Monitoringofbilateralcerebralsaturations PulmonaryarterypressuremonitoringwithaSwan-Ganzcatheter Technique Sitesfromwhichtheconduitcanbeharvestedincludethefollowing: Saphenousvein Leftinternalthoracic(mammary)artery(LITA) Radialartery Rightinternalthoracic(mammary)artery(RITA) Rightgastroepiploicartery Inferiorepigastricartery Shortsaphenousvein Cephalicveinandupperextremityvein TheusualincisionusedforCABGisamidlinesternotomy(seetheimagebelow),althoughananteriorthoracotomyforbypassoftheLADorlateralthoracotomyformarginalvesselsmaybeusedwhenanoff-pumpprocedureisbeingperformed.Cardiopulmonarybypass,cardioplegicarrest,andplacementofthegraftfollows. CoronaryArteryBypassGrafting.Illustrationofamediansternotomy. ViewMediaGallery AlternativeapproachestoCABGincludethefollowing: Off-pumpCABG MinimallyinvasivedirectCABG(MIDCAB) TotallyendoscopicCABG Hybridtechnique(bypassplusstenting) Robotic-assistedCABG Next: Background Coronaryarterybypassgrafting(CABG)isperformedforpatientswithcoronaryarterydisease(CAD)toimprovequalityoflifeandreducecardiac-relatedmortality.CADistheleadingcauseofmortalityintheUnitedStates [10]andthedevelopedworld, [11]and16.5millionUSadults(age≥20years)areaffectedbythisdiseaseannually. [10] Italoneaccountsfor530,989deathseachyearintheUnitedStates,andthelong-termmanifestationsofCADwithleftventriculardysfunctionandheartfailure areprojectedtoaffectover8millionpeopleagedatleast18yearsby2030. [10] CABGwasintroducedinthe1960swiththeaimofofferingsymptomaticrelief,improvedqualityoflife,andincreasedlifeexpectancytopatientswithCAD. [12,13]Bythe1970s,CABGwasfoundtoincreasesurvivalratesinpatientswithmultivesseldiseaseandleftmaindiseasewhencomparedwithmedicaltherapy. [14] TherelativelynewparadigmfortreatmentofCADcallsforaheartteamapproachthatinvolvesthecardiologistandthecardiacsurgeonevaluatingthecoronaryangiogramtogetherandofferingthebestpossibleoptiontothepatienttoachievecoronaryrevascularization,whetheritbeplacementofapercutaneouscoronarystentorCABG.ItisrecommendedthatIndividualsunderconsiderationforCABGundergo SocietyofThoracicSurgeons(STS)riskstratification. [1] EvaluationofCADcomplexityinpatientswithmultivesselCADusingtoolssuchastheSYNTAX (SynergyBetweenPCIWithTAXUSandCardiacSurgery) scoremaybeusefulinguidingrevacularization. [1] Atpresent,thetypicalpatientforCABGisolder,ismorelikelytohaveundergonepreviouspercutaneouscoronaryintervention(PCI),andhassignificantlymorecomorbidities.Despitetheseadverseriskfactors,CABGcontinuestobeoneofthemostimportantsurgicalproceduresinthehistoryofmodernmedicineandprobablyhasprolongedmorelivesandprovidedmoresignificantsymptomaticreliefthananyothermajoroperationinmedicine.Newer,less-invasiveoptions,advancementinanestheticandintensivecareunit(ICU) management,andtechnologicaladvancesarepushingtheboundariesofthisprocedure tonewheights. Historicalinformation AlexisCarrelreceivedtheNobelprizeinphysiologyandmedicineforhisworkin1912.Hisunderstandingoftheassociationbetweenanginapectorisandcoronaryarterystenosisallowedhimtoanastomoseacarotidarterysegmenttotheleftcoronaryarteryfromthedescendingthoracicaortain caninemodel. [15] Inthelate1940s,thefamousCanadiansurgeonArthurVinebergimplantedtheleftinternalthoracic(mammary)artery,directlyintothemyocardiumoftheanteriorleftventricleinpatientswithsevereanginapectoralis. [16,17,18]Surprisingly,thisprocedureproducedsignificantsymptomaticreliefinafewpatients. [19] In1962,Sabiston,atDukeUniversity,performedthefirst plannedsaphenousveinbypassoperationforcoronaryrevascularization. [20] In1964,Kolessovusedtheleftinternalthoracic(mammary)arterytobypasstheleftanteriordescendingarterywithoutcardiopulmonarybypass, [21]and,in1973,CarpentierintroducedtheuseofradialarterygraftsasconduitsforCABG. [22,23] Inthe1970sandearly1980s,CABGflourishedasthesoletherapyforCAD. Withtheadvent,introduction,andwidespreadadoptionofpercutaneouscoronaryarterystentinginthe1980sand1990stherewasadeclineinthenumberofCABGoperationsperformed.However,severalmulticenterstudiescomparingCABGwithcurrentstenttherapyhaveclearlydemonstratedthe superiorityofCABG,especiallywhencertainpatientcharacteristicssuchasdiabetes,multivesselCADandischemiccardiomyopathyaretakenintoaccount. Previous Next: Indications Coronaryarterybypassgrafting(CABG)isperformedforbothsymptomaticandprognosticreasons.IndicationsforCABGhavebeenclassifiedbytheAmericanCollegeofCardiology(ACC)andtheAmericanHeartAssociation(AHA)accordingtothelevelofevidencesupportingtheusefulnessandefficacyoftheprocedure [2,3]: ClassI:Conditionsforwhichthereisevidenceand/orgeneralagreementthatagivenprocedureortreatmentisusefulandeffective ClassII:Conditionsforwhichthereisconflictingevidenceand/oradivergenceofopinionabouttheusefulnessorefficacyofaprocedureortreatment ClassIIa:Weightofevidenceoropinionisinfavorofusefulnessorefficacy ClassIIb:Usefulnessorefficacyislesswellestablishedbyevidenceoropinion ClassIII:Conditionsforwhichthereisevidenceand/orgeneralagreementthattheprocedure/treatmentisnotusefuloreffective,andinsomecasesitmaybeharmful IndicationsforCABGasdetailedbytheACCandtheAHA arelistedinTable1below. Table1.ACC/AHAIndicationsforCoronaryArteryBypassGrafting [2,3](OpenTableinanewwindow) Indication AsymptomaticorMildAngina StableAngina UnstableAngina/NSTEMI PoorLeftVentricularFunction Leftmainstenosis>50% ClassI ClassI ClassI ClassI StenosisofproximalLADandproximalcircumflexartery>70% ClassI ClassI ClassI ClassI 3-Vesseldisease ClassI ClassI   ClassI,withproximalLADstenosis 2-Vesseldisease   ClassIifthereisalargeareaofviablemyocardiuminahigh-riskarea;ClassIIaifthereisamoderateviableareaandischemia ClassIIb   With>70%proximalLADstenosis ClassIIa ClassIwitheitheranejectionfraction<50%ordemonstrableischemiaonnoninvasivetesting ClassIIa ClassI InvolvingproximalLAD ClassIIb       1-Vesseldisease   ClassIifthereisalargeareaofviablemyocardiuminahigh-riskarea;ClassIIa,ifthereisaviablemoderateareaandischemia ClassIIb   With>70%proximalLADstenosis ClassIIa ClassIIa ClassIIa   InvolvingproximalLAD ClassIIb       ACC=AmericanCollegeofCardiology;AHA=AmericanHeartAssociation;LAD=leftanteriordescending(artery);NSTEMI=non–ST-segmentelevationmyocardialinfarction.   AlexanderandSmithintheNewEnglandJournalofMedicinenotedthefollowing indicationsforCABGareassociatedwithasurvivalbenefitovermedicaltherapy,withorwithoutpercutaneouscoronaryintervention(PCI)include [24]: AcuteST-segmentelevationmyocardialinfarction(STEMI) CADotherthanacuteSTEMI CoronaryanatomynotamenabletoPCI Mechanicalcomplications,suchasventricularseptaldefect,ruptureofthefreeventricularwall,orpapillary-musclerupturewithseveremitralregurgitation Leftmaindiseaseof50%stenosisorgreater,andintermediateorhighcomplexityforPCI(SynergyBetweenPCIwithTAXUSandCardiacSurgery[SYNTAX]score ≥33) Three-vesseldiseaseof70%stenosisorgreater,involvingtheLADandintermediateorhighcomplexityforPCI(SYNTAXscore ≥23) OtherindicationsforCABGincludethefollowing: Disablingangina(ClassI) Ongoingischemiainthesettingofanon-STsegmentelevationmyocardialinfarction(NSTEMI)thatisunresponsivetomedicaltherapy(ClassI) Poorleftventricularfunctionbutwithviable,nonfunctioningmyocardiumabovetheanatomicdefectthatcanberevascularized ClinicallysignificantCADof70%stenosisorgreater,in1ormorevessel(s),andrefractoryanginadespitemedicaltherapyandPCI [24] ClinicallysignificantCADof70%stenosisorgreater,in1ormorevessel(s),insurvivorsofsuddencardiacarrestpresumedtoberelatedtoischemicventriculararrhythmia [24] ClinicallysignificantCADof50%stenosisorgreater,in1ormorevessel(s), inpatientsundergoingcardiacsurgeryforotherindications(eg,valvereplacementoraorticsurgery) [24] CABGmaybeperformedasanemergencyprocedureinthecontextofaSTEMIincaseswhereithasnotbeenpossibletoperformPCIorwherethisprocedurehasfailedandthereispersistentpainandischemiathreateningasignificantareaofthemyocardiumdespitemedicaltherapy. OtherindicationsforCABGinthesettingofSTEMIareventricularseptaldefectrelatedtoMI,papillarymusclerupture,freewallrupture,ventricularpseudoaneurysm,life-threateningventriculararrhythmias,andcardiogenicshock.  FactorsthatincreasethesurvivalbenefitofCABGincludethefollowing [24]: Leftventricularejectionfractionof45%orless Diabetesmellitus Ischemicmitralregurgitation PCIfailure,withorwithoutacuteMI(AMI) IndicationsforCABGwhenPCIisnoninferiortoCABGandwhenPCIorCABGispreferredovermedicaltherapyincludethefollowing [24]: Leftmaindiseaseof50%stenosisorgreater,andlow-to-intermediatecomplexityforPCI(SYNTAXscore ≤32) Three-vesseldiseaseof70%stenosisorgreater,andlowcomplexityforPCI(SYNTAXscore ≤22) Two-vesseldiseaseof70%stenosisorgreater,involvingtheLADandlowcomplexityforPCI(SYNTAXscore ≤22) FactorsthatincreasethebenefitofPCIoverCABGincludethefollowing [24]: ElevatedmortalityriskwithCABG Elevatedstrokerisk Extremefrailty PriorCABG AcuteSTEMIatpresentation Table2belowshowstherecommendationsfortreatmentofpatientswithacuteheartfailureinthesettingofAMI. Table2.TreatmentRecommendationsforPatientswithAcuteHeartFailureinSettingofAcuteMyocardialInfarction(OpenTableinanewwindow)   ClassofRecommendation LevelofEvidence PatientswithNSTE-ACSorSTEMIandunstablehemodynamicsshouldimmediatelybetransferredforinvasiveevaluationandtargetvesselrevascularization ClassI A Immediatereperfusionisindicatedinacuteheartfailurewithongoingischemia ClassI B EchocardiographyshouldbeperformedtoassessLVfunctionandtoexcludemechanicalcomplications ClassI C EmergencyangiographyandrevascularizationofallcriticallynarrowedarteriesbyPCI/CABGasappropriateisindicatedinpatientsincardiogenicshock ClassI B IABPinsertionisrecommendedinpatientswithhemodynamicinstability(particularlythoseincardiogenicshockandwithmechanicalcomplications) ClassI C SurgeryformechanicalcomplicationsofAMIshouldbeperformedassoonaspossiblewithpersistenthemodynamicdeteriorationdespiteIABP ClassI B EmergencysurgeryafterfailureofPCIorfibrinolysisisindicatedonlyinpatientswithpersistenthemodynamicinstabilityorlife-threateningventriculararrhythmiaduetoextensiveischemia(leftmainorsevere3-vesseldisease) ClassI C Ifthepatientcontinuestodeterioratewithoutadequatecardiacoutputtopreventend-organfailure,temporarymechanicalassistance(surgicalimplantationofLVAD/BiVAD)shouldbeconsidered ClassIIa C Routineuseofpercutaneouscentrifugalpumpsisnotrecommended ClassIII B AMI=acutemyocardialinfarction;BiVAD=biventricularassistdevice;CABG=coronaryarterybypassgrafting;IABP=intra-aorticballoonpump;LV=leftventricle;LVAD=leftventricularassistdevice;NSTE-ACS=non–ST-segmentelevationacutecoronarysyndrome;PCI=percutaneouscoronaryintervention;STEMI=ST-segmentelevationmyocardialinfarction.   Specialrecommendationsinpatientswithcomorbiditiesarepresentedinthetablesbelow. Table3.SpecificTreatmentRecommendationsforCoronaryArteryDiseaseinPatientswithMildtoModerateChronicKidneyDisease(OpenTableinanewwindow)   Recommendation LevelofEvidence CABGshouldbeconsidered,ratherthanPCI,whentheextentofCADjustifiesasurgicalapproach,thepatient’sriskprofileisacceptable,andthelifeexpectancyisreasonable ClassIIa B Off-pumpCABGmaybeconsideredratherthanon-pumpCABG ClassIIb B ForPCI,drug-elutingstentsmaybeconsidered,ratherthanbaremetalstents ClassIIb C CABG=coronaryarterybypassgrafting;CAD=coronaryarterydisease;PCI=percutaneouscoronaryintervention.  Table4.SpecificTreatmentRecommendationsforCoronaryArteryDiseaseinDiabeticPatients(OpenTableinanewwindow)   Recommendation LevelofEvidence InpatientspresentingwithSTEMI,primaryPCIispreferredoverfibrinolysisifitcanbeperformedwithinrecommendedtimelimits ClassI A InstablepatientswithextensiveCAD,revascularizationisindicatedtoimproveMACCE-freesurvival ClassI A Useofdrug-elutingstentsisrecommendedtoreducerestenosisandrepeattargetvesselrevascularization ClassI A Inpatientsonmetformin,renalfunctionshouldbecarefullymonitoredaftercoronaryangiography/PCI ClassI C CABGshouldbeconsidered,ratherthanPCI,whentheextentofCADjustifiesasurgicalapproach(especiallymultivesseldisease)andthepatient’sriskprofileisacceptable ClassIIa B InpatientswithknownrenalfailureundergoingPCI,metforminmaybestopped48hoursbeforetheprocedure ClassIIb C Systematicuseofglucoseinsulinpotassiumindiabeticpatientsundergoingrevascularizationisnotindicated ClassIII B CABG=coronaryarterybypassgrafting;CAD=coronaryarterydisease;MACCE=majoradversecardiacandcerebralevent;PCI=percutaneouscoronaryintervention;STEMI=ST-segmentelevationmyocardialinfarction.  Table5.RecommendationsforCombiningValveSurgeryandCoronaryArteryBypassGrafting(OpenTableinanewwindow)   Recommendation LevelofEvidence Incombinationwithvalvesurgery: CABGisrecommendedinpatientswithaprimaryindicationforaortic/mitralvalvesurgeryandcoronaryarterystenosis=70% ClassI C CABGshouldbeconsideredinpatientswithaprimaryindicationforaortic/mitralvalvesurgeryandcoronaryarterystenosisof50-70% ClassIIa C IncombinationwithCABG: MitralvalvesurgeryisindicatedinpatientswithaprimaryindicationforCABGandsevereischemicmitralregurgitationandanEF>30%* ClassI C MitralvalvesurgeryshouldbeconsideredinpatientswithaprimaryindicationforCABGandmoderateischemicmitralregurgitation,providedthatvalverepairisfeasibleandperformedbyexperiencedoperators ClassIIa C AorticvalvesurgeryshouldbeconsideredinpatientswithaprimaryindicationforCABGandmoderateaorticstenosis(meangradient30-50mmHg,Dopplervelocityof3-4m/sec,orheavilycalcifiedaorticvalveevenwithDopplervelocityof2.5-3m/sec) ClassIIa C *Definitionofseveremitralregurgitationisathttp://www.escardio.org/guidelines.CABG=coronaryarterybypassgrafting;EF=ejectionfraction.  Table6.CarotidRevascularizationinPatientsScheduledforCoronaryArteryBypassGrafting(OpenTableinanewwindow)   Recommendation LevelofEvidence CEAorCASshouldbeperformedonlybyteamswithdemonstrated30-daycombineddeath-strokeratesof<3%inpatientswithoutpreviousneurologicsymptomsand<6%inpatientswithpreviousneurologicsymptoms ClassI A Indicationforcarotidrevascularizationshouldbeindividualizedafterdiscussionbyamultidisciplinaryteam,includinganeurologist ClassI C Timingofprocedures(synchronousorstaged)shouldbedictatedbylocalexpertiseandclinicalpresentation,withthemostsymptomaticterritorytargetedfirst ClassI C InpatientswithpreviousTIA/nondisablingstroke: Carotidrevascularizationisrecommendedfor70-99%carotidstenosis ClassI C Carotidrevascularizationmaybeconsideredfor50-69%carotidstenosisinmenwithsymptomsof<6months ClassIIb C Carotidrevascularizationisnotrecommendedifcarotidstenosisis<50%inmenand<70%inwomen ClassIII C InpatientswithnopreviousTIA/stroke: Carotidrevascularizationmaybeconsideredinmenwithbilateral70-99%carotidstenosisor70-99%carotidstenosisandcontralateralocclusion ClassIIb C Carotidrevascularizationisnotrecommendedinwomenorpatientswithalifeexpectancy<5years ClassIII C CAS=carotidarterystenting;CEA=carotidendarterectomy;TIA=transientischemicattack.  Table7.ManagementofPatientswithAssociatedCoronaryandPeripheralArterialDisease(OpenTableinanewwindow)   Recommendation LevelofEvidence InpatientswithunstableCAD,vascularsurgeryispostponedandCADtreatedfirst,exceptwhenvascularsurgerycannotbedelayedbecauseofalife-threateningcondition ClassI B Beta-blockersandstatinsareindicatedpreoperativelyandshouldbecontinuedpostoperativelyinpatientswithknownCADwhoarescheduledforhigh-riskvascularsurgery ClassI B ThechoicebetweenCABGandPCIshouldbeindividualizedandassessedbytheheartteamtakingintoaccountthepatternsofCAD,PAD,comorbidity,andclinicalpresentation ClassI C Prophylacticmyocardialrevascularizationbeforehigh-riskvascularsurgerymaybeconsideredinstablepatientsiftheyhavepersistentsignsofextensiveischemicorhighcardiacrisk ClassIIb B CABG=coronaryarterybypassgrafting;CAD=coronaryarterydisease;PAD=peripheralarterialdisease;PCI=percutaneouscoronaryintervention.  Table8.ManagementofPatientswithRenalArteryStenosis(OpenTableinanewwindow)   Recommendation LevelofEvidence Functionalassessmentofrenalarterystenosisseverityusingpressuregradientmeasurementsmaybeusefulinselectinghypertensivepatientswhomaybenefitfromrenalarterystenting ClassIIb B Routinerenalarterystentingtopreventdeteriorationofrenalfunctionisnotrecommended ClassIII B  Table9.RecommendationsforPatientswithChronicHeartFailureandSystolicLeftVentricularDysfunction(EjectionFraction=35%),PresentingPredominantlywithAnginaSymptoms(OpenTableinanewwindow)   Recommendation LevelofEvidence CABGisrecommendedforthefollowing: Significantleftmainstenosis Leftmainequivalent(proximalstenosisofbothleftanteriordescendingandleftcircumflex) Proximalleftanteriordescendingstenosiswith2-or3-vesseldisease ClassI B CABGwithsurgicalventricularreconstructionmaybeconsideredinpatientswithLVESVindex=60mL/m2andscarredleftanteriordescendingterritory ClassIIb B PCImaybeconsideredinthepresenceofviablemyocardiumiftheanatomyissuitable ClassIIb C CABG=coronaryarterybypassgrafting;LVESV=leftventricularend-systolicvolume;PCI=percutaneouscoronaryintervention.  Table10.RecommendationsforPatientswithChronicHeartFailureandSystolicLeftVentricularDysfunction(EjectionFraction=35%),PresentingPredominantlywithHeartFailureSymptoms(NoorMildAngina:CanadianCardiovascularSociety1-2)(OpenTableinanewwindow)   Recommendation LevelofEvidence LVaneurysmectomyduringCABGisindicatedinpatientswithalargeLVaneurysm ClassI C CABGshouldbeconsideredinthepresenceofviablemyocardium,irrespectiveoftheLVESV ClassIIa B CABGwithSVRmaybeconsideredinpatientswithscarredLADterritory ClassIIb B PCImaybeconsideredinthepresenceofviablemyocardiumiftheanatomyissuitable ClassIIb C Revascularizationintheabsenceofevidenceofmyocardialviabilityisnotrecommended ClassIII B CABG=coronaryarterybypassgrafting;LAD=leftanteriordescending(artery);LV=leftventricle;LVESV=leftventricularend-systolicvolume;PCI=percutaneouscoronaryintervention;SVR=surgicalventricularreconstruction. Previous Next: Contraindications Coronaryarterybypassgrafting(CABG)carriesariskofmorbidityandmortalityandisthereforenotconsideredappropriateinasymptomaticpatientswhoareatalowriskofmyocardialinfarctionordeath.Patientswhowillexperiencelittlebenefitfromcoronaryrevascularizationarealsoexcluded. CABGisperformedinelderlypatientsforsymptomaticrelief.Althoughadvancedageisnotacontraindication,CABGshouldbecarefullyconsideredintheelderly,especiallythoseolderthan85years.ThesepatientsarealsomorelikelytoexperienceperioperativecomplicationsafterCABG. Amultidisciplinaryheartteamapproachthatemphasizesshareddecisionmakinginpatientswithcomplexcoronaryarterydiseaseisessentialtoofferthepatientthebestchanceofasuccessfulrevascularizationstrategy. Previous Next: TechnicalConsiderations Bestpractices Either arteriesorveins maybeusedasconduitsforcoronaryarterybypassgrafting(CABG).Thesurvivalbenefitsofgraftingtheleftinternalthoracic(mammary)arterytotheleftanteriordescendingcoronaryarterywasestablishedmanyyearsagoinalandmarkpaperfromtheClevelandClinic. [25] Thisremainstrue;infact,bilateralinternalthoracic(mammary)arterygrafting,ifpossible,confersasignificantlong-termsurvivalbenefit.Robustevidencesuggeststhattheuseoffanadditionalarterialgraftratherthanaveingraftisassociatedwithfurtherimprovementinlateoutcomes. [26]Thegreatersaphenousveinand,veryrarely,theshortsaphenousveinarethemostcommonlyusedveingrafts,whereastheinternalthoracic(mammary)arteryisthemostcommonlyusedarterygraft.Theradialarterygraftwasreintroducedintoclinicalpracticeinthe1990sandcontinuestoshowhighpatencyratesof80%orhigherat10yearsfollow-up,especiallyifthetargetvesselstenosiswasgreaterthan90%. [27] Thedisadvantageofsaphenousveingraftsistheirdecliningpatencywithtime:10-20%areoccluded1yearaftersurgerybecauseoftechnicalerrors,thrombosis,andintimalhyperplasia. [2]Another1-2%ofveingraftsoccludeeveryyearfrom1-5yearsaftersurgery,and4-5%occludeeveryyearfrom6-10yearsaftersurgery.Veingraftocclusionthatoccurs1ormoreyearsafterCABGisduetoveingraftatherosclerosiswithdevelopingneointimalhyperplasia.At10yearsaftersurgery,only50-60%ofsaphenousveingraftsarepatent,andonlyhalfofthesearefreeofangiographicatherosclerosis. [2]Aspartofappropriatesecondaryprevention,patientsshouldreceivelife-longantiplatelettherapy,mostcommonlywithdailylow-dose(81mg)aspirin. Unlikesaphenousveingrafts,internalthoracic(mammary)arterygraftsexhibitstablepatencyovertime. [2]At10years,morethan90%ofinternalthoracic(mammary)arterygraftsarepatent.Theleftinternalthoracic(mammary)arteryshouldbetheconduitusedwhentheleftanteriorcoronaryarteryisbypassed. TechnicalrecommendationsforCABGarepresentedinTable11below. Table11.TechnicalRecommendationsforCoronaryArteryBypassGrafting(OpenTableinanewwindow)   Recommendation LevelofEvidence Proceduresshouldbeperformedinahospitalstructureandbyateamspecializedincardiacsurgery,usingwrittenprotocols ClassI B ArterialgraftingtotheLADsystemisindicated ClassI A Completerevascularizationwitharterialgraftingtoanon-LADcoronarysystemisindicatedinpatientswithareasonablelifeexpectancy ClassI A Minimizationofaorticmanipulationisrecommended ClassI C Graftevaluationisrecommendedbeforedeparturefromtheoperatingtheater ClassI C LAD=leftanteriordescending(artery). Procedureplanning Theformationofamultidisciplinary heartteamenablesabalanceddecision-makingprocess(seeTable12below). [28,29]Cliniciansshouldapproachtheinformedconsentprocessasanopportunitytoenhanceobjectivedecision-makingratherthansolelyasalegalrequirement.Itisvitaltobeawarethatfactorssuchassex,race,availability,technicalskills,localresults,referralpatterns,andpatientpreferencemayaffectthedecision-makingprocessindependentofclinicalfindings. [28] Table12.MultidisciplinaryDecisionPathways,PatientInformedConsent,andTimingofIntervention [28](OpenTableinanewwindow)    AcuteCoronarySyndrome   StableMultivesselDisease StablewithIndicationforAdHocPCI   Shock STEMI NSTE-ACS OtherACS Multidisciplinarydecisionmaking Notmandatory Notmandatory Notrequiredforculpritlesionbutrequiredfornonculpritvessel(s) Required Required Accordingtopredefinedprotocols Informedconsent Oralwitnessedinformedconsentorfamilyconsentifpossiblewithoutdelay Oralwitnessedinformedconsentmaybesufficientunlesswrittenconsentislegallyrequired Writteninformedconsent*(iftimepermits) Writteninformedconsent* Writteninformedconsent* Writteninformedconsent* Timetorevascularization Emergency:Nodelay Emergency:Nodelay Urgency:Within24hifpossibleandnolaterthan72h Urgency:Timeconstraintsapply Elective:Notimeconstraints Elective:Notimeconstraints Procedure Proceedwithinterventiononbasisofbestevidence/availability Proceedwithinterventiononbasisofbestevidence/availability Proceedwithinterventiononbasisofbestevidence/availability;nonculpritlesionstreatedaccordingtoinstitutionalprotocol Proceedwithinterventiononbasisofbestevidence/availability;nonculpritlesionstreatedaccordingtoinstitutionalprotocol Planmostappropriateintervention,allowingenoughtimefromdiagnosticcatheterizationtointervention Proceedwithinterventionaccordingtoinstitutionalprotocoldefinedbylocalheartteam *Maynotapplytocountriesthatlegallydonotaskforwritteninformedconsent,althoughEuropeanSocietyofCardiologyandEuropeanAssociationforCardiothoracicSurgerystronglyadvocatedocumentationofpatientconsentforallrevascularizationprocedures.ACS=acutecoronarysyndrome;NSTE-ACS=non–ST-segmentelevationacutecoronarysyndrome;PCI=percutaneouscoronaryintervention;STEMI=ST-segmentelevationmyocardialinfarction. Additionalinputfromgeneralpractitioners,anesthesiologists,geriatricians,andintensivistsmaybeneeded. Hospitalswithoutasurgicalcardiacunitorwithinterventionalcardiologistsworkinginanambulatorysettingshouldrefertostandardevidence-basedprotocolsdevisedincollaborationwithexpertinterventionalcardiologists andcardiacsurgeonsorshouldseektheopinionsofthesephysiciansforcomplexcases.Consensusonthebestrevascularizationtreatmentshouldbedocumented.Standardprotocolsthatareinaccordancewithcurrentguidelinesmaybeusedtoobviateindividualcasereviewofeachdiagnosticangiogram. AdhocPCIisatherapeuticinterventionalprocedurethatisperformeddirectlyafterthediagnosticprocedureratherthanduringadifferentsession. [28]Althoughitisconvenientandoftencost-effective,adhocPCIisnotdesirableforallcases;somepatientsmaybeincategoriesforwhichCABGisthemostsuitablechoice.Theanatomiccriteriaandclinicalfactorsthatdeterminewhetherapatientcanorcannotbetreatedbymeansofad-hocPCIshouldbedefinedbyinstitutionalprotocolsdesignedbytheheartteam. [28] Complicationprevention CerebrovascularcomplicationsareamajorcauseofmorbidityafterCABG.Themaincausesofthesecomplicationsarehypoperfusionorembolicevents.Accordingly,itisimportanttomaintainadequatemeanarterialpressuresasaprophylacticmeasureagainsthypoperfusion,althoughthereislittlethatcanbedonetoprotectthepatientfromembolicevents. Previous Next: Outcomes Inpatientswithmultivesselcoronarydisease,coronaryarterybypassgrafting(CABG),ascomparedwithpercutaneouscoronaryintervention(PCI),leads toareductioninlong-termmortalityandmyocardialinfarctions(MIs)aswellasreductionsinrepeatrevascularizations,regardlessofwhetherpatientsarediabeticarenot,accordingtoameta-analysisofsixrandomizedclinicaltrialscomprising6055patientsfromtheeraofarterialgraftingandstenting. [30] Inameta-analysisofeightrandomizedstudiesthatincludedatotalof3612adultpatientswithdiabetesandmultivesselcoronaryarterydisease(CAD),treatmentwithCABGsignificantlyreducedtheriskofall-causemortalityby33%at5years,ascomparedwithPCI.ThisrelativeriskreductiondidnotdiffersignificantlywhenpatientswhounderwentCABGwerecomparedwithsubgroupsofpatientswhoreceivedeitherbaremetalstentsordrug-elutingstents. [31,32] Inastudyof3723patientswithmultivesselcoronarydiseasethatcomparedwhethertheeffectonsurvivalfromPCI(n=1097)comparedwithCABG(n=5626) isrelatedtotheageofthepatient,BenedettoetalfoundthatCABGresultedinasignificantreductioninlate-phasemortalityacrossallagegroupscomparedtoPCI. [33]Atameanfollow-upof5.5±3.2years,therewere301deathsoverall(PCI:208;CABG:93).OverallsurvivalforthePCIgroupwas95%at1year,84%at5years,and75%at8yearscomparedto95%at1year,92.4%at5years,and90%at8yearsfortheCABGgroup. [33] Inaretrospective(1997-2013),nationwide,population-basedSwedishstudythatevaluated long-termsurvival,majoradversecardiovascularevents,andfactorsassociatedwithelevatedriskin4086youngadults(≤50years)undergoingCABG,Dalenetalfoundbetteroutcomesinyoungeradultsthantheiroldercounterparts. [34]Atamedianfollow-upof10.9years,490(12%)patientsdied,with96%survivalat5years,90%at10years,and82%at15years.Thesurvivalofpatientsaged51to70yearsandthoseolderthan70yearswhounderwentCABGduringthesameperiodwassignificantlyworse.Theprimaryriskfactorsforall-causemortalitywerechronickidneydisease,reducedleftventricularejectionfraction,peripheralvasculardisease,orchronicobstructivepulmonarydisease. [34] ResultsoftheSurgicalTreatmentforIschemicHeartFailure(STICH)ExtensionStudy(STICHES),whichevaluatedthelong-term,10-yearoutcomesofCABGin1212patientswithischemiccardiomyopathyandanejectionfractionof35%orless,concludedthattheratesofdeathfromanycause,deathfromcardiovascularcauses,anddeathfromanycauseorhospitalizationforcardiovascularcausesweresignificantlylowerinpatientswhounderwentCABGandreceivedmedicaltherapythanamongthosewhoreceivedmedicaltherapyalone. [35] However,morerecentevidencefrommeta-analysesandthe InternationalStudyofComparativeHealthEffectivenessWithMedicalandInvasiveApproaches(ISCHEMIA)trialfoundnoadvantageofCABGovermedicaltherapyinstableischemicheartdisease. [1] Insingle-centerretrospectiveanalysis(2003-2013)of763elderlypatients(age≥75years)withmultivesseldiseasewhounderwentPCIorCABGwithin30daysoftheindexcatherization, CABG wasassociatedwiththebestoverallclinicaloutcomes. [36]However,only20%ofthepatients(n=150)underwentCABG.Thebesttreatmentstrategyforthispopulationremainstobedetermined. [36] Similarly,results fromanalysisof2007-2014datafromtheNationalCardiovascularDataRegistryAcuteCoronaryTreatmentandInterventionOutcomesNetworkRegistry-GetWithThe GuidelinesthatevaluatedtrendsinCABGutilizationandin-hospitaloutcomesshowedthatCABGwasusedinfrequentlyin15,145patientswith ST-segmentelevationmyocardialinfarction(STEMI)duringtheindexhospitalization,withCABGratesdecliningovertime. [37] Inaddition,therewasawidehospital-levelvariationinCABGratesinSTEMI,andCABGwasgenerallyperformedwithin1-3daysfollowingangiography.In-hospitalmortalityratesweresimilarforpatientswhounderwentCABGandthosewhodidnot. [37] Inameta-analysisofcomparisonof5-yearoutcomesofPCIwithdrug-elutingstentsversusCABGin6637patientswithunprotectedleftmainCADfromninestudiesovera14-yearperiod(2003-2016),PCIwithdrug-elutingstentswasassociatedwithequivalentcardiacandall-causemortalitybutlowerratesofstrokeandhigherratesofrepeatrevascularization. [38]AtrendfavoringCABGoverPCIformajoradversecardiacandcerebrovasculareventsdidnotreachstatisticalsignificance. WithregardtoqualityoflifefollowingCABGcomparedwithPCIformultivesselCAD,bothinterventionsprovideimprovementsinthefrequencyofangina. [39]However,at1monthpostprocedure,PCIpatientsappeartorecoverfasterandhaveimprovedshort-termhealthstatuscomparedtopatientswhoundergoCABG,whereasat6monthsandlongerpostprocedure,CABGpatientsappeartohavegreateranginareliefandimprovedqualityofliferelativetothosewhoundergoPCI. [39] Previous Next: FutureDirections Despiteasteadyincreaseintheproportionofolderandhigherriskpatientsbeingreferredforsurgery,majorperioperativemorbidityandmortalitycontinuestobelow,andlong-termoutcomesareexcellent.Withanoperationthathas stoodthetestoftime,futureadvancesinpercutaneouscoronaryinterventions(PCIs),moleculartherapeutics,andnovelsurgicalapproachesmustberigorouslycomparedtothegoldstandardofcoronaryarterybypassgrafting(CABG). CurrentmortalityriskpredictionmodelsforCABGdonothaveastandardizedapproachtodefiningoutcomeandpredictorvariables,andtheyincludeproblematicissuessuchasinadequatesamplesizes,inappropriatehandlingofmissingdata,aswellassuboptimalstatisticaltechniques. [40]Futureriskmodellingwillneedtoimproveuponthesefactorstorefinethequalityofmortalityriskprediction. Thesurgicalrobotallowssurgeonstoremotelymanipulatefullyarticulatingvideoscopicinstrumentsbywayof"master-slave"servosandmicroprocessorcontrol.Theimprovedvideoresolutionisanadvantage,buttheaddedexpenseandtimerequired aswellas difficultywithlearningthistechnique,inadditiontothelimitedapplicationsinCABGsurgery,haslimitedtheroleofrobotic-assistedCABG. Arelativelyrecentdevelopmentishybridsurgicalandpercutaneousrevascularization.Inthisapproach,patientsundergonotonlyminimallyinvasiveCABG,mostoftenwiththeuseoftheleftinternalthoracic(mammary)arterygrafttotheleftanteriordescendingcoronaryartery,butalsoundergoPCIoflesionsinthecircumflexandrightcoronaryarteries.ThisstrategyprovidesthebenefitsofCABGwithalowermorbidityandcouldemergeasthenewstandardfor patients withmultivesselcoronaryarterydisease(CAD). [41,42] CABGdoesnotpreventtheprogressionofnativeCAD,however,bothdiseaseprogressionandveingraftfailurecanbeamelioratedbyaggressivesecondarypreventionwithmedicaltherapy. [43]TheAmericanHeartAssociationrecommendslife-longantiplatelettherapy. [44] Dailyintakeoflow-dose(81mg)aspirinmaybepreferabletominimizetheriskofbleeding.Betablockersshouldbeusedinpatientswithrecentmyocardialinfarction,leftventricularsystolicdysfunction,orinpatientswithnon-revascularizedCAD.Allpatients,regardlessoftheirlipidvaluesshouldreceivelife-longhigh-intensitystatintherapy.Diet,exercise,andsmokingcessationare wellknownadjunctstopromoteimprovedcardiovascularhealth. [44] Previous Periprocedure     References [Guideline]LawtonJS,Tamis-HollandJE,BangaloreS,etal.2021ACC/AHA/SCAIGuidelineforcoronaryarteryrevascularization:areportoftheAmericanCollegeofCardiology/AmericanHeartAssociationJointCommitteeonClinicalPracticeGuidelines.JAmCollCardiol.2022Jan18.79(2):e21-e129.[QxMDMEDLINELink].[FullText]. 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[Guideline]AldeaGS,BakaeenFG,PalJ,etal,fortheSocietyofThoracicSurgeons.TheSocietyofThoracicSurgeonsClinicalPracticeGuidelinesonArterialConduitsforCoronaryArteryBypassGrafting.AnnThoracSurg.2016Feb.101(2):801-9.[QxMDMEDLINELink]. GrubbKJ,KirtaneAJ.Thelong-awaitedrevascularizationguidelinesareout:What'sinthem?.Circulation.2022Jan18.145(3):155-7.[QxMDMEDLINELink].[FullText]. MediaGallery CoronaryArteryBypassGrafting.Illustrationofamediansternotomy. CoronaryArteryBypassGrafting.Illustrationofaninternalthoracic(mammary)artery(IMA)harvestasapedicle. CoronaryArteryBypassGrafting.Illustrationoftheopensaphenousveinharvesttechnique. CoronaryArteryBypassGrafting.Cannulation,illustrated. CoronaryArteryBypassGrafting.Illustrationofthedistalanastomotictechnique. CoronaryArteryBypassGrafting.Illustrationoftheproximalanastomotictechnique. CoronaryArteryBypassGrafting.Thisvideodemonstratescoronaryarterybypassgraftingwithcardiopulmonarybypassandcardioplegicarrest.VideocourtesyofDaleKMueller,MD. of 7 Tables Table1.ACC/AHAIndicationsforCoronaryArteryBypassGrafting [2,3] Table2.TreatmentRecommendationsforPatientswithAcuteHeartFailureinSettingofAcuteMyocardialInfarction Table3.SpecificTreatmentRecommendationsforCoronaryArteryDiseaseinPatientswithMildtoModerateChronicKidneyDisease  Table4.SpecificTreatmentRecommendationsforCoronaryArteryDiseaseinDiabeticPatients  Table5.RecommendationsforCombiningValveSurgeryandCoronaryArteryBypassGrafting  Table6.CarotidRevascularizationinPatientsScheduledforCoronaryArteryBypassGrafting  Table7.ManagementofPatientswithAssociatedCoronaryandPeripheralArterialDisease  Table8.ManagementofPatientswithRenalArteryStenosis  Table9.RecommendationsforPatientswithChronicHeartFailureandSystolicLeftVentricularDysfunction(EjectionFraction=35%),PresentingPredominantlywithAnginaSymptoms  Table10.RecommendationsforPatientswithChronicHeartFailureandSystolicLeftVentricularDysfunction(EjectionFraction=35%),PresentingPredominantlywithHeartFailureSymptoms(NoorMildAngina:CanadianCardiovascularSociety1-2) Table11.TechnicalRecommendationsforCoronaryArteryBypassGrafting Table12.MultidisciplinaryDecisionPathways,PatientInformedConsent,andTimingofIntervention [28] Table13.IndicationsforCoronaryArteryBypassGrafting  Table14.UpdatedACC/AHA/SCAIRecommendationsforRevascularizationforSurvivalImprovementinStableIschemicHeartDiseaseVersusMedicalTherapy [1] Table15.PreoperativemanagementofantiplatelettherapyinpatientsundergoingCABG Table16.PostoperativemanagementofantiplatelettherapyinpatientsundergoingCABG Table1.ACC/AHAIndicationsforCoronaryArteryBypassGrafting [2,3] Indication AsymptomaticorMildAngina StableAngina UnstableAngina/NSTEMI PoorLeftVentricularFunction Leftmainstenosis>50% ClassI ClassI ClassI ClassI StenosisofproximalLADandproximalcircumflexartery>70% ClassI ClassI ClassI ClassI 3-Vesseldisease ClassI ClassI   ClassI,withproximalLADstenosis 2-Vesseldisease   ClassIifthereisalargeareaofviablemyocardiuminahigh-riskarea;ClassIIaifthereisamoderateviableareaandischemia ClassIIb   With>70%proximalLADstenosis ClassIIa ClassIwitheitheranejectionfraction<50%ordemonstrableischemiaonnoninvasivetesting ClassIIa ClassI InvolvingproximalLAD ClassIIb       1-Vesseldisease   ClassIifthereisalargeareaofviablemyocardiuminahigh-riskarea;ClassIIa,ifthereisaviablemoderateareaandischemia ClassIIb   With>70%proximalLADstenosis ClassIIa ClassIIa ClassIIa   InvolvingproximalLAD ClassIIb       ACC=AmericanCollegeofCardiology;AHA=AmericanHeartAssociation;LAD=leftanteriordescending(artery);NSTEMI=non–ST-segmentelevationmyocardialinfarction. Table2.TreatmentRecommendationsforPatientswithAcuteHeartFailureinSettingofAcuteMyocardialInfarction   ClassofRecommendation LevelofEvidence PatientswithNSTE-ACSorSTEMIandunstablehemodynamicsshouldimmediatelybetransferredforinvasiveevaluationandtargetvesselrevascularization ClassI A Immediatereperfusionisindicatedinacuteheartfailurewithongoingischemia ClassI B EchocardiographyshouldbeperformedtoassessLVfunctionandtoexcludemechanicalcomplications ClassI C EmergencyangiographyandrevascularizationofallcriticallynarrowedarteriesbyPCI/CABGasappropriateisindicatedinpatientsincardiogenicshock ClassI B IABPinsertionisrecommendedinpatientswithhemodynamicinstability(particularlythoseincardiogenicshockandwithmechanicalcomplications) ClassI C SurgeryformechanicalcomplicationsofAMIshouldbeperformedassoonaspossiblewithpersistenthemodynamicdeteriorationdespiteIABP ClassI B EmergencysurgeryafterfailureofPCIorfibrinolysisisindicatedonlyinpatientswithpersistenthemodynamicinstabilityorlife-threateningventriculararrhythmiaduetoextensiveischemia(leftmainorsevere3-vesseldisease) ClassI C Ifthepatientcontinuestodeterioratewithoutadequatecardiacoutputtopreventend-organfailure,temporarymechanicalassistance(surgicalimplantationofLVAD/BiVAD)shouldbeconsidered ClassIIa C Routineuseofpercutaneouscentrifugalpumpsisnotrecommended ClassIII B AMI=acutemyocardialinfarction;BiVAD=biventricularassistdevice;CABG=coronaryarterybypassgrafting;IABP=intra-aorticballoonpump;LV=leftventricle;LVAD=leftventricularassistdevice;NSTE-ACS=non–ST-segmentelevationacutecoronarysyndrome;PCI=percutaneouscoronaryintervention;STEMI=ST-segmentelevationmyocardialinfarction. Table3.SpecificTreatmentRecommendationsforCoronaryArteryDiseaseinPatientswithMildtoModerateChronicKidneyDisease   Recommendation LevelofEvidence CABGshouldbeconsidered,ratherthanPCI,whentheextentofCADjustifiesasurgicalapproach,thepatient’sriskprofileisacceptable,andthelifeexpectancyisreasonable ClassIIa B Off-pumpCABGmaybeconsideredratherthanon-pumpCABG ClassIIb B ForPCI,drug-elutingstentsmaybeconsidered,ratherthanbaremetalstents ClassIIb C CABG=coronaryarterybypassgrafting;CAD=coronaryarterydisease;PCI=percutaneouscoronaryintervention.  Table4.SpecificTreatmentRecommendationsforCoronaryArteryDiseaseinDiabeticPatients   Recommendation LevelofEvidence InpatientspresentingwithSTEMI,primaryPCIispreferredoverfibrinolysisifitcanbeperformedwithinrecommendedtimelimits ClassI A InstablepatientswithextensiveCAD,revascularizationisindicatedtoimproveMACCE-freesurvival ClassI A Useofdrug-elutingstentsisrecommendedtoreducerestenosisandrepeattargetvesselrevascularization ClassI A Inpatientsonmetformin,renalfunctionshouldbecarefullymonitoredaftercoronaryangiography/PCI ClassI C CABGshouldbeconsidered,ratherthanPCI,whentheextentofCADjustifiesasurgicalapproach(especiallymultivesseldisease)andthepatient’sriskprofileisacceptable ClassIIa B InpatientswithknownrenalfailureundergoingPCI,metforminmaybestopped48hoursbeforetheprocedure ClassIIb C Systematicuseofglucoseinsulinpotassiumindiabeticpatientsundergoingrevascularizationisnotindicated ClassIII B CABG=coronaryarterybypassgrafting;CAD=coronaryarterydisease;MACCE=majoradversecardiacandcerebralevent;PCI=percutaneouscoronaryintervention;STEMI=ST-segmentelevationmyocardialinfarction.  Table5.RecommendationsforCombiningValveSurgeryandCoronaryArteryBypassGrafting   Recommendation LevelofEvidence Incombinationwithvalvesurgery: CABGisrecommendedinpatientswithaprimaryindicationforaortic/mitralvalvesurgeryandcoronaryarterystenosis=70% ClassI C CABGshouldbeconsideredinpatientswithaprimaryindicationforaortic/mitralvalvesurgeryandcoronaryarterystenosisof50-70% ClassIIa C IncombinationwithCABG: MitralvalvesurgeryisindicatedinpatientswithaprimaryindicationforCABGandsevereischemicmitralregurgitationandanEF>30%* ClassI C MitralvalvesurgeryshouldbeconsideredinpatientswithaprimaryindicationforCABGandmoderateischemicmitralregurgitation,providedthatvalverepairisfeasibleandperformedbyexperiencedoperators ClassIIa C AorticvalvesurgeryshouldbeconsideredinpatientswithaprimaryindicationforCABGandmoderateaorticstenosis(meangradient30-50mmHg,Dopplervelocityof3-4m/sec,orheavilycalcifiedaorticvalveevenwithDopplervelocityof2.5-3m/sec) ClassIIa C *Definitionofseveremitralregurgitationisathttp://www.escardio.org/guidelines.CABG=coronaryarterybypassgrafting;EF=ejectionfraction.  Table6.CarotidRevascularizationinPatientsScheduledforCoronaryArteryBypassGrafting   Recommendation LevelofEvidence CEAorCASshouldbeperformedonlybyteamswithdemonstrated30-daycombineddeath-strokeratesof<3%inpatientswithoutpreviousneurologicsymptomsand<6%inpatientswithpreviousneurologicsymptoms ClassI A Indicationforcarotidrevascularizationshouldbeindividualizedafterdiscussionbyamultidisciplinaryteam,includinganeurologist ClassI C Timingofprocedures(synchronousorstaged)shouldbedictatedbylocalexpertiseandclinicalpresentation,withthemostsymptomaticterritorytargetedfirst ClassI C InpatientswithpreviousTIA/nondisablingstroke: Carotidrevascularizationisrecommendedfor70-99%carotidstenosis ClassI C Carotidrevascularizationmaybeconsideredfor50-69%carotidstenosisinmenwithsymptomsof<6months ClassIIb C Carotidrevascularizationisnotrecommendedifcarotidstenosisis<50%inmenand<70%inwomen ClassIII C InpatientswithnopreviousTIA/stroke: Carotidrevascularizationmaybeconsideredinmenwithbilateral70-99%carotidstenosisor70-99%carotidstenosisandcontralateralocclusion ClassIIb C Carotidrevascularizationisnotrecommendedinwomenorpatientswithalifeexpectancy<5years ClassIII C CAS=carotidarterystenting;CEA=carotidendarterectomy;TIA=transientischemicattack.  Table7.ManagementofPatientswithAssociatedCoronaryandPeripheralArterialDisease   Recommendation LevelofEvidence InpatientswithunstableCAD,vascularsurgeryispostponedandCADtreatedfirst,exceptwhenvascularsurgerycannotbedelayedbecauseofalife-threateningcondition ClassI B Beta-blockersandstatinsareindicatedpreoperativelyandshouldbecontinuedpostoperativelyinpatientswithknownCADwhoarescheduledforhigh-riskvascularsurgery ClassI B ThechoicebetweenCABGandPCIshouldbeindividualizedandassessedbytheheartteamtakingintoaccountthepatternsofCAD,PAD,comorbidity,andclinicalpresentation ClassI C Prophylacticmyocardialrevascularizationbeforehigh-riskvascularsurgerymaybeconsideredinstablepatientsiftheyhavepersistentsignsofextensiveischemicorhighcardiacrisk ClassIIb B CABG=coronaryarterybypassgrafting;CAD=coronaryarterydisease;PAD=peripheralarterialdisease;PCI=percutaneouscoronaryintervention.  Table8.ManagementofPatientswithRenalArteryStenosis   Recommendation LevelofEvidence Functionalassessmentofrenalarterystenosisseverityusingpressuregradientmeasurementsmaybeusefulinselectinghypertensivepatientswhomaybenefitfromrenalarterystenting ClassIIb B Routinerenalarterystentingtopreventdeteriorationofrenalfunctionisnotrecommended ClassIII B  Table9.RecommendationsforPatientswithChronicHeartFailureandSystolicLeftVentricularDysfunction(EjectionFraction=35%),PresentingPredominantlywithAnginaSymptoms   Recommendation LevelofEvidence CABGisrecommendedforthefollowing: Significantleftmainstenosis Leftmainequivalent(proximalstenosisofbothleftanteriordescendingandleftcircumflex) Proximalleftanteriordescendingstenosiswith2-or3-vesseldisease ClassI B CABGwithsurgicalventricularreconstructionmaybeconsideredinpatientswithLVESVindex=60mL/m2andscarredleftanteriordescendingterritory ClassIIb B PCImaybeconsideredinthepresenceofviablemyocardiumiftheanatomyissuitable ClassIIb C CABG=coronaryarterybypassgrafting;LVESV=leftventricularend-systolicvolume;PCI=percutaneouscoronaryintervention.  Table10.RecommendationsforPatientswithChronicHeartFailureandSystolicLeftVentricularDysfunction(EjectionFraction=35%),PresentingPredominantlywithHeartFailureSymptoms(NoorMildAngina:CanadianCardiovascularSociety1-2)   Recommendation LevelofEvidence LVaneurysmectomyduringCABGisindicatedinpatientswithalargeLVaneurysm ClassI C CABGshouldbeconsideredinthepresenceofviablemyocardium,irrespectiveoftheLVESV ClassIIa B CABGwithSVRmaybeconsideredinpatientswithscarredLADterritory ClassIIb B PCImaybeconsideredinthepresenceofviablemyocardiumiftheanatomyissuitable ClassIIb C Revascularizationintheabsenceofevidenceofmyocardialviabilityisnotrecommended ClassIII B CABG=coronaryarterybypassgrafting;LAD=leftanteriordescending(artery);LV=leftventricle;LVESV=leftventricularend-systolicvolume;PCI=percutaneouscoronaryintervention;SVR=surgicalventricularreconstruction. Table11.TechnicalRecommendationsforCoronaryArteryBypassGrafting   Recommendation LevelofEvidence Proceduresshouldbeperformedinahospitalstructureandbyateamspecializedincardiacsurgery,usingwrittenprotocols ClassI B ArterialgraftingtotheLADsystemisindicated ClassI A Completerevascularizationwitharterialgraftingtoanon-LADcoronarysystemisindicatedinpatientswithareasonablelifeexpectancy ClassI A Minimizationofaorticmanipulationisrecommended ClassI C Graftevaluationisrecommendedbeforedeparturefromtheoperatingtheater ClassI C LAD=leftanteriordescending(artery). Table12.MultidisciplinaryDecisionPathways,PatientInformedConsent,andTimingofIntervention [28]    AcuteCoronarySyndrome   StableMultivesselDisease StablewithIndicationforAdHocPCI   Shock STEMI NSTE-ACS OtherACS Multidisciplinarydecisionmaking Notmandatory Notmandatory Notrequiredforculpritlesionbutrequiredfornonculpritvessel(s) Required Required Accordingtopredefinedprotocols Informedconsent Oralwitnessedinformedconsentorfamilyconsentifpossiblewithoutdelay Oralwitnessedinformedconsentmaybesufficientunlesswrittenconsentislegallyrequired Writteninformedconsent*(iftimepermits) Writteninformedconsent* Writteninformedconsent* Writteninformedconsent* Timetorevascularization Emergency:Nodelay Emergency:Nodelay Urgency:Within24hifpossibleandnolaterthan72h Urgency:Timeconstraintsapply Elective:Notimeconstraints Elective:Notimeconstraints Procedure Proceedwithinterventiononbasisofbestevidence/availability Proceedwithinterventiononbasisofbestevidence/availability Proceedwithinterventiononbasisofbestevidence/availability;nonculpritlesionstreatedaccordingtoinstitutionalprotocol Proceedwithinterventiononbasisofbestevidence/availability;nonculpritlesionstreatedaccordingtoinstitutionalprotocol Planmostappropriateintervention,allowingenoughtimefromdiagnosticcatheterizationtointervention Proceedwithinterventionaccordingtoinstitutionalprotocoldefinedbylocalheartteam *Maynotapplytocountriesthatlegallydonotaskforwritteninformedconsent,althoughEuropeanSocietyofCardiologyandEuropeanAssociationforCardiothoracicSurgerystronglyadvocatedocumentationofpatientconsentforallrevascularizationprocedures.ACS=acutecoronarysyndrome;NSTE-ACS=non–ST-segmentelevationacutecoronarysyndrome;PCI=percutaneouscoronaryintervention;STEMI=ST-segmentelevationmyocardialinfarction. Table13.IndicationsforCoronaryArteryBypassGrafting Indication ACC/AHA ESC/EACT Leftmaindisease ClassI ClassI Three-vesseldiseasewithorwithoutproximalLADarterydisease ClassI ClassI Two-vesseldiseasewithproximalLADarterydisease ClassI ClassI Two-vesseldiseasewithoutproximalLADarterydisease ClassIIa(withextensiveischemia) ClassIIb Single-vesseldiseasewithproximalLADarterydisease ClassIIa(withLIMAforlong-termbenefit) ClassI Single-vesseldiseasewithoutproximalLADarterydisease ClassIII—Harmful ClassIIb LVDysfunction ClassIIa(EF35%to50%)ClassIIb(EF<35%) ClassI(EF<40%) Survivorsofsuddencardiacdeathwithpresumedischemia-mediatedVT ClassI ClassI LAD=leftanteriordescending(artery);LV=leftventricle;LIMA=leftinternalmammaryarteryEF=ejectionfraction;VT=ventriculartachycardia  Table14.UpdatedACC/AHA/SCAIRecommendationsforRevascularizationforSurvivalImprovementinStableIschemicHeartDiseaseVersusMedicalTherapy [1]   Recommendation LevelofEvidence LVdysfunctionandmultivesselCAD PatientswithSIHDandmultivesselCADappropriateforCABGwithsevereLVsystolicdysfunction(LVEF<35%) ClassI B SelectedpatientswithSIHDandmultivesselCADappropriateforCABGandmild-to-moderateLVsystolicdysfunction(LVEFof35-50%):CABG(toincludeaLIMAgrafttotheLAD)isreasonable ClassIIa B LeftmainCAD PatientswithSIHDandsignificantleftmainstenosis ClassI B PatientswithSIHDandsignificantleftmainstenosisforwhomrevascularizationwithPCIcanprovideequivalenttothatpossiblewithCABG:PCIisreasonable ClassIIa B MultivesselCAD PatientswithSIHD,normalEF,significantstenosisof3majorcoronaryarteries(±proximalLAD),andsuitableanatomyforCABG:CABGmaybereasonable ClassIIb B PatientswithSIHD,normalEF,significantstenosisof3majorcoronaryarteries(±proximalLAD),andsuitableanatomyforPCI:PCIutilityisuncertain ClassIIb B StenosisintheproximalLADartery PatientswithSIHD,normalLVEF,andsignificantstenosisintheproximalLAD:coronaryrevascularizationutilityisuncertain ClassIIb B Single-ordouble-vesseldiseasenotinvolvingtheproimalLAD PatientswithSIHD,normalLVEF,and1-or2-vesselCADnotinvolvingtheproximalLAD:coronaryrevascularizationnotrecommended ClassIII B PatientswithSIHDwith≥1coronaryarteriesthatarenotanatomicallyorfunctionallysignificant(<70%diameterofnon–leftmaincoronaryarterystenosis,FFR>0.80):Donotperformcoronaryrevascularizationwiththeprimaryorsoleintenttoimprovesurvival ClassIII B CABG=coronaryarterybypassgrafting;CAD=coronaryarterydisease;EF=ejectionfraction;FFR=fractionalflowreserve;LAD=leftanteriordescending(artery);LIMA=Leftinternalmammaryartery; LV=leftventricle;PCI=percutaneouscoronaryintervention;SIHD=stableischemicheartdisease. Table15.PreoperativemanagementofantiplatelettherapyinpatientsundergoingCABG Recommendation 2011ACC/AHA 2012ACC/AHA 2014ACC/AHA 2014ESC/EACT 2012STS AdministeraspirintoCABGpatientspreoperatively (100mgto325mgdaily)ClassI ClassI (81–325mgdaily)ClassI (75–160mgdaily)ClassI   Inpatientsatincreasedriskforbleedingandthosewhorefusebloodtransfusion,discontinueaspirin3-5dayspriortosurgery       ClassI ClassIIa Fornon-urgentCABG,discontinueclopidogrelandticagrelorforatleast5daysbeforesurgeryandprasugrelforatleast7daystolimitbloodtransfusions ClassI ClassI ClassI ClassI   InpatientsreferredforurgentCABG,discontinueclopidogrelandticagrelorforatleast24hourstoreducemajorbleedingcomplications ClassI   ClassI     InpatientsreferredforurgentCABG,discontinueeptifibatideandtirofibanforatleast2-4hoursandabciximabforat12hours ClassI (Discontinueeptifibatideandtirofiban4hours)ClassI ClassI     Anticoagulanttherapy:unfractionatedheparin;discontinueenozaparin12-24hours;discontinuefondaparinuxfor24hours;discontinuebivalirudinfor3hours   ClassI       Table16.PostoperativemanagementofantiplatelettherapyinpatientsundergoingCABG Recommendation 2011ACC/AHA 2014ACC/AHA 2014ESC/EACT 2012STS AdministeraspirintoCABGpatientsindefinitely 100mgto325mgdaily-ClassI 81–325mgdaily(Only81mgwithticagrelor)ClassI 75–160mgdailyClassI ClassI Administerclopidogrelorticagrelor,inadditiontoaspirin,for12months   ClassI ClassIIb   Clopidogrel(75mgdaily)isareasonablealternativeinpatientsintolerantorallergictoaspirin ClassIIa   ClassI   InCABGafteracutecoronarysyndromes,restartdualantiplatelettherapywhenbleedingriskisdiminished.       ClassI Oncepostoperativebleedingriskisdecreased,considertestingofresponsetoantiplateletdrugs,eitherwithgenetictestingorwithpoint-of-careplateletfunctiontesting,tooptimizeantiplateletdrugeffectandminimizethromboticrisktoveingrafts       ClassIIb BacktoList ContributorInformationandDisclosures Author RohitShahani,MD,MCh,FACC,FACS AttendingPhysician,DepartmentofCardiothoracicSurgery,StatenIslandUniversityHospital,NorthwellHealth;AssistantProfessorofCardiovascularandThoracicSurgery,DonaldandBarbaraZuckerSchoolofMedicineatHofstra/Northwell RohitShahani,MD,MCh,FACC,FACSisamemberofthefollowingmedicalsocieties:AmericanAssociationofPhysiciansofIndianOrigin,AmericanCollegeofCardiology,AmericanCollegeofSurgeons,AmericanMedicalAssociation,IndianAssociationofCardiovascular-ThoracicSurgeons,MedicalSocietyoftheStateofNewYork,SocietyofThoracicSurgeonsDisclosure:Nothingtodisclose. ChiefEditor KarlheinzPeter,MD,PhD ProfessorofMedicine,MonashUniversity;HeadofCentreofThrombosisandMyocardialInfarction,HeadofDivisionofAtherothrombosisandVascularBiology,AssociateDirector,BakerHeartResearchInstitute;InterventionalCardiologist,TheAlfredHospital,Australia KarlheinzPeter,MD,PhDisamemberofthefollowingmedicalsocieties:AmericanHeartAssociation,GermanCardiacSociety,CardiacSocietyofAustraliaandNewZealandDisclosure:Nothingtodisclose. AdditionalContributors RHBilal,MBBS,MRCS SpecialistRegistrarinCardiothoracicSurgery,NorthWestCardiothoracicRotation,UK RHBilal,MBBS,MRCSisamemberofthefollowingmedicalsocieties:BritishMedicalAssociationDisclosure:Nothingtodisclose. AndrewJDuncan,MBChB,FRCS(C-Th) ConsultantCardiothoracicSurgeon,LancashireCardiacCentre,VictoriaHospital,UKDisclosure:Nothingtodisclose. DumborLaatehNgaage,MBBS,MS,FRCSEd,FWACS,FETCS,FRCS(C-Th) ConsultantCardiothoracicSurgeon,BlackpoolVictoriaHospital,UKDisclosure:Nothingtodisclose. BridieRO'Neill UniversityofManchester,UKDisclosure:Nothingtodisclose. MahvashZaman UniversityofLiverpoolFacultyofMedicine,UKDisclosure:Nothingtodisclose. SarahMahmood UniversityofLiverpoolFacultyofMedicine,UKDisclosure:Nothingtodisclose. Acknowledgements MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeofPharmacy;Editor-in-Chief,MedscapeDrugReference Disclosure:Nothingtodisclose. Acknowledgments MedscapeReferencethanksDaleKMueller,MD,forassistancewiththevideocontributiontothisarticle.DrMuellerisClinicalAssociateProfessorofSurgery,SectionChief,DepartmentofSurgery,UniversityofIllinoisCollegeofMedicine;Co-MedicalDirector,ThoracicCenterofExcellence,Vice-Chair,DepartmentofCardiovascularMedicineandSurgery,OSFStFrancisMedicalCenter;andDirector,AdultECMO,CardiovascularandThoracicSurgeon,HeartCareMidwest,SC. Close Whatwouldyouliketoprint? Whatwouldyouliketoprint? 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