This document discusses the history and guidelines for coronary artery bypass grafting (CABG). It provides: 1) Key events and innovations in the development of CABG, including the first successful procedures in the USSR, US, and Bulgaria. 2) Indications for CABG based on the number and location of diseased vessels and patient characteristics, as outlined in European and US guidelines. 3) Considerations for conduit choice, preoperative evaluation, and risk stratification prior to CABG. 4) An overview of how CABG differs from percutaneous coronary intervention (PCI) in treating both present and future coronary lesions due to the placement of bypass grafts in the mid coronary arteries.

1. HRISTO A. RAHMAN 30/07/20
CONCEPT
INDICATIONS
CONDUIT CHOICES
RESULTS

2. FIRST PAVLOV STATE MEDICAL
UNIVERSITY OF LENINGRAD
U.S.S.R.
VASILIY IVANOVICH KOLESOV
1-ST SUCCESSFUL LIMA-LAD

3. RENE FAVALORO
MAY/1967
SAPHENOUS VEIN GRAFT - RCA
CLEVELAND CLINIC, CLEVELAND,OH
MASON SONES
30/10/1958
PERFORMED 1-ST SELECTIVE
ANGIOGRAPHY OF THE RCA
BY ACCIDENT

4. 10/11/1974
1-st SUCCESSFUL CABG
SOFIA,BULGARIA

5. • STENOSES IN CORONARY ARTERIES CAUSE IMPAIRED BLOOD FLOW AND CAN RESULT
IN:
• MYOCARDIAL ISCHAEMIA,
• ANGINA,
• ARRHYTHMIAS,
• MYOCARDIAL DEATH,
• DEATH OF THE PATIENT
• THE STENOSES OCCUR IN THE PROXIMAL CORONARY ARTERIES
• IF BYPASS GRAFTS CAN BE CONSTRUCTED THAT ROUTE BLOOD AROUND & BEYOND THE
STENOSES, SYMPTOMS WILL BE LESS, QALITY OF LIFE - BETTER, AND SURVIVAL WILL BE
PROLONGED

6. • NOWADAYS WE HAVE 2 WAYS TO
DELIVER REVASCULARIZATION
• 1. BYPASS GRAFT (CABG);
• 2. PERCUTANEOUS STENTING (PCI)
WHERE WE TRAVERSE THE LESION WITH
A CATHETER AND DEPLOY A STENT TO
OPEN UP THE BLOCKAGE TO
RECONSTITUTE FLOW THROUGH THE
LESION
• BASED ON THE MECHANISM OF
REVASCULARIZATION BETWEEN THESE 2,
AFFECTS WHO SHOULD GET WHAT AND
WHERE
PCI vs. CABG

7. • LEFT MAIN >50%
• OTHER >70%
• IF IN DOUBT ON ANGIOGRAPHY,
ADDITIONAL MEANS - FFR
• - FRACTIONAL FLOW RESERVE (FFR);
• - DURING CATHETERIZATION, PRESSURE
DIFFERENCES ACROSS STENOSIS ARE
MEASURED TO DETERMINE LIKELIHOOD
THE STENOSIS IMPEDES OXYGEN
DELIVERY TO THE MYOCARDIUM
• - SIGNIFICANT WHEN <0.8
SIGNIFICANT STENOSES

8. • ANGIOGRAPHIC GRADING TOOL TO
DETERMINE THE COMPLEXITY OF
CAD
• INCORPORATES LESION
COMPLEXITY, LOCATION AND
NUMBER
• LOW SCORE = LOW COMPLEXITY
• LOW SCORE: 0-22
• INTERMEDIATE: 23-32
• HIGH >/= 33
SYNTAX SCORE

11. BROAD INDICATIONS
• LEFT MAIN DESEASE >50%
• LEFT MAIN EQUIVALENT (LAD % LCX STENOSED)
• THREE VESSEL DISEASE
• MULTIVESSEL DISEASE WITH LEFT VENTRICULAR DYSFUNCTION
• LIFESTYLE LIMITING ANGINAUNRESPONSIVE TO MAXIMUM MEDICAL
THERAPY OR PERCUTANEOUS STENTING (PCI)

12. BROAD INDICATIONS
• ONGOING ISCHAEMIA IN SETTING OF NSTEMI UNRESPONSIVE TO
MEDICAL THERAPY
• IN STEMI WHEN NOT POSSIBLE TO PCI LESION OR WHERE PCI HAS
FAILED
• IN COMBINED WITH VALVE, AORTIC, OTHER CARDIAC SURGICAL
PROCEDURE

13. GUIDELINES

14. BASED ON ALL AVAILABLE EVIDENCE
A. BASED ON STRONG EVIDENCE;
B. BASED ON MODERATE EVIDENCE;
C. BASED ON EXPERT OPINION
GREEN: STRONG RECOMMENDATION
YELLOW: MODERATE
RECOMMENDATION
ORANGE: WEAK RECOMMENDATION
RED: NO BENEFIT, POTENTIAL HARM

15. CABG vs. PCI
BOTH EUROPEAN & US GUIDELINES
- EUROPEAN SOCIETY OF CARDIOLOGY (ESC)
- EUROPEAN ASSOCIATION FOR CARDIOTHORACIC SURGERY
(EACTS)
-
- AMERICAN COLLEGE OF CARDIOLOGY (ACC)
- AMERICAN HEART ASSOCIATION (AHA)
SPECIFIC RECOMMENDATIONS
- BY VESSELS AFFECTED AND COMPLEXITY OF DISEASE
(SYNTAX)

16. INDICATIONS
- ASYMPTOMATIC PATIENTS OR PATIENTS WITH MILD ANGINA PECTORIS;
- PATIENTS WITH CHRONIC STABLE ANGINA PECTORIS;
- PATIENTS WITH UNSTABLE ANGINA OR NON-ST ELEVATION MI;
- PATIENTS WITH ST ELEVATION MI;
- PATIENTS WITH POOR LV FUNCTION;
- PATIENTS WITH LIFE-THREATENING VENTRICULAR ARRHYTHMIAS;
- PATIENTS AFTER FAILED PCI;
- PATIENTS WITH PREVIOUS CABG

17. FOR ASYMPTOMATIC PATIENTS OR PATIENTS WITH MILD ANGINA
PECTORIS
CLASS OF
RECOMMENDATION DEFINITION RECOMMENDATION
CLASS I
1. SIGNIFICANT LMCA DISEASE (>50%);
2. LMCA DISEASE EQUIVALENT (LADp & LCXp >70%);
3. 3-VCAD WITH LVEF <50%;
4. 1-VCAD / 2-CAD (incl. LADp) WITH LVEF <5O%
BENEFICIAL, USEFUL,
EFFECTIVE
CLASS II
CLASS IIa 1.1-VCAD / 2-VCAD (incl. LADp) WITH LVEF >50%
USEFULNESS/EFFICASY
++/-
CLASS IIb
1.1-VCAD / 2-VCAD (without LADp) BUT WITH LARGE AREA
OF MYOCARDIUM AT RISK, DEMONTRATED ON NON-
INVASIVE TESTING
USEFULNESS/EFFICASY
+/- -
CLASS III
NOT USEFUL/EFFECTIVE
HARMFUL

18. FOR PATIENTS WITH CHRONIC STABLE ANGINA PECTORIS
CLASS OF
RECOMMENDATION DEFINITION RECOMMENDATION
CLASS I
1. SIGNIFICANT LMCA DISEASE (>50%);
2. LMCA DISEASE EQUIVALENT (LADp & LCXp >70%);
3. 3-VCAD WITH LVEF <50%;
4. 1-VCAD / 2-CAD (incl. LADp) WITH LVEF <5O%;
5. 1-VCAD / 2-VCAD (without LADp) BUT WITH LARGE AREA OF MYOCARDIUM
AT RISK, DEMONTRATED ON NON-INVASIVE TESTING
BENEFICIAL, USEFUL,
EFFECTIVE
CLASS II
CLASS IIa
1. 1-VCAD / 2-CAD (incl. LADp) WITH LVEF <5O%;
2. 1-VCAD / 2-VCAD (without LADp) BUT WITH MODERATE AREA OF
MYOCARDIUM AT RISK, DEMONSTRATED ON NON-INVASIVE TESTING
USEFULNESS/EFFICASY
++/-
CLASS IIb
USEFULNESS/EFFICASY
+/- -
CLASS III
1. 1-VCAD / 2-VCAD (without LADp) WITH NO MYOCARDIUM AT RISK;
2. BORDERLINE STENOSIS 50-60% WITH NO MYOCARDIUM AT RISK;
3. INSIGNIFICANT STENOSIS (<50%)
NOT USEFUL/EFFECTIVE
HARMFUL
CONTRAINDICATED

19. • Broad agreement in guidelines
between Europe and US - though
Europe a bit more “PCI friendly”
• GREEN- DO
• RED-DON’T
INDICATIONS IN CHRONIC STABLE ANGINA
EUROPEAN AND US GUIDELINES
HEART TEAM
CABG when three vessels
involved
PCI when non LAD
disease one or 2 vessels

20. • LEFT MAIN DISEASE +
MULTIPLE VESSELS
• CABG
• EU, US, BG
INDICATIONS IN LEFT MAIN CAD
EUROPEAN AND US GUIDELINES

21. FOR PATIENTS WITH UNSTABLE ANGINA OR NON-ST ELEVATION
MI
CLASS OF
RECOMMENDATION DEFINITION RECOMMENDATION
CLASS I
1. SIGNIFICANT LMCA DISEASE (>50%);
2. LMCA DISEASE EQUIVALENT (LADp & LCXp >70%);
3. OTHER CAD WITH ONGOING ISCHAEMIA UNRESPONSIVE
TO MAXIMAL NON-SURGICAL TREATMENT
BENEFICIAL, USEFUL,
EFFECTIVE
CLASS II
CLASS IIa 1. 1-VCAD / 2-CAD (incl. LADp) WITH LVEF <5O%;
USEFULNESS/EFFICASY
++/-
CLASS IIb
1. 1-VCAD / 2-VCAD (without LADp) WHEN PCI IS NOT AN
OPTION BUT A LARGE AREA OF MYOCARDIUM IS AT RISK
USEFULNESS/EFFICASY
+/- -
CLASS III
NOT USEFUL/EFFECTIVE
HARMFUL
CONTRAINDICATED

22. FOR PATIENTS WITH ST ELEVATION MI
CLASS OF
RECOMMENDATION DEFINITION RECOMMENDATION
CLASS I
1. EMERGENCY OR URGENT CABG IS INDICATED WHEN THE PATIENT HAS SUITABLE
CORONARY ANATOMY AND:
2. FAILED PCI WITH HAEMODYNAMIC INSTABILITY;
3. PERSISTENT OR RECURRENT ISCHAEMIA WITH LARGE AREA OF MYOCARDIUM AT RISK
BUT NOT SUITABLE FOR PCI;
4. MECHANICAL COMPLICATIONS OF CAD: VSD,IMR,LV RUPTURE;
5. CARDIOGENIC SHOCK WITHIN 36 HOURS OF MI;
6. LIFE-THREATENING VENTRICULAR ARRHYTHMIAS WITH LMCAD >50% OR 3-VCAD
BENEFICIAL, USEFUL,
EFFECTIVE
CLASS II
CLASS IIa
1. PRIMARY RE-PERFUSION WITHIN 6-12 HOURS OF MI, IN PATIENTS NOT
SUITABLE FOR, OR FOLLOWING FAILED PCI AND THROMBOLYSIS
USEFULNESS/EFFICASY
++/-
CLASS IIb
USEFULNESS/EFFICASY
+/- -
CLASS III
1. HAEMODYNAMICALLY STABLE PATIENT WITH A SMALL AREA OF
MYOCARDIUM AT RISK
NOT USEFUL/EFFECTIVE
HARMFUL
CONTRAINDICATED

23. FOR PATIENTS WITH POOR LV FUNCTION
CLASS OF
RECOMMENDATION DEFINITION RECOMMENDATION
CLASS I
1. SIGNIFICANT LMCA DISEASE (>50%);
2. LMCA DISEASE EQUIVALENT (LADp & LCXp >70%);
3. 3-VCAD WITH LVEF <50%;
4. 1-VCAD / 2-CAD (incl. LADp)
BENEFICIAL, USEFUL,
EFFECTIVE
CLASS II
CLASS IIa
1. SIGNIFICANT VIABLE NON-CONTRACTING REVASCULARISABLE
MYOCARDIUM (WITHOUT ABOVE ANATOMY)
USEFULNESS/EFFICASY
++/-
CLASS IIb
USEFULNESS/EFFICASY
+/- -
CLASS III
1. NO EVIDENCE OF INTERMITTENT ISCHAEMIA OR VIABLE NON-CONTRACTING
REVASCULARISABLE MYOCARDIUM
NOT USEFUL/EFFECTIVE
HARMFUL
CONTRAINDICATED

24. FOR PATIENTS WITH LIFE-THREATENING VENTRICULAR
ARRHYTHMIAS
CLASS OF
RECOMMENDATION DEFINITION RECOMMENDATION
CLASS I
1. LIFE-THREATENING VENTRICULAR ARRHYTHMIA CAUSED
BY LMCAD OR 3-VCAD;
2. RESUSCITATED SCD OR SUSTAINED VENTRICULAR
TACHYCARDIA IN PATIENTS WITH 1-VCAD / 2-VCAD
BENEFICIAL, USEFUL,
EFFECTIVE
CLASS II
CLASS IIa
1. LIFE-THREATENING VENTRICULAR ARRHYTHMIA CAUSED BY 1-VCAD /
2-VCAD
USEFULNESS/EFFICASY
++/-
CLASS IIb
USEFULNESS/EFFICASY
+/- -
CLASS III
1. VENTRICULAR TACHYCARDIA WITH MYOCARDIAL SCAR AND NO EVIDENCE
OF ISCHAEMIA
NOT USEFUL/EFFECTIVE
HARMFUL
CONTRAINDICATED

25. FOR PATIENTS AFTER FAILED PCI
CLASS OF
RECOMMENDATION DEFINITION RECOMMENDATION
CLASS I
1. ONGOING ISCHAEMIA;
2. THREATENED OCCLUSION;
3. HAEMODYNAMIC COMPROMISE
BENEFICIAL, USEFUL,
EFFECTIVE
CLASS II
CLASS IIa
1. RETAINED FOREIGN BODY;
2. HAEMODYNAMIC COMPROMISE WITH IMPAIRED CLOTTING AND NO
PREVIOUS MEDIAN STERNOTOMY
USEFULNESS/EFFICASY
++/-
CLASS IIb
1. HAEMODYNAMIC COMPROMISE WITH IMPAIRED CLOTTING AND
PREVIOUS MEDIAN STERNOTOMY
USEFULNESS/EFFICASY
+/- -
CLASS III
1. NO EVIDENCE OF ISCHAEMIA;
2. NO SUITABLE TARGETS FOR GRAFTING
NOT USEFUL/EFFECTIVE
HARMFUL
CONTRAINDICATED

26. FOR PATIENTS WITH PREVIOUS CABG
CLASS OF
RECOMMENDATION DEFINITION RECOMMENDATION
CLASS I
1. DISABLING ANGINA PECTORIS DESPITE MAXIMAL NON-
SURGICAL THERAPY;
2. IF 0 GRAFTS ARE PATENT, INDICATIONS ARE SIMILAR TO
PRIMARY CABG ( LMCAD, 3-VCAD )
BENEFICIAL, USEFUL,
EFFECTIVE
CLASS II
CLASS IIa
1. THREATENED MYOCARDIUM, DEMONSTRATED BY NON-INVASIVE
STUDIES;
2. ATHEROSCLEROTIC VEIN GRAFTS WITH >50% STENOSIS SUPPLYING A
LARGE AREA OF MYOCARDIUM
USEFULNESS/EFFICASY
++/-
CLASS IIb
USEFULNESS/EFFICASY
+/- -
CLASS III
NOT USEFUL/EFFECTIVE
HARMFUL
CONTRAINDICATED

27. PCI treats present lesion:
stenosis that is visible or the
plaque that has just ruptured
but the rest of the vessels are
unprotected,
Whereas:
Bypass graft (CABG)- usually
placed in the mid/distal vessel
so anything proximal or the
coronary stenoses usually
develop, we may have
ongoing disease there, but we
still have blood flow around it,
and more complete
revascularization is achieved
that way.
CABG treats present and
future lesions

28. • CAD IS LOCATED MAILY IN PROXIMAL CORONARY ARTERIES
• PLACING A BYPASS IN THE MID CORONARY ARTERY PROTECTS
AGAINST FUTURE LESIONS
• CAD IS A PROGRESSIVE DISEASE - CONTINUES TO DEVELOP
• PCI ONLY TREATS ONE LESION, DOES NOT TREAT FUTURE LESIONS

30. PREOPERATIVE REVIEW
• DOCUMENT CO-MORBIDITIES: RISK STRATIFICATION (EUROSCORE 2)
• AVAILABILITY OF CONDUITS
• - RADIAL ARTERY, SAPHENOUS VEINS
• - MEDIASTINAL IRRADIATION —> PFTs, +/- RHC (USUALLY NO LIMA)
• CXR OR CT SCAN - ASCERTAIN AORTIC CALCIFICATION
• CAROTID BRUITS, TIA, CVA —> CAROTID ARTERY DUPLEX
• - <50%: PERIOPERATIVE CVA <1%
• - 50-80%: PERIOPERATIVE CVA 10%
• - >80%: PERIOPERATIVE CVA 11-18%
• RECENT ISCHAEMIC STROKE: HEAD CT, 4 WEEK DELAY OF CABG

31. CHEST WALL DEFECT WITH INFECTION IN FEMALE PATIENT AFTER LIMA
HARVESTING FOR CABGx3 WITH PREVIOUS HISTORY OF LEFT RADICAL
MASTECTOMY FOLLOWED BY RADIOTHERAPY
CAUTION IN FEMALE PATIENTS
WITH MASTECTOMY

32. PREOPERATIVE REVIEW
• MEDICATIONS:
• - DISCONTINUE ANTIPLATELET DRUGS 7 DAYS PRIOR SURGERY
• - BUT CONTINUE WITH HEPARIN/LMWH UP TO SURGERY (LMCAD)
• -NORMALIZE INR (DISCONTINUE ANTICOAGULATION 7 DAYS PRIOR SURGERY)
• -PLAVIX - AVOID IF POSSIBLE PRIOR SURGERY OR REPLACE WITH HEPARIN
• ECHOCARDIOGRAPHY:
• - FUNCTIONAL SIGNIFICANCE OF CAD (LVEF)
• - VALVES
• - LV SYSTOLIC WALL MOTION, RV FUNCTION
• CORONARY ANGIOGRAPHY:
• - IDENTIFY TARGET VESSELS

33. PREOPERATIVE REVIEW
• VIABILITY STUDIES (LVEF <35%)
• - DETERMINE: HIBERNATION, SCAR, STRESS-INDUCED ISCHAEMIA, LV
REMODELING
• - 20-40% OF VIABLE MYOCARDIUM NEEDED TO BENEFIT FROM
REVASCULARIZATION
C-MRI PET/SPECT
LV FUNCTION/VOLUMES ++++ +++
ISCHAEMIA ++ ++++
VIABILITY ++ ++++
SCAR ++++ +++
ACCURACY +++ +++

34. WHO NEEDS VIABILITY STUDIES?
• CLINICAL
• - NO ANGINA, ONLY DYSPNOEA
• ANGIOGRAPHIC
• - POOR LAD/LCx RUN-OFF
• - TOTALLY OCCLUDED PROXIMAL LAD
• ECHOCARDIOGRAPHIC
• - LVEDV >220; LVESV >140; LVEF <20%
• - AKINETIC, DYSKINETIC SEGMENTS
• -1. 55-90,6% AKINETIC SEGMENTS = NON VIABLE
• -2. 3,4-60% HYPOKINETIC SEGMENTS = NON VIABLE
LVEF <35%

35. • ARTERIAL:
• - Left/Right Internal Thoracic Arteries ( LIMA/RIMA );
• - Radial artery ( RA );
• - Right Gastroepiploic Artery ( rGEA ).
• VENOUS:
• - Greater Saphenous Vein (GSV);
• - Smaller Saphenous Vein (SSV)

36. SAPHENOUS VEINS
• BENEFITS
• - EASILY AVAILABLE,
HARVESTED
• - ACCEPTABLE PATENCY FOR
2,0 MM. OR LARGER
CORONARY TARGETS
• - NO SPASM
• - EXCELLENT IMMEDIATE
FLOW
• PITFALLS
- LOW SHORT -/LONG-TERM
PATENCY
- VEIN-GRAFT
ATHEROSCLEROSIS (INTIMAL
HYPERPLASIA)
- LEG WOUND
COMPLICATIONS

37. GREATER SAPHENOUS
VEIN HARVESTING

38. GREATER SAPHENOUS
VEIN HARVESTING

39. GREATER SAPHENOUS VEIN
TECHNIQUES & FINAL RESULTS
Conventional
Bridge Technique
Endoscopic

40. INTIMAL HYPERPLASIA
LEG WOUND INFECTION
AFTER SVG HARVESTING

41. THROMBOSED SAPHENOUS VEIN
GRAFTS

42. INTERNAL THORACIC ARTERY
• BENEFITS
• ELASTIC ARTERY
• NO SPASM
• NO INTIMAL HYPERPLASIA
• RARE ATHEROSCLEROSIS
• EXCELLENT PATENCY:
• - 5 YEARS —> 97%
• - 10 YEARS —> 90-95%
• PITFALLS
- COMPETITIVE FLOW ( BEST IN
60% OR GREATER )
- PHRENIC NERVE INJURY
- STERNAL ISCHAEMIA
- DIFFICULT MANAGEMENT AT
REOPERATION
- KINKING IF SEQUENTIAL
ANASTOMOSES PERFORMED

44. INTERNAL THORACIC ARTERY
• MOBILIZATION
• - PEDICLE: INCREASED STERNAL DEVASCULARIZATION; SHORTER IMA
• - SKELETONIZED; LONGER IMA
• PAPAVERINE INFUSION FOR DILATATION PRIOR ANASTOMOSIS
• IN SITU OR FREE GRAFT IMAs
• CRITERIA FOR REJECTION:
• - DISSECTION
• - ATHEROSCLEROSIS (VERY RARE)
• - LOW FLOW (<50 ML/MIN)
• - DAMAGE
• - LSCA STENOSIS
POTENTIAL FREE ITA GRAFT

45. LEFT INTERNAL THORACIC
ARTERY HARVESTING

46. BITA
• SURVIVAL ADVANTAGE AND LOWER REINTERVENTION INTO 3-RD DECADE
• SKELETONIZE LITA & RITA
• RITA:
• - IN SITU VIA TRANSVERSE SINUS TO HIGH OM BRANCHES
• - IN SITU TO LAD ( NOT FAVORED)
• - FREE GRAFT VIA HOOD OF SVG OR Y- GRAFT FROM IN SITU LITA
• AVOID IN :
• OBESITY +/- COPD ON STEROIDS;
• EMERGENCY CABG;
• INSULIN DEPENDENT DIABETES ( check HgA1C)

47. Free Y-RITA composite
from LITA
RIMA - LAD:
NOT FAVORED

48. RADIAL ARTERY
HARVESTING

49. RIGHT GASTROEPIPLOIC
ARTERY HARVESTING

50. RIGHT GASTROEPIPLOIC
ARTERY HARVESTING

52. CABG
CONVENTIONAL TECHNIQUE ON CPB
• 1/ STERNOTOMY;
• 2/ GRAFT (CONDUIT) HARVESTING;
• 3/ CPB ESTABLISHMENT;
• 4/ CARDIOPLEGIC ARREST;
• 5/ DISTAL ANASTOMOSES;
• 6/ PROXIMAL ANASTOMOSES;
• 7/ CPB WEANING-OFF;
• 8/ HAEMOSTASIS;
• 9/ CLOSURE

53. FULL STERNOTOMY

54. CABG
RCA
LAD
LIMA
RA
CABG x 3
all arterial

55. CABG
RCA
LAD
LIMA
SVG
CABG x 3
LAD-LIMA
RCA,OM- sequential SVG
OM

56. CABG
LAD
LIMA
RIMA
CABG x 2
all arterial
LAD-RIMA
OM-LIMA
OM

57. CABG
LAD
LIMA
RIMA
CABG x 2
all arterial
LAD-LIMA
RCA-RIMA
RCA

58. CABG
RCx
OM
SVG
CABG x 3
RCA,RCx,OM- sequential SVG
RCA

59. CABG
RCA/PD/
SVG
CABG x 2
RCA,RCA/PD/- sequential SVG
RCA

60. CABG
LIMA
SVG
CABG x 3
LAD-LIMA
RCA, RDg-SVG
SVG