Synonyms: bypass grafting, triple bypass, quadruple bypass
This is one of two coronary revascularisation techniques currently used in the treatment of coronary artery disease, the other being percutaneous coronary intervention (PCI). The patient will already have had a clinical diagnosis of coronary heart disease (CHD), confirmed by coronary angiography to delineate the obstruction. If PCI is feasible, it may be performed at the time of coronary angiography (ad hoc PCI). Coronary artery bypass grafting (CABG - pronounced 'cabbage') may be performed as a primary procedure, after failed PCI, or as a repeat procedure.
Benefits of treatment
The main purpose of revascularisation is to relieve the symptoms of stable angina and both CABG and PCI are effective.
Three major randomised controlled trials (RCTs) originally compared CABG with medical therapy. They are:
- The Coronary Artery Surgery Study (CASS).
- The Veterans Administration (VA) Co-operative Study.
- The European Coronary Surgery Study (ECSS).
A meta-analysis of these three studies from 1994 showed that in high- and medium-risk patients there was definite survival benefit from CABG but not in low-risk patients.
Subsequently the development of PCI has led its use in people with increasingly complex disease, such as multivessel and left main coronary disease. This has led to debate as to which is the optimum revascularisation technique. In the SYNTAX (SYNergy between PCI with TAXus and cardiac surgery) study, CABG was compared with PCI, confirming that CABG is superior to PCI in patients with stable, complex coronary artery disease with a reduction in major adverse outcomes with CABG. The patients in this study had left main coronary artery disease, triple vessel disease or both. The researchers augmented the SYNTAX score (a combination of clinical and anatomical features) to include additional prognostic variables, including gender, age and comorbidities, to decide which patients should be offered CABG. The use of the improved SYNTAX score II helped to choose those patients most likely to benefit from CABG. Other models for risk stratification have been developed, including The European System for Cardiac Operative Risk Evaluation (EuroSCORE); however, no one specific model is recommended.
Choice of revascularisation procedure
- The choice of CABG or PCI depends on the distribution of the coronary artery disease, comorbidities and patient preference.
- Any patient with left main vessel or complex three-vessel disease or with other relevant clinical factors should be the subject of a multidisciplinary team (the Heart Team) meeting, to discuss the risks and benefits of the revascularisation techniques in their individual case, followed by an explanation and discussion with the patient.
- A systematic review of CABG versus PCI concluded that:
- Patients with significant left main disease, multivessel disease or left ventricular (LV) dysfunction, if the severity is deemed to be more complex (SYNTAX >22) benefit from CABG, due to lower cardiac events with CABG surgery.
- Patients with less complex disease (SYNTAX <22) and/or the patient is a higher surgical risk benefit from PCI.
- Patients with diabetes, irrespective of the severity of their coronary anatomy, benefit from CABG, due to improved long-term survival and lower major adverse cardiac and cerebrovascular events.
- The incidence of revascularisation after PCI is higher than after CABG.
- The incidence of stroke is higher after CABG surgery than after PCI.
- A meta-analysis of studies comparing patients with multi-vessel coronary disease who underwent CABG versus PCI (6,055 participants) demonstrated unequivocal benefit of CABG in long-term mortality and myocardial infarctions, regardless of whether or not the participants had diabetes.
- It is recommended that no more than two weeks should elapse between diagnostic catheterisation and revascularisation (CABG or PCI) in patients with severe symptoms or high-risk anatomy. In all other patients, with stable coronary artery disease but in whom the symptoms aren't satisfactorily controlled with medical treatment, it is desirable to perform revascularisation within six weeks.
- It should be noted that the majority of randomised controlled studies for revascularisation included mainly male patients who were relatively young.
There were 17,630 isolated CABG operations in Great Britain and Ireland in 2013 compared with 23,126 performed in 2004.
Internationally there is considerable geographical variation in terms of numbers of revascularisation procedures and the proportion that are surgical. In England there is a 13-fold difference in the ratio of elective PCI to CABG, which is not explained by overall procedure volume or deprivation.
- The operation is usually performed through a mid-sternal incision.
- Veins may be harvested from the saphenous vein in the legs but arteries are also used and these give better long-term outcomes, particularly the internal mammary artery.
- The most commonly used arteries are the internal thoracic (internal mammary) but the gastro-epiploic also avoids the need for a proximal anastamosis, although it is currently rarely used.
- Endoscopic vein harvestingand radial artery harvesting are an alternative to open harvesting and are being used increasingly, although there is no unequivocal evidence of beneficial long-term patency.
- Bilateral internal mammary artery grafting is associated with improved long-term survival and non-fatal events. There is a small increased risk of sternal dehiscence and mediastinitis, especially in the obese and people with diabetes, when the radial artery is recommended as the second arterial graft.
- Over 75% of patients have at least three grafts and at least one is usually an artery.
- It is possible to use a smaller incision in a technique called minimally invasive direct coronary artery bypass (MIDCAB) with a more lateral approach:
- In minimal access surgery, a small incision is made directly over the artery to be bypassed.
- MIDCAB should be considered in patients with isolated left arterial disease.
- Minimally invasive procedures are still being evaluated and are not yet available routinely.
- Operating without cardioplegia (off-pump CABG) is possible, the rationale being that much of the morbidity related to CABG is caused by the cardiopulmonary bypass, in particular the risk of stroke:
- Large RCTs have not shown any difference in 30-day or 1-year clinical outcomes between on-pump and off-pump CABG.
- Outcomes may depend on the expertise of the surgical team.
- There may be a subgroup of patients with end-stage chronic kidney disease who might benefit from off-pump CABG; they appear to benefit from lower in-hospital mortality and fewer new renal replacements with off-pump compared with on-pump CABG.
- On-pump CABG remains the standard surgical procedure.
- Most surgeons prefer cardioplegia with cardiopulmonary bypass.
- CABG significantly improves symptoms of angina, quality of life and exercise capacity; it reduces the need for anti-anginal therapy compared with medical treatment.
- 10-year cumulative survival rates are in the order of 77% decreasing to 15% at 30 years. In the same centre, 94% of patients needed repeat intervention.
- At 10 years the benefit of CABG over medical therapy is lost in those who had only saphenous vein grafts but after arterial grafts, it remains.
- Survival is improved, with the greatest relative benefit going to those with left main stem (LMS) stenosis of >50%. Patients with angina and triple-vessel disease or two-vessel disease, including proximal LAD stenosis, also survive longer but those with two-vessel disease excluding proximal LAD stenosis or with single-vessel disease, gain no survival advantage.
- Patients with abnormal LV function or strongly positive exercise tests derive greater absolute survival benefit from CABG surgery than from medical therapy.
- Women undergoing both CABG and PCI have greater complications and early mortality compared to men, which is independent of comorbidity and age. However, despite this, long-term survival does not differ between genders.
Most benefit is gained in people with:
- Significant LMS stenosis of 50% or more.
- Triple-vessel disease.
- Two-vessel disease including a significant proximal LAD stenosis.
- Diabetes mellitus.
- Impaired LV function or a strongly positive exercise test.
The operative mortality rate is around 1-2% but varies according to case type.
Both operative mortality and outcome are more likely to be adverse in the following:
- Increasing age.
- Female gender (the reason for this is debated but is probably multifactorial).
- Overweight or obesity.
- Being short.
- LMS disease, poor LV function and multivessel disease.
- If the operation was an emergency for unstable angina or shortly after myocardial infarction.
- Myocardial infarction occurs in 1-2% with probably rather more cases of diffuse myocardial damage.
- Acute kidney injury.
- Low output states requiring supportive measures.
- Ventricular arrhythmias like broad complex tachycardias.
- Stroke occurs in 1-2%. Reducing handling of the aorta may reduce cerebral embolism: in patients with significant atherosclerosis of the ascending aorta, off-pump CABG and/or no-touch on-pump techniques are recommended:
- Pre-operative Doppler ultrasound scanning is recommended in patients with a history of stroke/transient ischaemic attack.
- In selected patients, carotid artery revascularisation at the same time as CABG may be performed.
- Damage to other organs is rare in elective surgery but the risk increases with bypass time and increasing age.
- Antiplatelet therapy:
- Low-dose aspirin should be maintained except in those patients at very high risk of peri-operative bleeding or those who refuse transfusion, in whom it should be stopped three days prior to CABG.
- Clopidogrel should be stopped five or more days prior to CABG, to avoid bleeding complications that may increase peri-operative mortality. The only exception is if there is uncontrolled ischaemia. Discontinuation does not appear to increase cardiac risk.
- Prasugrel should be stopped seven days prior to CABG.
- Ticagrelor should be stopped five days prior to CABG.
- Bridging therapies, using short-acting antiplatelets or an antiplatelet antagonist, are being explored.
- Cognitive decline following CABG has been reported in various studies. Most changes in cognition are thought to be mild and to reverse within the first few months after surgery. This has been confirmed in a study of 696 patients in whom neurocognitive deficits were identified both at discharge and at three months postoperatively but were not associated with any significant clinical differences in quality of life or patient outcomes.
Attention must be paid to secondary prevention of CHD and cardiac rehabilitation. Stopping smoking is essential where relevant. Use of long-term aspirin is essential, as is the use of an angiotensin-converting enzyme (ACE) inhibitor (or angiotensin-II receptor antagonist (AIIRA) agent) and beta-blockers. Statins should be used to achieve target cholesterol levels. Control of blood pressure and any diabetes should be optimised. Encourage exercise and a healthy diet.
Further reading and references
Yusuf S, Zucker D, Peduzzi P, et al; Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 1994 Aug 27344(8922):563-70.
Mohr FW, Morice MC, Kappetein AP, et al; Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013 Feb 23381(9867):629-38. doi: 10.1016/S0140-6736(13)60141-5.
Farooq V, van Klaveren D, Steyerberg EW, et al; Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II. Lancet. 2013 Feb 23381(9867):639-50. doi: 10.1016/S0140-6736(13)60108-7.
Windecker S, Kolh P, Alfonso F, et al; 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014 Oct 135(37):2541-619. doi: 10.1093/eurheartj/ehu278. Epub 2014 Aug 29.
Management of stable angina; NICE Clinical Guideline (July 2011)
Deb S, Wijeysundera HC, Ko DT, et al; Coronary artery bypass graft surgery vs percutaneous interventions in coronary revascularization: a systematic review. JAMA. 2013 Nov 20310(19):2086-95. doi: 10.1001/jama.2013.281718.
Sipahi I, Akay MH, Dagdelen S, et al; Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era. JAMA Intern Med. 2014 Feb 1174(2):223-30. doi: 10.1001/jamainternmed.2013.12844.
Blue Book Online (UK National Adult Cardiac Surgery Audit); The Society for Cardiothoracic Surgery in Great Britain and Ireland
Baig SS, Altman DG, Taggart DP; Major geographical variations in elective coronary revascularization by stents or surgery in England. Eur J Cardiothorac Surg. 2015 May47(5):855-9. doi: 10.1093/ejcts/ezu276. Epub 2014 Jul 17.
Endoscopic saphenous vein harvest for coronary artery bypass grafting; NICE Interventional Procedure Guidance, June 2014
Head SJ, Borgermann J, Osnabrugge RL, et al; Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects. Eur Heart J. 2013 Oct34(37):2873-86. doi: 10.1093/eurheartj/eht284.
Off-pump coronary artery bypass grafting; NICE Interventional Procedure Guidance, January 2011
Moller CH, Penninga L, Wetterslev J, et al; Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease. Cochrane Database Syst Rev. 2012 Mar 14(3):CD007224. doi: 10.1002/14651858.CD007224.pub2.
Lindquist R, Dupuis G, Terrin ML, et al; Comparison of health-related quality-of-life outcomes of men and women after coronary artery bypass surgery through 1 year: findings from the POST CABG Biobehavioral Study. Am Heart J. 2003 Dec146(6):1038-44.
van Domburg RT, Kappetein AP, Bogers AJ; The clinical outcome after coronary bypass surgery: a 30-year follow-up study. Eur Heart J. 2009 Feb30(4):453-8. doi: 10.1093/eurheartj/ehn530. Epub 2008 Dec 9.
Kim C, Redberg RF, Pavlic T, et al; A systematic review of gender differences in mortality after coronary artery bypass graft surgery and percutaneous coronary interventions. Clin Cardiol. 2007 Oct30(10):491-5.
Mikhail GW; Coronary revascularisation in women. Heart. 2006 May92 Suppl 3:iii19-23.
Terada T, Johnson JA, Norris C, et al; Severe Obesity Is Associated With Increased Risk of Early Complications and Extended Length of Stay Following Coronary Artery Bypass Grafting Surgery. J Am Heart Assoc. 2016 Jun 15(6). pii: e003282. doi: 10.1161/JAHA.116.003282.
Penicka M, Bartunek J, Lang O, et al; Severe left ventricular dyssynchrony is associated with poor prognosis in patients with moderate systolic heart failure undergoing coronary artery bypass grafting. J Am Coll Cardiol. 2007 Oct 250(14):1315-23. Epub 2007 Sep 17.
Sousa-Uva M, Storey R, Huber K, et al; Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery. Eur Heart J. 2014 Jun 1435(23):1510-4. doi: 10.1093/eurheartj/ehu158. Epub 2014 Apr 18.
Toeg HD, Nathan H, Rubens F, et al; Clinical impact of neurocognitive deficits after cardiac surgery. J Thorac Cardiovasc Surg. 2013 Jun145(6):1545-9. doi: 10.1016/j.jtcvs.2013.02.061. Epub 2013 Mar 25.
Lipid modification - cardiovascular risk assessment and the modification of blood lipids for the prevention of primary and secondary cardiovascular disease; NICE Clinical Guideline, July 2014 (updated September 2016)