I. Efficacy

  1. Graft patency after Coronary Artery Bypass Graft
    1. Internal mammary graft stays patent in >90% for >10 years
    2. Saphenous vein graft patency is much more tenuous
      1. Year 2: 85% are patent
      2. Year 5: 75% are patent
      3. Year 8: 65% are patent
  2. References
    1. Loop (1986) N Engl J Med 314:1

II. Precautions: PTCA as an alternative for Left Main Disease

  1. PTCA with DES may be a reasonable alternative to CABG in moderate coronary disease cases previously limited to CABG (e.g. Left main disease)
    1. For moderate left main disease, PTCA with DES outcomes over 10 years are similar to CABG outcomes
    2. PTCA is a safe, much less invasive procedure than CABG
    3. CABG has a higher rate of perioperative Cerebrovascular Accident
  2. Caveats
    1. CABG is associated with decreased Angina
    2. CABG is associated with a better outcome with severe left main disease or multi-vessel disease
    3. CABG has better outcomes when repeat revascularization is required
  3. References
    1. Rihal (2012) Mayo POIM Conference, Rochester

III. Indications: Absolute Indications in Stable CAD

  1. Disabling Angina despite maximal medical therapy given acceptable surgical risk
    1. If atypical Angina, confirm cardiac ischemia is cause of symptoms
  2. Significant proximal LAD stenosis (>70%)
  3. Significant left main Coronary Artery stenosis
  4. One to two vessel CAD (without proximal LAD stenosis)
    1. LARGE area of viable Myocardium and
    2. High risk criteria on noninvasive testing
  5. Two vessel CAD
    1. Significant proximal LAD stenosis and
    2. Ejection Fraction (EF) <50% or ischemia on noninvasive testing
  6. Three vessel CAD
    1. Especially if Ejection Fraction (EF) <50%

IV. Indications: Possible Indications in Stable CAD

  1. One vessel CAD and
    1. Proximal LAD Stenosis
  2. One to two vessel CAD (without proximal LAD stenosis)
    1. MODERATE area of viable Myocardium and
    2. Ischemia on noninvasive testing

V. Indications: Avoid CABG in these patients (cases in which CABG is NOT recommended)

  1. Borderline Coronary Artery stenosis (<60%) not involving left main Coronary Artery and negative noninvasive testing
  2. Insignificant Coronary Artery stenosis (<50%)
  3. One to two vessel CAD (without proximal LAD stenosis)
    1. SMALL area of viable Myocardium and
    2. No ischemia on noninvasive testing and
    3. Mild symptoms unlikely to be ischemia or inadequate medical management trial

VI. Complications (based on STS Guidelines from 2008)

  1. Transfusion required: <50%
  2. Incomplete revascularization: <20%
  3. Major morbidity (e.g. CVA): <5%
  4. Mortality: <2%

Images: Related links to external sites (from Google)

Ontology: Coronary Artery Bypass Surgery (C0010055)

Definition (MEDLINEPLUS)

If you have coronary artery disease (CAD), the arteries that supply blood and oxygen to the heart muscle become hardened and narrowed. If lifestyle changes and medicines don't help, your doctor may recommend coronary artery bypass surgery.

The surgery uses a piece of a vein from the leg or artery from the chest or wrist. The surgeon attaches this to the coronary artery above and below the narrowed area or blockage. This allows blood to bypass the blockage. Some people need more than one bypass.

You may need bypass surgery for various reasons. Another procedure for CAD, angioplasty, may not have widened the artery enough. In some cases, the angioplasty tube can't reach the blockage.

A bypass also can close again. This happens in more than 10 percent of bypass surgeries, usually after 10 or more years.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI) Surgery in which a healthy blood vessel taken from another part of the body is used to make a new path for blood around a blocked artery leading to the heart. This restores the flow of oxygen and nutrients to the heart.
Definition (MSH) Surgical therapy of ischemic coronary artery disease achieved by grafting a section of saphenous vein, internal mammary artery, or other substitute between the aorta and the obstructed coronary artery distal to the obstructive lesion.
Definition (CSP) surgical procedure creating a bridge between the ascending aorta and one or more of the three major coronary arteries, distal to an obstructive lesion, using autologous tissue transplanted from the saphenous vein.
Definition (NCI) Surgery performed to bypass partially or completely occluded coronary arteries, thereby increasing the blood supply of the heart.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D001026
ICD9 36.10, 36.1
SnomedCT 149173009, 149174003, 119563008, 149169006, 175006004, 67166004, 232717009, 90205004
English Aortocoronary Bypass, Aortocoronary Bypasses, Artery Bypass, Coronary, Artery Bypasses, Coronary, Bypass Surgery, Coronary Artery, Bypass, Coronary Artery, Bypasses, Aortocoronary, Bypasses, Coronary Artery, Coronary Artery Bypass, Coronary Artery Bypass Grafting, Coronary Artery Bypasses, Aorto-coronary artery bypass graft, Cardiac revascularization with bypass anastomosis, NOS, Aortocoronary bypass for heart revascularization, NOS, CAB graft, Coronary bypass, Bypass, Aortocoronary, CORONARY ARTERY BYPASS, CORONARY BYPASS, coronary bypass, CABG - Coronary art bypass gr, Coronary Artery Bypass Graft, Heart Bypass, CABG, Coronary artery bypass, CORONARY ARTERY BYPASS SURG, BYPASS SURG CORONARY ARTERY, coronary artery bypass graft, coronary artery bypass graft (CABG) (treatment), coronary artery bypass graft (coronary artery bypass graft), coronary bypass surgery, coronary artery bypass graft (CABG), CABG (coronary artery bypass graft), Coronary artery bypass graft (procedure), Coronary artery operations (& bypass) (procedure), Coronary art bypass graft ops, CORONARY ARTERY BYPASS GRAFT, Aortocoronary bypass NOS, Coronary artery bypass graft (CABG), Graft;coronary artery bypass, coronary artery bypass surgery, coronary artery bypass graft (GABG), aortocoronary bypass, coronary artery bypass, CAB, Aortocoronary artery bypass graft, ACB graft, Vascular aortocoronary bypass, Cardiac revascularization with aortocoronary bypass anastomosis, CABG - Coronary artery bypass graft, CAG - Coronary artery graft, CBG - Coronary bypass graft, Coronary artery bypass graft, Coronary artery bypass grafting, Coronary artery bypass graft operations, Cardiac revascularisation with aortocoronary bypass anastomosis, Cardiac revascularisation with bypass anastomosis, Cardiac revascularization with bypass anastomosis (procedure), Cardiac revascularization with bypass anastomosis, Coronary artery bypass grafting (procedure), Aortocoronary artery bypass graft (procedure), Aortocoronary bypass for heart revascularisation, Aortocoronary bypass for heart revascularization, Coronary A. operations, Coronary artery bypass graft (procedure) [Ambiguous], Coronary artery operations (& bypass), Coronary artery operations, Coronary Artery Bypass Surgery, Aortocoronary bypass for heart revascularization, not otherwise specified, Bypass anastomosis for heart revascularization
Dutch CABG, arteria coronaris bypass, coronaire bypass, coronaire bypassoperatie, Bypass, aortocoronaire, Bypass, coronaire arterie-, Coronaire arteriebypass
French Pontage de l'artère coronaire, Pontage coronaire, Pontage aorto-coronarien, Pontage aortocoronarien, PAC (Pontage AortoCoronarien), Revascularisation coronaire par pontage, Pontage aorto-coronaire, Pontage aortocoronaire, Greffe de pontage de l'artère coronaire
German Koronar-Bypass, CABG, koronare Bypass-Operation, Aortokoronarer Shunt, Bypass, koronarer, Koronararterien-Bypass
Italian Bypass coronarico, Bypass di arteria coronarica, Innesto di bypass coronarico, Bypass aortocoronarico, Innesto sull’arteria coronaria con by-pass, Chirurgia con bypass dell'arteria coronaria, Innesto di bypass di arteria coronaria, Bypass dell'arteria coronaria
Portuguese Enxerto de bypass de artéria coronária, Bypass coronário, Bypass de artéria coronária, Enxerto de bypass da artéria coronária, Derivação da Artéria Coronária, Ponte Aortocoronária, Ponte de Artéria Coronária
Spanish AACI, Coronary artery bypass graft, Coronary artery bypass grafting, Coronary artery operations (& bypass), Coronary artery operations, Coronary A. operations, Coronary artery bypass graft operations, Injerto anastomótico coronario, Derivación arterial coronaria, Derivación coronaria, bypass coronario, derivación aortocoronaria para revascularización cardíaca, revascularización cardíaca por derivación aortocoronaria, puente coronario, bypass aortocoronario con injerto, injerto en puente aortocoronario, derivación aortocoronaria vascular, bypass de arteria coronaria, injerto - puente de arteria coronaria (procedimiento), injerto - puente de arteria coronaria, injerto puente aortocoronario (procedimiento), injerto puente aortocoronario, injerto puente coronario (concepto no activo), injerto puente coronario (procedimiento), injerto puente coronario, revascularización cardíaca con anastomosis por bypass, revascularización cardíaca con anastomosis por puente, revascularización cardíaca con anastomosis quirúrgica (procedimiento), revascularización cardíaca con anastomosis quirúrgica, Derivacion de la Arteria Coronaria, Puente Aortocoronario, Puente de Arteria Coronaria, Derivación de la Arteria Coronaria
Japanese 冠動脈バイパス, カンドウミャクバイパス, カンドウミャクバイパスイショク, CABG, CABG, 冠状動脈バイパス術, A-Cバイパス, バイパス術-大動脈冠状動脈, 冠動脈バイパス手術, 冠状動脈バイパス, 冠状動脈バイパスグラフト, 冠状動脈バイパス手術, 大動脈冠状動脈バイパス術, A-Cバイパス術, ACバイパス, バイパス手術-冠動脈, バイパス手術-冠状動脈, 冠動脈バイパスグラフト, 冠動脈バイパス移植, 冠動脈バイパス術, 冠動脈大動脈バイパス, 大動脈冠動脈バイパス
Swedish Koronar-bypass
Czech aortokoronární bypass, koronární artérie - bypass, Implantát bypassu koronární artérie, Aortokoronární bypass, CABG, Bypass koronární tepny
Finnish Sepelvaltimoiden ohitusleikkaus
Russian KORONARNOI ARTERII SHUNTIROVANIE, AORTOKORONARNOE SHUNTIROVANIE, SHUNTIROVANIE KORONARNOI ARTERII, АОРТОКОРОНАРНОЕ ШУНТИРОВАНИЕ, КОРОНАРНОЙ АРТЕРИИ ШУНТИРОВАНИЕ, ШУНТИРОВАНИЕ КОРОНАРНОЙ АРТЕРИИ
Croatian KORONARNA ARTERIJA, PREMOŠTENJE
Polish Pomostowanie tętnic wieńcowych, Pomostowanie naczyń wieńcowych, CABG, Pomostowanie aortalno-wieńcowe, Wszczepienie pomostów aortalno-wieńcowych, Bypass wieńcowy
Hungarian Arteria coronaria bypass, CABG, Arteria coronaria bypass graft, Coronaria bypass