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'''For the WikiPatient page for this topic, click [[Coronary artery bypass surgery (patient information)|here]]'''
'''For the WikiPatient page for this topic, click [[{{PAGENAME}} (patient information)|here]]'''
 
{{Coronary artery bypass surgery}}
{{SI}}
{{CMG}}; '''Associate Editors-In-Chief:''' [[User: Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; {{Anahita}}; {{CZ}}; {{VK}} {{PTD}}
 
'''Editors-In-Chief:''' [[C. Michael Gibson]], M.S., M.D. Duke Clinical Research Institute  [mailto:mgibson@perfuse.org]; John Alexander, M.D.  [mailto:john.h.alexander@duke.edu], Duke Clinical Research Institute
   
   
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'''''Synonyms and keywords:''''' Coronary artery bypass grafting, and colloquially heart bypass, bypass, bypass surgery, open heart surgery, or CABG (pronounced like cabbage), aortocoronary bypass (ACB). The term Coronary Artery Graft Surgery (CAGS) is often used outside the United States and should not be confused with [[Coronary angiography|Coronary Angiography (CAG)]]. OPCAB refers to [[Off-pump coronary artery bypass]], a procedure during which the patient is not placed on extracorporeal circulation ("the pump").
'''''Synonyms and keywords:''''' Coronary artery bypass grafting, and colloquially heart bypass, bypass, bypass surgery, open heart surgery, or CABG (pronounced like cabbage), aortocoronary bypass (ACB). The term Coronary Artery Graft Surgery (CAGS) is often used outside the United States and should not be confused with [[Coronary angiography|Coronary Angiography (CAG)]]. OPCAB refers to [[Off-pump coronary artery bypass]], a procedure during which the patient is not placed on extracorporeal circulation ("the pump").


==Overview==
==[[Coronary artery bypass surgery overview|Overview]]==
 
[[Coronary artery bypass surgery]] ([[Coronary artery bypass surgery|CABG]]) is a [[surgery|surgical]] [[coronary revascularization|revascularization]] procedure that is used to circumvent or bypass blockages in the [[Epicardium|epicardial]] [[coronary arteries]] associated with [[acute coronary syndromes]] (including [[ST elevation MI]], [[non ST elevation MI]], [[unstable angina]]) and [[stable angina]]. The technique was pioneered by Argentine [[cardiac surgeon]] [[René Favaloro]] at the [[Cleveland Clinic]] in the late 1960s. As part of the procedure, [[artery|arteries]] or [[vein]]s from elsewhere in the [[patient]]'s body are [[medical grafting|grafted]] from the [[aorta]] to the [[coronary artery|coronary arteries]] to bypass [[atherosclerosis|atherosclerotic]] [[stenosis|narrowings]] and improve the [[blood]] supply to the [[coronary circulation]] supplying the [[myocardium]] ([[myocardium|heart muscle]]). This surgery is usually performed with the [[heart]] stopped, necessitating the usage of [[cardiopulmonary bypass]]. However, recent advances allow the procedure to be performed with the [[heart]] beating and through smaller [[incisions]]. Currently, about 500,000 [[Coronary artery bypass surgery]] ([[Coronary artery bypass surgery|CABG]]) are performed in the United States each year.
Coronary artery bypass surgery is a surgical revascularization procedure that is used to circumvent or bypass blockages in the epicardial coronary arteries associated with [[acute coronary syndromes]] (including [[ST elevation MI]], [[non ST elevation MI]], [[unstable angina]]) and [[stable angina]]. The technique was pioneered by Argentine [[cardiac surgeon]] [[René Favaloro]] at the [[Cleveland Clinic]] in the late 1960s.<ref>Captur G. Memento for Rene Favaloro. Tex Heart Inst J. 2004;31(1):47-60. PMID 15061628. [http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=15061628 Free Full Text].</ref> As part of the procedure, [[artery|arteries]] or [[vein]]s from elsewhere in the patient's body are [[medical grafting|grafted]] from the [[aorta]] to the [[coronary artery|coronary arteries]] to bypass [[atherosclerosis|atherosclerotic]] [[stenosis|narrowings]] and improve the [[blood]] supply to the [[coronary circulation]] supplying the [[myocardium]] (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of [[cardiopulmonary bypass]]. However, recent advances allow the procedure to be performed with the heart beating and through smaller incisions. Currently, about 500,000 CABGs are performed in the United States each year.
 
==Indications for CABG==
 
Several alternative treatments for coronary artery disease exist. They include:
 
* Medical management ([[statins]], [[antihypertensive]]s, [[smoking cessation]], tight [[blood sugar]] control in [[diabetes mellitus|diabetics]])
* [[Percutaneous coronary intervention]] (PCI)
 
Both PCI and CABG are more effective than medical management at relieving symptoms,<ref name=rihal>{{cite journal |author=Rihal C, Raco D, Gersh B, Yusuf S |title=Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable angina: review of the evidence and methodological considerations |journal=Circulation |volume=108 |issue=20 |pages=2439-45 |year=2003 |pmid=14623791}} [http://circ.ahajournals.org/cgi/content/full/108/20/2439 Full Free Text].</ref> (e.g. [[Angina pectoris|angina]], [[dyspnea]], [[fatigue (medical)|fatigue]]), but repeat procedures are required more frequently after PCI.<ref name=rihal/>
 
CABG is the preferred treatment with:<ref name=rihal/>
* Disease of the [[left main coronary artery]] (LMCA). LMCA disease is associated with [[sudden death]]; therefore, lesions of the LMCA are sometimes referred to as ''widow makers''.
* Disease of all three coronary vessels ([[left anterior descending|LAD]], [[circumflex artery|LCX]] and [[right coronary artery|RCA]]).
* Diffuse disease not amendable to treatment with a PCI.
 
CABG is the likely the preferred treatment with other high-risk patients such as those with severe ventricular dysfunction (i.e. low [[ejection fraction]]), or [[diabetes mellitus]] patients, particularly those with disease involving the [[left anterior descending artery]].<ref name=rihal/>
 
==Prognosis Following CABG==
 
Prognosis following CABG depends on a variety of factors. Saphenous vein grafts remain open (patent) for approximately 8-15 years. In general, CABG improves the chances of survival of patients who are at high risk, such as those patients with [[left main]] disease.  After approximately 5 years the difference in survival rate between those who have had surgery and those treated by drug therapy diminishes. Age at the time of CABG is critical to the prognosis, younger patients with no complicating diseases have a high probability of greater longevity.
 
==Post-Operative Complications==
 
Patients undergoing coronary artery bypass grafting are at risk for the same complications as any surgery. There are also additional risks associated specifically with CABG.
 
===CABG Associated Complications===
*[[Postperfusion syndrome]] (also known as "pumphead"), is a transient neurocognitive impairment associated with [[cardiopulmonary bypass]].  Some research demonstrated that the incidence is initially decreased by [[Off-pump coronary artery bypass]], but no difference in neurocognitive function was observed beyond three months after surgery.  A neurocognitive decline over time has been demonstrated in people with coronary artery disease regardless of treatment (OPCAB, conventional CABG or medical management).  The neurocognitive decline has also been attributed to the administration of general anesthesia as part of the procedure.
*[[Nonunion]] of the [[sternum]]; [[internal thoracic artery]] (LIMA) harvesting devascularizes the sternum and may increase the risk.
*[[Myocardial infarction]] due to hypoperfusion, [[reperfusion injury]], early graft occlusion due to thrombosis or technical failures at the anastomotic site, or graft failure.  In the PREVENT IV study, perioperative MI was defined as a [[creatinine kinase-MB]] increase > or = 10 X the upper limit of normal or a > or = 5 X the upper limit of  normal with the development of new 30-ms [[Q waves]] within 24 hours of surgery.  Perioperative MI was observed in 9.8% of patients. Perioperative MI was associated with 1) longer surgery (250 vs 230 minutes; p <0.001), higher rates of on-pump surgery as compared with minimally invasive surgery (83% vs 78%; p = 0.048), and worse quality of target vessels (p <0.001).  Perioperative MI was associated with more frequent angiography within 30 days of the procedure (1.7% vs 0.6%; p =  0.021) as well as higher rates of SVG failure at one year (62.4% vs  43.8%, p  <0.001). Perioperative MI was associated with an increased risk of death, MI, or  revascularization at two years(19.4% vs 15.2%; p = 0.039, multivariate hazard ratio 1.33, 95% confidence  interval 1.00 to 1.76, p = 0.046) adjusting for differences in  significant predictors. <ref name="pmid18721510">{{cite journal |author=Yau JM, Alexander JH, Hafley G, Mahaffey KW, Mack MJ, Kouchoukos N, Goyal A, Peterson ED, Gibson CM, Califf RM, Harrington RA, Ferguson TB |title=Impact of perioperative myocardial infarction on angiographic and clinical outcomes following coronary artery bypass grafting (from PRoject of Ex-vivo Vein graft ENgineering via Transfection [PREVENT] IV) |journal=[[The American Journal of Cardiology]] |volume=102 |issue=5 |pages=546–51 |year=2008 |month=September |pmid=18721510 |doi=10.1016/j.amjcard.2008.04.069 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(08)00748-0 |issn= |accessdate=2010-07-14}}</ref>
*Late graft [[stenosis]], particularly of [[Great saphenous vein|saphenous vein]] grafts due to [[atherosclerosis]] and excessive intimal hyperplasia causing recurrent [[Angina pectoris|angina]] or [[myocardial infarction]].
*[[Acute renal failure]] due to hypoperfusion and reperfusion injury.
*[[Stroke]], secondary to aortic manipulation or hypoperfusion and reperfusion injury.
 
===General Surgical Complications===
*[[Infection]] at incision sites or [[sepsis]]. Women, obese patients, and diabetic patients are at greater risk of this complication.
*[[Deep vein thrombosis]] (DVT)
*[[Anesthesia|Anesthetic]] complications such as [[malignant hyperthermia]].
*[[Keloid]] scarring
*[[Chronic pain]] at incision sites
*[[Chronic stress]] related illnesses
*[[Death]]
 
==The Traditional Coronary Artery Bypass Grafting Procedure (Simplified)==
#The patient is brought to the [[operating room]] and moved onto the operating table.
#An anesthetist places a variety of [[intravenous]] lines, often including a [[pulmonary artery catheter]] and injects an induction agent (usually [[propofol]]) to render the patient unconscious and to anesthetize the patient.
#An [[endotracheal tube]] is inserted and secured by the anesthetist or a [[respiratory therapist]] and [[mechanical ventilation]] is started.
#The chest is opened via a [[median sternotomy]] and the heart is examined by the surgeon.
#The grafts are harvested - frequent conduits are the [[internal thoracic artery|internal thoracic arteries]], [[radial artery|radial arteries]] and [[saphenous vein]]s.
#The surgeon stops the heart and initiates [[cardiopulmonary bypass]]; or in the case of [[Off-pump coronary artery bypass|"off-pump"]] surgery, places devices to stabilize the heart.
#One end of each graft is sewn onto the [[coronary artery|coronary arteries]] beyond the [[coronary artery disease|blockages]] and the other end is attached to the [[aorta]].
#The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In some cases, the [[aorta]] is partially occluded by a C shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating. This reduces time spent on the heart lung machine.
#The [[sternum]] is wired together and the incisions are [[suture]]d closed.
#The patient is moved to the [[intensive care unit]] (ICU) to recover.  After awakening and stabilizing in the ICU (approximately 1 day), the patient is transferred to the cardiac surgery unit until ready to go home (approximately 4 days).
 
==Minimally Invasive CABG==
Alternate methods of minimally invasive coronary artery bypass surgery have been developed in recent times.  [[Off-pump coronary artery bypass surgery|Off-pump coronary artery bypass surgery (OPCAB)]] is a technique of performing bypass surgery without the use of [[cardiopulmonary bypass]] (the heart-lung machine).  Futher refinements to OPCAB have resulted in [[Minimally invasive direct coronary artery bypass surgery|Minimally invasive direct coronary artery bypass surgery (MIDCAB)]] which is a technique of performing bypass surgery through a 5 to 10 cm incision.
 
==Conduits used for bypass==
 
The choice of conduits (arteries and/or veins from elsewhere in the body) to bypass the blockages is highly surgeon and institution dependent.  Typically, the left [[internal thoracic artery]] (LITA) (also referred to as the ''[[left internal mammary artery]]'' or ''[[LIMA]]'') is grafted to the [[Left Anterior Descending]] artery and a combination of other arteries and veins is used for other coronary arteries.  The right internal thoracic artery (RITA), the [[great saphenous vein]] from the leg and the [[radial artery]] from the forearm are frequently used.  The [[right gastroepiploic artery]] from the [[stomach]] is infrequently used given the difficult mobilization from the [[abdomen]].
 
===Saphenous Vein Anatomy===
 
The [[great saphenous vein]] ([[GSV]]) is frequently used as a conduit for CABG. It originates from where the dorsal vein of the [[first digit]] (the large [[toe]]) merges with the [[dorsal venous arch of the foot]].
 
After passing anterior to the [[medial malleolus]] (where it often can be visualized and [[Palpation|palpated]]), it runs up the [[medial]] side of the leg. At the [[knee]], it runs over the posterior border of the [[medial epicondyle]] of the [[femur]] bone.
 
The [[great saphenous vein]] then courses laterally to lie on the anterior surface of the thigh before entering an opening in the [[fascia lata]] called the [[saphenous opening]]. It joins with the [[femoral vein]] in the region of the [[femoral triangle]] at the saphenofemoral junction.
 
The '''small saphenous vein''' (also '''lesser saphenous vein''') originates where the dorsal vein from the [[fifth digit]] (smallest toe) merges with the [[dorsal venous arch of the foot]], which attaches to the [[great saphenous vein]]. It is considered a [[superficial vein]] and is [[subcutaneous]] (just under the skin). From its origin, it courses around the lateral aspect of the foot (inferior and posterior to the [[lateral malleolus]]) and runs along the posterior aspect of the leg (with the [[sural nerve]]), passes between the heads of the [[gastrocnemius muscle]], and drains into the [[popliteal vein]], approximately at or above the level of the [[knee]] joint.
 
<gallery perRow="3">
Image:Gray432 color.png|Cross-section through the middle of the thigh.
Image:Gray440_color.png|Cross-section through middle of leg.
Image:Great_saphenous_vein.png|The great saphenous vein and landmarks along its course
Image:Gray580.png|The great saphenous vein and its tributaries at the [[Saphenous opening|fossa ovalis]] in the [[groin]].
Image:Gray582.png|Small saphenous vein and its tributaries.
</gallery>
 
==Saphenous Vein Harvesting==
 
The saphenous vein can be harvested by either direct visualization or via an endoscopic approach. The endoscopic approach has been associated with lower rates of wound infection, but higher rates of failure and adverse events such as death and MI.<ref name="pmid19605828">{{cite journal |author=Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, Mehta RH, Gibson CM, Mack MJ, Kouchoukos NT, Califf RM, Alexander JH |title=Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery |journal=[[The New England Journal of Medicine]] |volume=361 |issue=3 |pages=235–44 |year=2009 |month=July |pmid=19605828 |doi=10.1056/NEJMoa0900708 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=19605828&promo=ONFLNS19 |issn= |accessdate=2010-07-12}}</ref> Veins that are used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft.
 
Complications associated with saphenous vein harvesting include the following:
 
* [[Saphenous nerve]] injury
* [[Infection]] at incision sites or [[sepsis]].
* [[Deep vein thrombosis]] ([[DVT]])
* [[Keloid]] scarring
* [[Chronic pain]] at incision sites
 
===Videos on Spahenous Vein Graft Harvesting===
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==Conduit Nomenclature==
The terms ''single bypass'', ''double bypass'', ''triple bypass'', ''quadruple bypass'' and ''quintuple bypass'' refer to the number of coronary arteries bypassed in the procedure.
 
In other words, a double bypass means two coronary arteries are bypassed (e.g. the [[left anterior descending|left anterior descending (LAD)]] coronary artery and [[right coronary artery|right coronary artery (RCA)]]); a triple bypass means three vessels are bypassed (e.g. LAD, RCA, [[left circumflex artery|left circumflex artery (LCX)]]); a quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagonal artery of the LAD) while quintuple means five.  Less commonly more than four coronary arteries may be bypassed.
 
A greater number of bypasses does not imply a person is "sicker," nor does a lesser number imply a person is "healthier."<ref>{{cite journal |author=Ohki S, Kaneko T, Satoh Y, ''et al'' |title=[Coronary artery bypass grafting in octogenarian] |language=Japanese |journal=Kyobu geka. The Japanese journal of thoracic surgery |volume=55 |issue=10 |pages=829–33; discussion 833–6 |year=2002 |pmid=12233100 |doi=}}</ref>  A person with a large amount of [[coronary artery disease|coronary artery disease (CAD)]] may receive fewer bypass grafts owing to the lack of suitable "target" vessels.


A patient with a single [[stenosis]] ("narrowing") of the [[Left coronary artery|left main]] coronary artery often requires only two bypasses (to the LAD and the LCX). However, depending upon the anatomy, grafts may also need to be placed to a large [[diagonal artery]], or to additional large [[obtuse marginal]] branches.
==Pathophysiology==
[[Coronary artery bypass surgery saphenous vein graft disease| Saphenous Vein Graft Disease]] | [[Coronary artery bypass surgery other non-atherosclerotic saphenous vein graft diseases|Other Non-Atherosclerotic Saphenous Vein Graft Diseases]]


==Assessment of Target Vessels for Saphenous Vein Grafting==
==[[Coronary artery bypass surgery indications|Indications for CABG]]==
A coronary artery may be unsuitable for bypass grafting for the following reasons:
[[Coronary artery bypass surgery in patients with acute MI|CABG in Patients with Acute MI]] | [[Coronary artery bypass surgery in ventricular arrhythmias|CABG in Patients with Ventricular Arrhythmias]] | [[Coronary artery bypass surgery after failed PCI|Emergency CABG after Failed PCI]] | [[Coronary artery bypass surgery in association with other cardiac procedures|CABG in Association with Other Cardiac Procedures]] | [[Coronary artery bypass surgery heart team approach to revascularization decisions|Heart Team Approach to Revascularization Decisions]] | [[Coronary artery bypass surgery of left main CAD to improve survival|Revascularization of Left Main CAD to Improve Survival]] | [[Coronary artery bypass surgery of non–left main CAD to improve survival|Revascularization of Non-Left Main CAD to Improve Survival]] | [[Coronary artery bypass surgery revascularization to improve symptoms|Revascularization to Improve Symptoms]] | [[Coronary artery bypass surgery CABG in left ventricular dysfunction|CABG in Left Ventricular Dysfunction]]
*'''Size:''' If the native target artery it is small (< 1 mm or < 1.5 mm depending on surgeon preference)
*'''Location:''' Some distal locations of the native target artery may not be accessible, or a conduit may not reach the far down the native artery.
*'''Native artery calcification:''' Heavily calcified native arteries are sometimes technically not amenable to anastamosis of a conduit.
*'''Diffuse disease:''' The native artery may not have a section of vessel that has minimal disease where a conduit can be grafted to.
*'''The native artery lies in the heart muscle or is intramyocardial:''' In this scenario the native coronary artery is located within the heart muscle rather than on the surface of the heart and a graft cannot be attached to it.


Although the cardiothoracic surgeon reviews the [[coronary angiogram]] prior to surgery and identifies the lesions (or "blockages") in the coronary arteries and will estimate the number of bypass grafts prior to surgery, the final decision is made in the operating room based upon the direct examination of the heart and the suitability of the native target vessel for bypassing.
==[[Coronary artery bypass surgery prognosis|Prognosis]]==


==Pathophysiology of Saphenous Vein Graft Disease==
==Imaging in the patient undergoing CABG==
[[Coronary artery bypass surgery X-ray|Chest x-ray]] | [[Coronary artery bypass surgery angiography|Coronary Angiography]]
|  [[Coronary artery bypass surgery CT angiography|CT Angiography]]  |  [[Coronary artery bypass surgery mri angiography|MRI Angiography]] | [[Coronary artery bypass surgery TEE|Trans-Esophageal Echocardiography]] | [[Coronary artery bypass surgery epiaortic ultrasound|Epiaortic Ultrasound]]


===Early Failure of Saphenous Vein Grafts===
==[[Coronary artery bypass surgery goals of treatment|Goals of Treatment]]==
Early failure of saphenous vein grafts can be due to a variety of factors.


====Technical Failures====
==[[Coronary artery bypass surgery perioperative management|Perioperative and Intraoperative Management]]==
This is due to a technical failure at the site where the conduit is sutured to the aorta proximally or to the native target vessel distally. This technical failure then leads to thrombosis of the conduit.  This failure can in some cases be treated by emergency re-operation or percutaneously by angioplasty and stenting. Care must be taken during the percutaneous approach to assure that the sutures are not disrupted and that there is not a rupture at the site of the anastomosis.
[[Coronary artery bypass surgery aspirin and clopidogrel|Aspirin and Clopidogrel]] | [[Coronary artery bypass surgery use of beta-blockers|Beta-Blockers]] | [[Coronary artery bypass surgery use of ACE Inhibitors/ARBs|ACE Inhibitors/ARBs]] | [[Coronary artery bypass surgery management of hyperlipidemia|Management of Hyperlipidemia]] | [[Coronary artery bypass surgery management of perioperative infection|Management of Mediastinitis/Perioperative Infection]] | [[Coronary artery bypass surgery percutaneous coronary intervention (PCI) to treat saphenous vein graft failure|Percutaneous Coronary Intervention (PCI) To Treat Saphenous Vein Graft Failure]] | [[Coronary artery bypass surgery maintaining glucose level|Maintaining Glucose Level]] | [[Coronary artery bypass surgery bleeding/transfusion]] | [[Coronary artery bypass surgery management of dysrhythmias|Management of Dysrhythmias]] | [[Coronary artery bypass surgery smoking cessation|Smoking Cessation]] | [[Coronary artery bypass surgery perioperative management of myocardial dysfunction|Perioperative Management of Myocardial Dysfunction]] | [[Coronary artery bypass surgery perioperative carotid artery noninvasive screening|Perioperative Carotid Artery Noninvasive Screening]]


====Failure of Pharmacotherapy====
==[[Coronary artery bypass surgery perioperative monitoring|Perioperative and Intraoperative Monitoring]]==
Aspirin administration has been associated with a lower rate of early graft failure, as well as improved SVG patency through one year.
[[Coronary artery bypass surgery electrocardiographic monitoring|Electrocardiographic Monitoring]] | [[Coronary artery bypass surgery pulmonary artery catheterization|Pulmonary Artery Catheterization]] | [[Coronary artery bypass surgery central nervous system monitoring|Central Nervous System Monitoring]]


====[[No reflow]] Downstream in the Myocardium====
==[[Coronary artery bypass surgery surgical procedure|Surgical Procedure]]==
Despite restoration of into or improved flow down the epicardial artery, myocardial edema, embolization, and capillary blistering may result in impaired perfusion into the myocardium. This in turn may lead to poor flow through the graft, and subsequent thrombosis.
[[Coronary artery bypass surgery anesthetic considerations|Anesthetic Considerations]] | [[Coronary artery bypass surgery the traditional coronary artery bypass grafting procedure (simplified)| The Traditional Coronary Artery Bypass Grafting Procedure (Simplified)]] | [[Coronary artery bypass surgery minimally invasive CABG| Minimally Invasive CABG]] | [[Coronary artery bypass surgery conduits used for bypass|Conduits Used for Bypass]] | [[Coronary artery bypass surgery videos on spahenous vein graft harvesting| Videos on Saphenous Vein-Graft Harvesting]] | [[Coronary artery bypass surgery videos on Coronary artery bypass surgery|Videos on Coronary Artery Bypass Surgery]] | [[Coronary artery bypass surgery cardiopulmonary bypass|Cardiopulmonary Bypass]]


===Late Failure of Saphenous Vein Grafts===
==[[Coronary artery bypass surgery post-operative care and complications|Post-Operative Care and Complications]]==
Multiple pathophysiologic processes contribute to late graft degeneration or late graft failure. These processes  including [[intimal hyperplasia]], atherosclerotic [[plaque]] formation, and graft remodeling.  Additionally, arterialization of the graft accelerates [[atherosclerosis]].  In addition to mechanically obstructing flow, these blockages  are more "friable" (i.e. they easily break into small pieces and embolize downstream into the myocardium impairing perfusion) and more prone to [[thrombus]] than [[plaques]] found in native vessels.  Another pathophysiologic mechanism whereby SVGs are more susceptible to [[thrombotic occlusion]] is the fact that they lack side branches.
[[Coronary artery bypass surgery postoperative antiplatelet therapy|Postoperative Antiplatelet Therapy]]
==Special Scenarios==
[[Coronary artery bypass surgery in anomalous coronary arteries|Anomalous Coronary Arteries]] | [[Coronary artery bypass surgery in patients with COPD/respiratory insufficiency|Chronic Obstructive Pulmonary Disease/Respiratory Insufficiency]] | [[Coronary artery bypass surgery in patients with existing renal disease|Existing Renal Disease]] | [[Coronary artery bypass surgery in patients with valvular disease|Concomitant Valvular Disease]] | [[Coronary artery bypass surgery in patients with previous cardiac surgery|Previous Cardiac Surgery]] | [[Coronary artery bypass surgery in patients with menopause|Menopause]] | [[Coronary artery bypass surgery carotid disease evaluation before surgery|Carotid Disease Evaluation Before Surgery]]


==Saphenous Vein Graft Patency==
==Related Chapters==
 
===Definitions===
The rate of saphenous vein graft failure varies depending upon the defnition used and the nature of the study design. <ref>FitzGibbon GM, Leach AJ, Keon WJ, Burton JR,
Kafka HP. Coronary bypass graft fate. J Thorac Cardiovasc Surg. 1986;91:773-778.</ref><ref>Fitzgibbon GM, Kafka HP, Leach AJ, Keon WJ, Hooper GD, Burton JR. Coronary bypass graft fate and patient outcome. J AmColl Cardiol. 1996;28:616-626.</ref><ref>Desai ND, Cohen EA, Naylor CD, Fremes SE; Radial Artery Patency Study Investigators. A randomized
comparison of radial-artery and saphenous-vein coronary bypass grafts. N Engl JMed. 2004;351:2302-2309.</ref><ref>Goldman S, Zadina K, Moritz T, et al. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery. J Am Coll Cardiol. 2004;44:2149-2156.</ref> Rates estimated based upon retrospective studies of patients who are symptomatic underestimate the true rate of SVG failure because only those patients who survive who are symptomatic undergo catheterization. The most accurate assessment is based upon prospective studies in which all patients undergo mandatory cardiac catheterization at a uniform timepoint. The rates will also vary depending upon the complexity of disease, the diffuse nature of the disease, the extent of revascularization, and whether a per-lesion or a per-patient analysis is undertaken.
 
Saphenous vein graft occlusion is defined as a complete, 100% occlusion of a saphenous vein graft. <ref name="pmid16287955">{{cite journal |author=Alexander JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Lorenz TJ, Goyal A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT |title=Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=294 |issue=19 |pages=2446–54 |year=2005 |month=November |pmid=16287955 |doi=10.1001/jama.294.19.2446 |url= |issn= |accessdate=2010-07-12}}</ref>
 
Saphenous vein failure is defined as an occlusion of the vein graft or a 75% or greater stenosis.
 
The rate of occlusion or failure of saphenous vein grafts is calculated on a per graft basis and a per patient basis. The per patient basis is higher, because only one vein graft out of several must fail for the patient to be characterized as a failure.
 
Current rates of graft occlusion and failure are as follows:<ref name="pmid16287955">{{cite journal |author=Alexander JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Lorenz TJ, Goyal A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT |title=Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=294 |issue=19 |pages=2446–54 |year=2005 |month=November |pmid=16287955 |doi=10.1001/jama.294.19.2446 |url= |issn= |accessdate=2010-07-12}}</ref>
 
The rate of '''per patient vein graft occlusion''' at 12-18 months is about 42%
 
The rate of '''per patient vein graft failure''' at 12-18 months is about 46%
 
The rate of '''per graft vein graft occlusion''' at 12-18 months is about 26%
 
The rate of '''per graft vein graft failure''' at 12-18 months is about 29%
 
As a comparison, the rate of [[internal mammary artery]] failure at 12-18 months was only 8%.
 
===Determinants of Sapheous Vein Graft Patency===
Graft patency is dependent on a number of factors, including the type of graft used ([[internal thoracic artery]], [[radial artery]], or [[great saphenous vein]]), the size or the [[coronary artery]] that the graft is anastomosed with, and, of course, the skill of the surgeon(s) performing the procedure. Arterial grafts (e.g. left internal mammary (LIMA), radial) are far more sensitive to rough handling than the [[saphenous vein]]s and may go into spasm if handled improperly.
 
====In-situ vs Free Grafts====
Generally the best patency rates are achieved with the in-situ (the proximal end is left connected to the [[subclavian artery]]) left [[internal thoracic artery]] (a LIMA) with the distal end being anastomosed with the [[coronary artery]] (typically the [[left anterior descending artery]] or a diagonal branch artery). Lesser patency rates can be expected with [[radial artery]] grafts and "free" [[internal thoracic artery]] grafts (where the proximal end of the thoracic artery is excised from its origin from the [[subclavian artery]] and re-anastomosed with the [[ascending aorta]]).
 
====Venous vs Arterial Conduits====
Saphenous vein grafts have poorer patency rates than arterial grafts, but are more available, as the patients can have multiple segments of the [[saphenous vein]] used to bypass different arteries.
 
LITA grafts are longer-lasting than vein grafts, both because the artery is more robust than a vein and because, being already connected to the arterial tree, the LITA need only be grafted at one end. The LITA is usually grafted to the [[left anterior descending coronary artery]] ([[LAD]]) because of its superior long-term patency when compared to saphenous vein grafts.<ref>Kitamura S, Kawachi K, Kawata T, Kobayashi S, Mizuguchi K, Kameda Y, Nishioka H, Hamada Y, Yoshida Y. [Ten-year survival and cardiac event-free rates in Japanese patients with the left anterior descending artery revascularized with internal thoracic artery or saphenous vein graft: a comparative study] Nippon Geka Gakkai Zasshi. 1996 Mar;97(3):202-9. PMID 8649330.</ref><ref>Arima M, Kanoh T, Suzuki T, Kuremoto K, Tanimoto K, Oigawa T, Matsuda S. Serial Angiographic Follow-up Beyond 10 Years After Coronary Artery Bypass Grafting. Circ J. 2005 Aug;69(8):896-902. PMID 16041156. [http://www.jstage.jst.go.jp/article/circj/69/8/896/_pdf].</ref>
 
====Impact of Harvesting Method on Saphenous Vein Graft Patency====
The method of harvesting vein grafts may be associated with late vein graft patency at 12-18 months.<ref name="pmid19605828">{{cite journal |author=Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, Mehta RH, Gibson CM, Mack MJ, Kouchoukos NT, Califf RM, Alexander JH |title=Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery |journal=[[The New England Journal of Medicine]] |volume=361 |issue=3 |pages=235–44 |year=2009 |month=July |pmid=19605828 |doi=10.1056/NEJMoa0900708 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=19605828&promo=ONFLNS19 |issn= |accessdate=2010-07-12}}</ref> In a non-randomized subgroup analysis from the PREVENT IV study, harvesting of vein-grafts with the use of endoscopy (endoscopic harvesting) was associated with a higher rate of saphenous vein graft failure compared with open harvesting of the veins under direct visualization (46.7% vs. 38.0%, P<0.001 at 12-18 months). Likewise, clinical outcomes were worse at 3 years: use of endoscopy was associated with higher rates of death, [[myocardial infarction]], or repeat [[revascularization]] (20.2% vs. 17.4%; p=0.04), death or myocardial infarction (9.3% vs. 7.6%; p=0.01), and death (7.4% vs. 5.8%; adjusted hazard ratio, 1.52; 95% CI, 1.13 to 2.04; p=0.005).  Although these observational data are provocative, further randomized clinical trials would be needed to compare the safety and effectiveness of the two harvesting technique.
====Perioperative MI Is Associated with a Higher Rate of SVG Failure====
The rate of one-year saphenous vein graft failure has been documented to be 62.4% of patients  with and 43.8% of patients without perioperative MI (p <0.001).<ref name="pmid18721510">{{cite journal |author=Yau JM, Alexander JH, Hafley G, Mahaffey KW, Mack MJ, Kouchoukos N, Goyal A, Peterson ED, Gibson CM, Califf RM, Harrington RA, Ferguson TB |title=Impact of perioperative myocardial infarction on angiographic and clinical outcomes following coronary artery bypass grafting (from PRoject of Ex-vivo Vein graft ENgineering via Transfection [PREVENT] IV) |journal=[[The American Journal of Cardiology]] |volume=102 |issue=5 |pages=546–51 |year=2008 |month=September |pmid=18721510 |doi=10.1016/j.amjcard.2008.04.069 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(08)00748-0 |issn= |accessdate=2010-07-14}}</ref>
 
====Factors Not Associated with Saphenous Vein Graft Patency====
Although a creatinine clearance < 60 ml / sec has been associated with higher rates of death / MI/ and revascularization, it was not associated with a higher rate of SVG or internal thoracic artery failure rates. <ref name="pmid19026795">{{cite journal |author=Mehta RH, Hafley GE, Gibson CM, Harrington RA, Peterson ED, Mack MJ, Kouchoukos NT, Califf RM, Ferguson TB, Alexander JH |title=Influence of preoperative renal dysfunction on one-year bypass graft patency and two-year outcomes in patients undergoing coronary artery bypass surgery |journal=[[The Journal of Thoracic and Cardiovascular Surgery]] |volume=136 |issue=5 |pages=1149–55 |year=2008 |month=November |pmid=19026795 |doi=10.1016/j.jtcvs.2008.02.085 |url=http://linkinghub.elsevier.com/retrieve/pii/S0022-5223(08)01090-8 |issn= |accessdate=2010-07-14}}</ref>
 
==Association of Saphenous Vein Graft Failure with Clinical Events==
In the PREVENT IV study, SVG failure was associated with a 13.9% rate of death and MI (122/878) vs 0.9% (9/1,042) for those patients without SVG failure (these numbers exclude peri-operative MI).<ref name="pmid16287955">{{cite journal |author=Alexander  JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Lorenz TJ, Goyal  A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT  |title=Efficacy and safety of edifoligide, an E2F transcription factor  decoy, for prevention of vein graft failure following coronary artery  bypass graft surgery: PREVENT IV: a randomized controlled trial  |journal=[[JAMA : the Journal of the American Medical Association]]  |volume=294 |issue=19 |pages=2446–54 |year=2005 |month=November  |pmid=16287955 |doi=10.1001/jama.294.19.2446 |url= |issn=  |accessdate=2010-07-12}}</ref> Likewise, the rate of death / MI / and revascularization was higher among patients with SVG failure (26.0% vs 1.8%). Despite these elevated rates of adverse events, it shoud be noted that about half of the patients with SVG failure did not have clinical events. This may be because the native artery remained open or because there was extensive collaterals. It should slo be noted that the development of [[heart failure]] or [[angina]] following SVG failure may not be captured in the endpoint of death / MI / and revascularization.
 
==Other Non-Atherosclerotic Saphenous Vein Graft Diseases==
 
===Saphenous Vein Graft Aneurysms===
 
This disease process is also known as SVGA, aortocoronary saphenous vein graft aneurysms, saphenous vein graft aneurysm disease and saphenous vein graft aneurysmal dilatation. Causes of saphenous vein graft aneurysms include the following:
 
* [[Atherosclerosis]]
* [[Hypertension]]
* Mycotic 
* Postoperative [[mediastinitis]]
* Previous aneurysms
* Torn sutures
 
===Amyloidosis of Saphenous Coronary Bypass Grafts===
Amyloid has been associated with accelarated disease in saphenous vein grafts.<ref>Marti MC, Bouchardy B, Cox JN. Aortocoronary bypass with autogenous saphenous vein grafts: histopathological aspects. Virchows Arch Abt A Path Anat 1971; 352: 255–66.</ref> <ref>Garrett HE, Dennis EW, DeBakey ME. Aortocoronary bypass with saphenous vein graft. JAMA 1973; 223: 792–4.</ref> <ref>Zemva A, Ferluga D, Zorc M, Popovic M, Porenta OV, Radovanovic N. Amyloidosis in saphenous vein aortocoronary bypass grafts. J Cardiovasc Surg 1990; 31: 441–4.</ref> <ref>Salerno TA, Wasan SM, Charrette EJ. Prospective analysis of heart biopsies in coronary artery surgery. Ann Thorac Surg 1979; 28: 436–9.</ref> <ref>Pelosi F, Capehart J, Roberts WC. Effectiveness of cardiac transplantation for primary (AL) cardiac amyloidosis. Am J Cardiol 1997; 79: 532–5.</ref>
 
===Rupture of the Saphenous Vein Coronary Artery Bypass Grafts===
 
Aspergillus species causing a necrotizing [[vasculitis]] have been associated with rupture of a saphenous vein grafts.
 
==Diagnostic & Evaluation Findings==
 
===Chest X-Ray===
 
[http://www.radswiki.net Images courtesy of RadsWiki]. The images below show presence of median sternotomy wires and CABG clips that are seen on conventional CXRs.
 
<gallery>
Image:CABG-clips-001.jpg|Median sternotomy wires and CABG clips
Image:CABG-clips-002.jpg|Lateral graphy: Median sternotomy wires and CABG clips
</gallery>
 
===Coronary Angiography===
====Prior to Coronary Artery Bypass Grafting====
It is often recommended that the first view that is performed on diagnostic coronary angiography is the RAO caudal so that any stenoses in the circumflex and the left anterior descending as well as the distal targets can be assessed in case the patient becomes critically ill following the initial injection in the left main. If the patient is not critically ill, then angiography should be performed in an adequate number of views to identify all blockages that should be bypassed as well as the size, calcification and disease extent of target vessels. Angiography should continue for a sufficient duration of time so as to evaluate the presence and quality of distal vessels that are collateralized that my need to be bypassed. Although left ventriculography  is helpful in the assessment of left ventricular function, this can also be assessed on echocardiography to minimize the dye load and the potential for hemodynamic collapse with excess contrast agent.
====Following Coronary Artery Bypass Grafting====
Use of radio-opaque saphenous vein graft markers has been associated with the following in non-randomized observational studies:
#Reduced volume of contrast injections
#Shorter cardiac catheterization procedure times
#Greater rates of identification of occluded SVGs (90.7% vs 72.1%, p < 0.001)<ref name="pmid18222256">{{cite journal |author=Olenchock SA, Karmpaliotis D, Gibson WJ, Murphy SA, Southard MC, Ciaglo L, Buros J, Mack MJ, Alexander JH, Harrington RA, Califf RM, Kouchoukos NT, Ferguson TB, Gibson CM |title=Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters |journal=[[The Annals of Thoracic Surgery]] |volume=85 |issue=2 |pages=520–4 |year=2008 |month=February |pmid=18222256 |doi=10.1016/j.athoracsur.2007.10.061 |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(07)02191-1 |issn= |accessdate=2010-07-13}}</ref>
#No increase in the risk of SVG failure <ref name="pmid18222256">{{cite journal |author=Olenchock SA, Karmpaliotis D, Gibson WJ, Murphy SA, Southard MC, Ciaglo L, Buros J, Mack MJ, Alexander JH, Harrington RA, Califf RM, Kouchoukos NT, Ferguson TB, Gibson CM |title=Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters |journal=[[The Annals of Thoracic Surgery]] |volume=85 |issue=2 |pages=520–4 |year=2008 |month=February |pmid=18222256 |doi=10.1016/j.athoracsur.2007.10.061 |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(07)02191-1 |issn= |accessdate=2010-07-13}}</ref>
#An unexplained increase in the risk of perioperative MI in non-randomized analyses <ref name="pmid18222256">{{cite journal |author=Olenchock SA, Karmpaliotis D, Gibson WJ, Murphy SA, Southard MC, Ciaglo L, Buros J, Mack MJ, Alexander JH, Harrington RA, Califf RM, Kouchoukos NT, Ferguson TB, Gibson CM |title=Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters |journal=[[The Annals of Thoracic Surgery]] |volume=85 |issue=2 |pages=520–4 |year=2008 |month=February |pmid=18222256 |doi=10.1016/j.athoracsur.2007.10.061 |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(07)02191-1 |issn= |accessdate=2010-07-13}}</ref>
#No increase in the risk of death or MI by 12-18 months of follow-up.
 
===CT Angiography===
 
===MR Angiography===
 
 
==Treatment==
 
==Goals of Treatment==
 
Primarily, the goal should be to detect and treat a [[SVG]] [[stenosis]] early in the development of [[ischemia]] while the [[SVG]] is still [[patency|patent]].  Although intervention on a chronic total occlusion of a [[SVG]] may seem like an effective treatment strategy, it is best avoided.  As long as the [[SVG]] is not completely [[occlusion|occluded]], intervention can be performed.
 
Two additional overall goals of treating [[SVG]] [[stenosis]] include the resolution of symptomatic [[ischemia]] and the prevention/treatment of [[embolism|distal embolization]].
 
==Treatment Options==
 
==Perioperative Medical Therapy==
===Aspirin===
Aspirin is a simple cost effective therapy that has been associated with improved clinical outcomes among patients undergoing CABG. The optimal timing of aspirin administration appears to be in the 48 hours immediately after CABG.
 
Rigorous randomized trials have been required to document the benefits of aspirin, to determine the optimal timing of aspirin, and to overcome fears surrounding the risk of bleeding associated with administration of aspirin in the setting of CABG.  There has been a hesitancy to recommend the administration of antiplatelet agents in the setting of CABG for several reasons:
*Platelet counts and platelet concentration are reduced during the peri-operative period as a result of sequestration and hemodilution<ref name="pmid1614220">{{cite journal |author=Khuri SF, Wolfe JA, Josa M, Axford TC, Szymanski I, Assousa S, Ragno G, Patel M, Silverman A, Park M |title=Hematologic changes during and after cardiopulmonary bypass and their relationship to the bleeding time and nonsurgical blood loss |journal=[[J. Thorac. Cardiovasc. Surg.]] |volume=104 |issue=1 |pages=94–107 |year=1992 |month=July |pmid=1614220 |doi= |url= |issn= |accessdate=2010-07-22}}</ref>
*Platelet function is impaired following CABG due to both hypothermia <ref name="pmid7359906">{{cite journal |author=Hessel EA, Schmer G, Dillard DH |title=Platelet kinetics during deep hypothermia |journal=[[J. Surg. Res.]] |volume=28 |issue=1 |pages=23–34 |year=1980 |month=January |pmid=7359906 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0022-4804(80)90078-5 |issn= |accessdate=2010-07-22}}</ref> and/or mechanical filtering.<ref name="pmid7686785">{{cite journal |author=Kestin AS, Valeri CR, Khuri SF, Loscalzo J, Ellis PA, MacGregor H, Birjiniuk V, Ouimet H, Pasche B, Nelson MJ |title=The platelet function defect of cardiopulmonary bypass |journal=[[Blood]] |volume=82 |issue=1 |pages=107–17 |year=1993 |month=July |pmid=7686785 |doi= |url=http://www.bloodjournal.org/cgi/pmidlookup?view=long&pmid=7686785 |issn= |accessdate=2010-07-22}}</ref><ref name="pmid9527196">{{cite journal |author=Morse DS, Adams D, Magnani B |title=Platelet and neutrophil activation during cardiac surgical procedures: impact of cardiopulmonary bypass |journal=[[Ann. Thorac. Surg.]] |volume=65 |issue=3 |pages=691–5 |year=1998 |month=March |pmid=9527196 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(97)01425-2 |issn= |accessdate=2010-07-22}}</ref><ref name="pmid1718190">{{cite journal |author=Rinder CS, Mathew JP, Rinder HM, Bonan J, Ault KA, Smith BR |title=Modulation of platelet surface adhesion receptors during cardiopulmonary bypass |journal=[[Anesthesiology]] |volume=75 |issue=4 |pages=563–70 |year=1991 |month=October |pmid=1718190 |doi= |url= |issn= |accessdate=2010-07-22}}</ref>
 
In so far as the focus of clinical care has at times been on reducing the risk of bleeding rather than on reducing the risk of thrombosis, there has likewise been a tendency to discontinue aspirin and reverse anticoagulant therapy before surgery, to administer platelet transfusions during surgery, and to administer prothrombotic agents(antifibrinolytic agents).<ref>Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA guidelines for
coronary artery bypass graft surgery: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee to Revise the 1999 Guidelines for Coronary Artery Bypass
Graft Surgery). J Am Coll Cardiol 1999;34:1262-347.</ref> There is little randomized controlled data to support these practices. 
 
====Benefit of Early Post-Operative Aspirin Administration====
In one of the first studies in this field, Goldman et al compared the rate of SVG patency among CABG patients treated with a variety of antiplatelet regimens.<ref name="pmid3286040">{{cite journal |author=Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Doherty J, Read R, Chesler E, Sako Y |title=Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study |journal=[[Circulation]] |volume=77 |issue=6 |pages=1324–32 |year=1988 |month=June |pmid=3286040 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=3286040 |issn= |accessdate=2010-07-22}}</ref> All therapies except aspirin were started 48 hours before CABG. When aspirin was part of the regime, one 325 mg dose was given 12 hours pre-operatively, and the assigned therapy was maintained thereafter. 
The 60 day rates of angiographic patency (555 patients with 1,781 grafts) were:
*Aspirin, 325 mg daily: 93.5%
*Aspirin, 325 mg three times daily: 92.3%
*Aspirin plus dipyridamole (325 mg and 75 mg, respectively, three times daily): 91.9%
*Sulfinpyrazone (267 mg three times daily): 90.2%
*Placebo (three times daily): 85.2%
(P<0.05 for all aspirin regimens vs placebo)
 
Aspirin was associated with a greater median chest tube drainage within the first 35 hours post-operatively compared with placebo (p<0.02):
*Aspirin daily (965 ml)
*Aspirin three times daily (1175 ml)
*Aspirin plus dipyridamole (1000 ml)
*Sulfinpyrazone (775 ml)
*Placebo (805 ml)
 
The rate of reoperation was higher (p<0.01) among patients treated with aspirin (6.5%) than among those patients not treated with aspirin  (1.7%).
 
At one year of follow-up in the same cohort of patients (n=406 patients with 1,315 SVGs), the rate of SVG occlusion was 15.8% in all the aspirin groups combined vs 22.6% among those treated with placebo (p = 0.029).<ref name="pmid2680158">{{cite journal |author=Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Doherty J, Read R, Chesler E, Sako Y |title=Saphenous vein graft patency 1 year after coronary artery bypass surgery and effects of antiplatelet therapy. Results of a Veterans Administration Cooperative Study |journal=[[Circulation]] |volume=80 |issue=5 |pages=1190–7 |year=1989 |month=November |pmid=2680158 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=2680158 |issn= |accessdate=2010-07-22}}</ref> This benefit was signficant among those SVGs in which the target vessel was less than or equal to 2.0 mm in diameter (20.1%  vs 32.3% for the placebo group (p = 0.008), while in those SVGs anastomosed to target vessels > 2.0 mm in diameter there was no difference in the rate of SVG occlusion (8.7% vs. 9.0%, p = 0.918).
 
While there were benefits in early patency and patency at one year in this cohort of patients, between years one and three, there was no benefit in the rate of occlusion. Among those SVGs that were patent at 1 year, the occlusion rate at 3 years was 4.8% for aspirin treated patients vs 4.2% for placebo treated patients (p=NS).<ref name="pmid8124800">{{cite journal |author=Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Kern KB, Sethi G, Sharma GV, Khuri S |title=Long-term graft patency (3 years) after coronary artery surgery. Effects of aspirin: results of a VA Cooperative study |journal=[[Circulation]] |volume=89 |issue=3 |pages=1138–43 |year=1994 |month=March |pmid=8124800 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8124800 |issn= |accessdate=2010-07-22}}</ref>
 
The benefits of early antiplatelet therapy were also documented by Chesebro et al who performed a double blind randomized trial evaluating the benefit of dipyridamole (administered two days before operation) plus aspirin (added seven hours after operation) in 407 patients.<ref name="pmid7045659">{{cite journal |author=Chesebro JH, Clements IP, Fuster V, Elveback LR, Smith HC, Bardsley WT, Frye RL, Holmes DR, Vlietstra RE, Pluth JR, Wallace RB, Puga FJ, Orszulak TA, Piehler JM, Schaff HV, Danielson GK |title=A platelet-inhibitor-drug trial in coronary-artery bypass operations: benefit of perioperative dipyridamole and aspirin therapy on early postoperative vein-graft patency |journal=[[N. Engl. J. Med.]] |volume=307 |issue=2 |pages=73–8 |year=1982 |month=July |pmid=7045659 |doi= |url= |issn= |accessdate=2010-07-22}}</ref> At one month, the angiographic rate of SVG occlusion on a per lesion basis was 3% vs 10% of grafts, and on a per patient basis the rate of having at least one SVG occluded was 8% vs 21% for treated vs untreated patients respectively.  Likewise, at one year, the angiographic rate of SVG occlusion on a per lesion basis was 11% vs  25% of grafts, and on a per patient basis the rate of having at least  one SVG occluded was 22% vs 47% for treated vs untreated patients  respectively.<ref name="pmid6361561">{{cite journal |author=Chesebro JH, Fuster V, Elveback LR, Clements IP, Smith HC, Holmes DR, Bardsley WT, Pluth JR, Wallace RB, Puga FJ |title=Effect of dipyridamole and aspirin on late vein-graft patency after coronary bypass operations |journal=[[N. Engl. J. Med.]] |volume=310 |issue=4 |pages=209–14 |year=1984 |month=January |pmid=6361561 |doi= |url= |issn= |accessdate=2010-07-22}}</ref>
 
In a non-randomized retrospective analysis of 7,500 variables, Mangano et al evaluated the relationship between early aspirin use and clinical outcomes in 5,065 patients at 70 centers in 17 countries.<ref name="pmid12397188">{{cite journal |author=Mangano DT |title=Aspirin and mortality from coronary bypass surgery |journal=[[N. Engl. J. Med.]] |volume=347 |issue=17 |pages=1309–17 |year=2002 |month=October |pmid=12397188 |doi=10.1056/NEJMoa020798 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12397188&promo=ONFLNS19 |issn= |accessdate=2010-07-22}}</ref> Mortality was 1.3% among those patients treated with aspirin in the first 48 hours after CABG vs 4.0% among those who were not treated with aspirin (p<0.001). Likewise, aspirin therapy reduced the risk of MI from 5.4% to 2.8% (p<0.001), the risk of stroke from 2.6% to 1.3% (p=0.01), the risk of bowel infarction from 0.8% to 0.3% (p=0.01) and the risk of renal failure from 3.4% to 0.9%, p<0.001). Aspirin treatment was not associated with an increased risk of hemorrhage or impaired wound healing.
 
====Pre-Operative vs Post-Operative Administration of Aspirin====
Although the aforementioned studies demonstrated improved early and late patency with the pre-opeartive administration of aspirin, there was a higher rate of bleeding. Goldman et al conduted a prospective, randomized, double-blind, placebo-controlled trial to compare the safety and effectiveness of 325 mg of aspirin therapy initiated either the night before before CABG vs aspirin initiated via nasogastric tube 6 hours post-operatively.<ref name="pmid1860197">{{cite journal |author=Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Kern KB, Sethi G, Sharma GV, Khuri S |title=Starting aspirin therapy after operation. Effects on early graft patency. Department of Veterans Affairs Cooperative Study Group |journal=[[Circulation]] |volume=84 |issue=2 |pages=520–6 |year=1991 |month=August |pmid=1860197 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=1860197 |issn= |accessdate=2010-07-22}}</ref> The rate of saphenous vein graft occlusion rate was 7.4% vs 7.8% for pre vs post-operative aspirin administration. Pre-operative aspirin was associated with a greater amount of blood volume transfused (900 versus 725 cc, p = 0.006), greater chest tube drainage at 6 hours (500 vs 448 cc, p=0.011) and a higher rate of re-operation for bleeding (6.3% vs 2.4%, p = 0.036).
 
==Percutaneous Coronary Intervention (PCI) to Treat Saphenous Vein Graft Failure==
There are many different choices to consider when deciding the most appropriate treatment for [[SVG]] [[stenosis]], including [[PTCA]], [[PCI]] with [[bare metal stent|bare metal]] or [[drug-eluting stents]], [[PCI]] with covered [[stents]], embolic protection devices, [[debulking]]/[[thrombus]] removal, and surgical [[revascularization]]. 
 
===Percutaneous Transluminal Coronary Angioplasty (PTCA)===
 
[[PTCA]] has high initial [[revascularization]] success rates in the treatment of SVG [[stenosis]].  However, it is also associated with high rates of periprocedural complications, including acute vessel closure secondary to [[dissection]] and in-situ [[thrombosis]].  Additional complications include [[embolism|distal embolization]] and [[no reflow]], which can lead to periprocedural [[infarction]].
 
In modern [[interventional cardiology]], [[PTCA]] is not often used as the sole means of treatment for SVG [[stenosis]].  Instead, [[stenting]] has become the cornerstone of treatment, while the use of [[PTCA]] has been limited to pre-dilation and post-dilation.
 
===PCI with Bare Metal Stents (BMS) or Drug-eluting Stents (DES)===
 
Most current vein graft treatment strategies utilize PCI with stents ([[BMS]] or [[DES]]), since stenting is a superior treatment when compared to [[PTCA]] alone.  As demonstrated in the SAVED (Saphenous Vein De Novo) Trial<ref name="pmid9287229">{{cite journal |author=Savage MP, Douglas JS, Fischman DL, ''et al.'' |title=Stent placement compared with balloon angioplasty for obstructed coronary bypass grafts. Saphenous Vein De Novo Trial Investigators |journal=N. Engl. J. Med. |volume=337 |issue=11 |pages=740–7 |year=1997 |month=September |pmid=9287229 |doi= |url=}}</ref>, the use of [[stents]] is associated with higher [[revascularization]] success rates, decreased [[restenosis]] rates, and improved clinical outcomes when compared to [[PTCA]].  Generally, [[DES]] are preferred over [[BMS]], since [[DES]] are associated with reduced rates of [[restenosis]] and target vessel [[revascularization]].
 
Despite their higher success rates, stents are not immune to [[restenosis]].  Predictors for [[restenosis]] include long [[stent]] length, multiple [[stents]], overlapping [[stents]], smaller vessel size, [[diabetes mellitus]], and [[stenosis]] at the coronary or aortic [[anastomosis]].
 
===PCI with Covered Stents===
 
Theoretically, [[stents]] covered with a polymer membrane would have higher success rates than standard [[BMS]] and [[DES]].  One would expect covered stents to effectively trap friable [[atheroma]] and isolate the graft [[Lumen (anatomy)|lumen]] from the diseased wall, thereby reducing incidence of [[restenosis]], distal [[embolization]], and [[no reflow]] in comparison to traditional [[stents]].  However, the RECOVERS (The Randomized Evaluation of polytetrafluoroethylene COVERed stent in Saphenous vein grafts)<ref name="pmid12821546">{{cite journal |author=Stankovic G, Colombo A, Presbitero P, ''et al.'' |title=Randomized evaluation of polytetrafluoroethylene-covered stent in saphenous vein grafts: the Randomized Evaluation of polytetrafluoroethylene COVERed stent in Saphenous vein grafts (RECOVERS) Trial |journal=Circulation |volume=108 |issue=1 |pages=37–42 |year=2003 |month=July |pmid=12821546 |doi=10.1161/01.CIR.0000079106.71097.1C |url=}}</ref> and STING (STents IN Grafts)<ref name="pmid14563575">{{cite journal |author=Schächinger V, Hamm CW, Münzel T, ''et al.'' |title=A randomized trial of polytetrafluoroethylene-membrane-covered stents compared with conventional stents in aortocoronary saphenous vein grafts |journal=J. Am. Coll. Cardiol. |volume=42 |issue=8 |pages=1360–9 |year=2003 |month=October |pmid=14563575 |doi= |url=}}</ref> trials did not show any advantage in using covered [[stents]] when compared to [[bare metal stents]] for [[SVG lesions]].
 
===Embolic Protection Devices===
 
During [[PCI]] of [[SVGs]], [[Atheroembolism|atheroembolic]] debris can be liberated.  This debris contains [[vasoactive]] substances that can contribute to [[no reflow]], which can in turn considerably increase the risk of major adverse clinical events (MACE)<ref name="pmid16264199">{{cite journal |author=Salloum J, Tharpe C, Vaughan D, Zhao DX |title=Release and elimination of soluble vasoactive factors during percutaneous coronary intervention of saphenous vein grafts: analysis using the PercuSurge GuardWire distal protection device |journal=J Invasive Cardiol |volume=17 |issue=11 |pages=575–9 |year=2005 |month=November |pmid=16264199 |doi= |url=}}</ref>.  Fortunately, embolic protection devices help capture this debris and improve outcomes in [[PCI]] for [[SVG]] [[stenosis]].  Therefore, it is recommended that these devices should be utilized in the intervention of most [[SVG]] lesions. 
 
Currently, the [[FDA]] has approved five embolic protection devices in the United States.  Specifically, these devices include one distal occlusion device, three filters, and one proximal occlusion device.
 
The FDA-approved distal occlusion device is called the PercuSurge Guardwire®, which involves inflating a balloon distal to the [[stenosis]] to occlude flow, thereby trapping the debris and [[vasoactive]] substances and preventing them from flowing downstream.  Due to its small size, it requires little landing zone to deploy.  The SAFER (Saphenous vein graft Angioplasty Free of Emboli Randomized) trial<ref name="pmid11901037">{{cite journal |author=Baim DS, Wahr D, George B, ''et al.'' |title=Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts |journal=Circulation |volume=105 |issue=11 |pages=1285–90 |year=2002 |month=March |pmid=11901037 |doi= |url=}}</ref> showed that when compared to conventional guidewires, balloon occlusion devices (PercuSurge Guardwire®) reduced the rates of infarction and [[no-reflow]] after intervention.  Despite these advantages, the PercuSurge Guardwire® may not be the best option for all, as some patients may not tolerate the necessary 3-5 minutes of [[ischemic]] time associated with this device.  Additionally, it is known to cause both [[hemodynamic]] and arrhythmic complications.
 
Filter devices allow continual distal perfusion while macroscopic [[emboli]] are trapped in the filter.  The FIRE (FilterWire EX During Transluminal Intervention of Saphenous Vein Grafts) trial<ref name="pmid12874191">{{cite journal |author=Stone GW, Rogers C, Hermiller J, ''et al.'' |title=Randomized comparison of distal protection with a filter-based catheter and a balloon occlusion and aspiration system during percutaneous intervention of diseased saphenous vein aorto-coronary bypass grafts |journal=Circulation |volume=108 |issue=5 |pages=548–53 |year=2003 |month=August |pmid=12874191 |doi=10.1161/01.CIR.0000080894.51311.0A |url=}}</ref><ref name="pmid16569562">{{cite journal |author=Halkin A, Masud AZ, Rogers C, ''et al.'' |title=Six-month outcomes after percutaneous intervention for lesions in aortocoronary saphenous vein grafts using distal protection devices: results from the FIRE trial |journal=Am. Heart J. |volume=151 |issue=4 |pages=915.e1–7 |year=2006 |month=April |pmid=16569562 |doi=10.1016/j.ahj.2005.09.018 |url=}}</ref> showed that FilterWire may be preferred over PercuSurge Guardwire® due to improved clinical outcomes.  While they may reduce [[ischemic]] time, filter devices are associated with their own set of potential complications. They are more difficult to deliver than balloon [[occlusion]] devices, so their own delivery may lead to distal [[embolization]], and they may not trap microscopic mediators of [[no reflow]].  Additionally, they require a significant landing zone distal to the [[lesion]] for the filter placement, which can be problematic for certain distal lesions that do not have enough room.  There have also been case reports of filter entrapment in the [[Great saphenous vein#Use in cardiovascular procedures|graft]] after the completion of the [[PCI]]. 
 
The FDA-approved proximal occlusion device is called the Proxis® device.  Some advantages of this decide are that its deployment does not require crossing the [[stenosis]], it provides superior support that is helpful where balloon or [[stent]] delivery is difficult, and it provides protected crossing of the [[lesion]], if required.  However, as shown by the PROXIMAL (Proximal Protection During Saphenous Vein Graft Intervention Using the Proxis Embolic Protection System) trial<ref name="pmid17919563">{{cite journal |author=Mauri L, Cox D, Hermiller J, ''et al.'' |title=The PROXIMAL trial: proximal protection during saphenous vein graft intervention using the Proxis Embolic Protection System: a randomized, prospective, multicenter clinical trial |journal=J. Am. Coll. Cardiol. |volume=50 |issue=15 |pages=1442–9 |year=2007 |month=October |pmid=17919563 |doi=10.1016/j.jacc.2007.06.039 |url=}}</ref>, in terms of overall outcomes, there is no significant difference in death, [[MI]], or target vessel [[revascularization]] (TVR) between distal and proximal [[embolic]] protection devices.
 
===Debulking/Thrombus Removal===
 
Data has not demonstrated a durable clinical benefit associated with [[debulking]]/[[thrombus]] removal.  However, there are certain situations in which [[debulking]] techniques may be useful when treating [[saphenous vein grafts]].  For instance, severely [[calcified]] and [[stenotic]] [[lesions]] can make regular [[stent]] insertion especially difficult.  When [[SVG]] [[lesions]] are too [[calcified]] to be crossed by a balloon or adequately dilated prior to [[stent]] placement, [[debulking]] and [[thrombus removal]] can change the compliance of the vessel wall.  In addition, this technique is also useful if a [[lesion]] is at the aorto-ostial junction.  Adjunctive stenting leads to better short and long term results.
 
There are several [[debulking]]/[[thrombus]] removal techniques, including directional coronary atherectomy, transluminal extraction catheter thrombectomy, rotational atherectomy, and laser atherectomy.
 
* Directional coronary atherectomy (DCA) uses a circular cutting blade that excises [[atheroma]] into a chamber for removal.  It is useful for aorto-ostial [[lesions]] and focal [[lesions]] in large vessels.  However, due to its bulky nature, it is generally not used in vessels with [[angulation]], [[tortuosity]], or heavy [[calcification]].  CAVEAT II (Coronary Angioplasty Versus Excisional Atherectomy Trial)<ref name="pmid7895354">{{cite journal |author=Holmes DR, Topol EJ, Califf RM, ''et al.'' |title=A multicenter, randomized trial of coronary angioplasty versus directional atherectomy for patients with saphenous vein bypass graft lesions. CAVEAT-II Investigators |journal=Circulation |volume=91 |issue=7 |pages=1966–74 |year=1995 |month=April |pmid=7895354 |doi= |url=}}</ref> examined how PTCA and DCA compared in the treatment of patients with coronary artery bypass graft stenoses.  This study demonstrated that DCA was associated with higher initial angiographic success rates and larger acute luminal dimensions in comparison to PTCA.  However, despite these successes, DCA also displayed an increased rate of non-Q wave myocardial infusion and distal embolization than PTCA.  Furthermore, both techniques displayed similar [[restenosis]] rates.
 
:Additionally, a retrospective study compared DCA vs. [[PTCA]] alone vs. [[PCI]] with stenting in [[SVG]] lesions.  It showed no differences in [[mortality]], [[angina]], [[infarction]], or repeat [[revascularization]] among the different methods.  However, this study displayed increased angiographic complications with DCA use.
 
* Transluminal extraction catheter (TEC) thrombectomy is designed to remove [[thrombus]] from [[SVGs]] prior to stenting.  It operates through the use of cutting blades with a rotating catheter and an external suction device.  However, because the TEC Best trial showed no benefit of TEC prior to the stenting of [[SVGs]], this technique has fallen out of favor.  Furthermore, TEC is also associated with a significant incidence of distal [[embolization]] and [[no reflow]].
 
* Rotational atherectomy (RA) uses a rotating cutting blade to grind [[calcified]] [[atheroma]].  Despite its ability to grind [[calcification]], this method is associated with high rates of [[no reflow]], distal [[embolization]], [[perforation]], and [[dissection]].  Furthermore, this method is [[contraindicated]] for [[lesions]] located in the body of [[SVGs]] or in degenerated vein grafts.
 
* Laser atherectomy uses [[monochromatic]] light energy to disrupt [[plaques]].  Despite this approach's innovation, there is no evidence that this strategy improves outcomes in lesions, and it has been complicated by high rates of [[dissection]] and [[perforation]].
 
===Surgical Revascularization===
 
Given increased perioperative [[mortality]], surgical revascularization is not an optimal treatment strategy, as many patients with [[graft disease]] are poor surgical candidates.  However, surgery may be required in patients with multi-vessel disease and when [[PCI]] fails.
 
Additionally, reoperation is not strongly encouraged, as it does not provide the same level of [[revascularization]] and resolution of [[angina]] as the initial procedure.  Furthermore, a [[LIMA]] may be jeopardized in a reoperation.
 
==Making a Selection==
 
At the earliest signs of recurrent [[ischemia]], it is important to strongly consider the possibility of a patent but [[stenosed]] [[SVG]], so that the graft [[lesion]] can be treated before the graft becomes completely [[occluded]].  Prompt treatment is essential, since a graft is lost once it becomes completely occluded.
 
Regardless of treatment choice, all patients should be given [[statins]] and [[aspirin]] (begun immediately following [[CABG]]), which are effective in the secondary prevention of [[SVG]] [[stenosis]].
 
For most [[SVG]] [[lesions]], [[PCI]] with [[stenting]] appears to be the therapy of choice.  [[DES]] are associated with a decreased [[restenosis]] rate over [[BMS]], and should be used preferentially if the patient is able to tolerate dual platelet therapy for a minimum of a year.  Furthermore, [[embolic]] protection devices should be strongly considered for all [[SVG]] [[lesions]], especially those with high risks for distal [[embolization]]. 
In cases in which [[stent]] delivery and expansion may be difficult due to heavily [[calcified]] and [[stenotic]] [[lesions]], [[atherectomy]] devices, used with stenting, may be considered.  Furthermore, these devices can be useful in [[lesions]] that are aorto-ostial.
 
Zoghbi et al. conducted a study to investigate the role of pretreatment with [[nitroprusside]] before [[SVG]] intervention<ref name="pmid19182287">{{cite journal |author=Zoghbi GJ, Goyal M, Hage F, ''et al.'' |title=Pretreatment with nitroprusside for microcirculatory protection in saphenous vein graft interventions |journal=J Invasive Cardiol |volume=21 |issue=2 |pages=34–9 |year=2009 |month=February |pmid=19182287 |doi= |url=}}</ref>.  They studied sixty-four consecutive patients with normal preprocedural cardiac [[enzymes]] that underwent [[SVG]] [[PCI]], without the use of [[embolic]] protection devices.  They found that pretreatment with [[nitroprusside]] results in a lower magnitude and frequency of post-procedural cardiac [[enzyme]] elevation.  Thus, it is important to consider [[nitroprusside]] use.
 
Finally, while [[Glycoprotein IIb/IIIa inhibitors|GP IIb/IIIa inhibitors]] are frequently used in the setting of [[SVG]] intervention, their benefit has not been fully evaluated in randomized trials of this lesion subset.
 
==Other Concerns==
 
As with all medical procedures, complications for [[SVG]] intervention can occur.  Risk factors for complications include: older [[graft]] age (>3-5 years), the presence of [[thrombus]], and diffuse disease.
 
Although [[PCI]] with [[stenting]] is effective for focal lesions, there is uncertainty regarding the best treatment for diffusely degenerated [[SVGs]].  In these cases, it is often a better choice to abandon the [[graft]] and intervene on the native vessel instead.
 
As mentioned above, prevention of [[no reflow]] should be attempted with [[embolic]] protection devices, pretreatment using [[nitroprusside]] and the avoidance of high-pressure inflations and unnecessary pre/post-dilation and oversizing.  However, in the event that [[no reflow]] develops, it should be aggressively managed with intracoronary [[vasodilators]] (i.e. [[diltiazem]], [[nicardipine]], [[adenosine]], and [[nitroprusside]]).
 
===Pathological Findings===
 
[http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
 
<gallery perRow="3">
Image:Saphenous vein graft 001.jpg|Saphenous vein coronary bypass graft: Gross, natural color, external view of heart with thrombosed veins
Image:Saphenous vein graft 002.jpg|Saphenous vein coronary bypass graft: Thrombosis, Acute: Gross, fixed tissue but well shown cross sections of bypass graft and anastomotic site with thrombosis. 61 yo male, with and acute infarct treated with streptokinase and two days later had bypass. Died 5 days post op. Two veins are thrombosed
Image:Saphenous vein graft 003.jpg|Myocardial Infarct Acute Reflow Type: Gross, fixed tissue but good color. A very enlarged heart with moderate LV dilation and high anterior wall hemorrhagic infarct. Initially treated with streptokinase and two days later had saphenous vein grafts. Both grafts are thrombosed. He died after 5 days
Image:Saphenous vein graft 004.jpg|
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</gallery>
 
==References==
{{Reflist|2}}
 
==Additional Resources==
{{refbegin|2}}
* S. A. Hassantash, B. Bikdeli, S. Kalantarian, M. Sadeghian, and H. Afshar Pathophysiology of Aortocoronary Saphenous Vein Bypass Graft Disease Asian Cardiovasc Thorac Ann, August 1, 2008; 16(4): 331 - 336.
* A. Coolong, D. S. Baim, R. E. Kuntz, A. J. O'Malley, S. Marulkar, D. E. Cutlip, J. J. Popma, and L. Mauri. Saphenous Vein Graft Stenting and Major Adverse Cardiac Events: A Predictive Model Derived From a Pooled Analysis of 3958 Patients. Circulation, February 12, 2008; 117(6): 790 - 797.
* R. F. Padera Jr. and F. J. Schoen. Pathology of Cardiac Surgery Card. Surg. Adult, January 1, 2008; 3(2008): 111 - 178. 
* E. Gongora and T. M. Sundt III. Myocardial Revascularization with Cardiopulmonary Bypass. Card. Surg. Adult, January 1, 2008; 3(2008): 599 - 632.
* P. Widimsky, Z. Straka, P. Stros, K. Jirasek, J. Dvorak, J. Votava, L. Lisa, T. Budesinsky, M. Kolesar, T. Vanek, et al. One-Year Coronary Bypass Graft Patency: A Randomized Comparison Between Off-Pump and On-Pump Surgery Angiographic Results of the PRAGUE-4 Trial Circulation, November 30, 2004; 110 (22): 3418 - 3423.
* M. A. Hlatky, D. B. Boothroyd, K. A. Melsop, M. M. Brooks, D. B. Mark, B. Pitt, G. S. Reeder, W. J. Rogers, T. J. Ryan, P. L. Whitlow, et al. Medical Costs and Quality of Life 10 to 12 Years After Randomization to Angioplasty or Bypass Surgery for Multivessel Coronary Artery Disease Circulation, October 5, 2004; 110 (14): 1960 - 1966.
* J. G. Lobo Filho, M. C. d. A. Leitao, and A. J. d. V. Forte Studying the lumen in composite Y internal thoracic artery-saphenous vein grafts J. Thorac. Cardiovasc. Surg., September 1, 2004; 128(3): 490 - 491.
* E. McGregor, L. Kempster, R. Wait, M. Gosling, M. J. Dunn, and J. T. Powell. F-actin Capping (CapZ) and Other Contractile Saphenous Vein Smooth Muscle Proteins Are Altered by Hemodynamic Stress: a proteomic approach Mol. Cell. Proteomics, February 1, 2004; 3(2): 115 - 124.
* M. Endo, Y. Tomizawa, and H. Nishida Bilateral Versus Unilateral Internal Mammary Revascularization in Patients with Diabetes Circulation, September 16, 2003; 108(11): 1343 - 1349.
* T. D. Rea, M. Crouthamel, M. S. Eisenberg, L. J. Becker, and A. R. Lima. Temporal Patterns in Long-Term Survival After Resuscitation From Out-of-Hospital Cardiac Arrest Circulation, September 9, 2003; 108(10): 1196 - 1201.
* M. Hilker, T. Langin, U. Hake, F.-X. Schmid, W. Kuroczynski, H.-A. Lehr, H. Oelert, and M. Buerke Gene expression profiling of human stenotic aorto-coronary bypass grafts by cDNA array analysis Eur. J. Cardiothorac. Surg., April 1, 2003; 23(4): 620 - 625.
* J. L. Sperry, C. B. Deming, C. Bian, P. L. Walinsky, D. A. Kass, F. D. Kolodgie, R. Virmani, A. Y. Kim, and J. J. Rade Wall Tension Is a Potent Negative Regulator of In Vivo Thrombomodulin Expression Circ. Res., January 10, 2003; 92(1): 41 - 47.
* F. J. Schoen and R. F. Padera Jr. Cardiac Surgical Pathology Card. Surg. Adult, January 1, 2003; 2(2003): 119 - 185.
* A. Y. Kim, P. L. Walinsky, F. D. Kolodgie, C. Bian, J. L. Sperry, C. B. Deming, E. A. Peck, J. G. Shake, G. B. Ang, R. H. Sohn, et al. Early Loss of Thrombomodulin Expression Impairs Vein Graft Thromboresistance: Implications for Vein Graft Failure Circ. Res., February 8, 2002; 90(2): 205 - 212.
* K. B. Kim, C. Lim, C. Lee, I.-H. Chae, B.-H. Oh, M.-M. Lee, and Y.-B. Park Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts Ann. Thorac. Surg., September 1, 2001; 72(3): S1033 - 1037.
* Z. Yang, T. Kozai, B. van de Loo, H. Viswambharan, M. Lachat, M. I. Turina, T. Malinski, and T. F. Luscher. HMG-CoA reductase inhibition improves endothelial cell function and inhibits smooth muscle cell proliferation in human saphenous veins J. Am. Coll. Cardiol., November 1, 2000; 36(5): 1691 - 1697.
* H. Hirose, A. Amano, S. Yoshida, A. Takahashi, N. Nagano, and T. Kohmoto Coronary Artery Bypass Grafting in the Elderly Chest, May 1, 2000; 117(5): 1262 - 1270.
 
* D. R. Holmes Jr and P. B. Berger. Percutaneous Revascularization of Occluded Vein Grafts : Is It Still a Temptation to Be Resisted? Circulation, January 12, 1999; 99(1): 8 - 11.
* Y. K. Wong, M. Thomas, V. Tsang, P. J. Gallagher, and M. E. Ward. The prevalence of Chlamydia pneumoniae in atherosclerotic and nonatherosclerotic blood vessels of patients attending for redo and first time coronary artery bypass graft surgery. J. Am. Coll. Cardiol., January 1, 1999; 33(1): 152 - 156.
* F. D. Loop Coronary artery surgery: the end of the beginning Eur. J. Cardiothorac. Surg., December 1, 1998; 14(6): 554 - 571.
* Z. G. Zhu, H.-H. Li, and B.-R. Zhang. Expression of Endothelin-1 and Constitutional Nitric Oxide Synthase Messenger RNA in Saphenous Vein Endothelial Cells Exposed to Arterial Flow Shear Stress Ann. Thorac. Surg., November 1, 1997; 64(5): 1333 - 1338.
* A. Y. Kim, P. L. Walinsky, F. D. Kolodgie, C. Bian, J. L. Sperry, C. B. Deming, E. A. Peck, J. G. Shake, G. B. Ang, R. H. Sohn, et al. Early Loss of Thrombomodulin Expression Impairs Vein Graft Thromboresistance: Implications for Vein Graft Failure. Circ. Res., February 8, 2002; 90(2): 205 - 212.
{{refend}}
 
==See Also==


* [[CABG]]
* [[CABG]]
* [[Hybrid bypass]]
* [[Hybrid bypass]]
* [[Off-pump coronary artery bypass surgery|Off-pump coronary artery bypass surgery (OPCAB)]]
* [[Off-pump coronary artery bypass surgery|Off-Pump Coronary Artery Bypass Surgery (OPCAB)]]
* [[Minimally invasive direct coronary artery bypass surgery]] ([[MIDCAB]])
* [[Minimally invasive direct coronary artery bypass surgery]] ([[MIDCAB]])
* [[Cardiothoracic surgery]]
* [[Cardiothoracic surgery]]
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* [[Hybrid bypass]]
* [[Hybrid bypass]]


==External links==
==External Links==
*[http://www.texheartsurgeons.com/ Advances in Cardiovascular Surgery and Cardiothoracic Surgical Procedures]
*[http://www.texheartsurgeons.com/ Advances in Cardiovascular Surgery and Cardiothoracic Surgical Procedures]
*[http://www.ctsnet.org/residents/ctsn/ Cardiothoracic Surgery Notes] an online interactive review developed by residents in cardiothoracic surgery
*[http://www.ctsnet.org/residents/ctsn/ Cardiothoracic Surgery Notes] an online interactive review developed by residents in cardiothoracic surgery
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*[http://info.med.yale.edu/intmed/cardio/imaging/ Yale: Introduction to Cardiothoracic Imaging]
*[http://info.med.yale.edu/intmed/cardio/imaging/ Yale: Introduction to Cardiothoracic Imaging]


{{Cardiac surgery}}
==References==
{{SIB}}
{{Reflist|2}}


[[Category:Cardiac surgery]]
[[Category:Cardiac surgery]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:mature chapter]]
[[Category:Surgery]]
[[Category:Surgical procedures]]
[[Category:Overview complete]]
[[Category:Template complete]]


[[de:Koronararterien-Bypass]]
[[es:Bypass]]
[[es:Bypass]]
[[fi:Sepelvaltimon ohitusleikkaus]]
[[fr:pontage aorto-coronarien]]
[[fr:pontage aorto-coronarien]]
[[he:ניתוח מעקפים]]
[[mk:Бајпас операција]]
[[nl:CABG]]
[[ja:冠動脈大動脈バイパス移植術]]
[[ja:冠動脈大動脈バイパス移植術]]
[[pl:CABG]]
[[pl:CABG]]
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Latest revision as of 06:26, 22 October 2022

For the WikiPatient page for this topic, click here

Coronary Artery Bypass Surgery Microchapters

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Overview

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Saphenous Vein Graft Disease
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Mohammed A. Sbeih, M.D. [2]; Anahita Deylamsalehi, M.D.[3]; Cafer Zorkun, M.D., Ph.D. [4]; Varun Kumar, M.B.B.S. [5] Prince Tano Djan, BSc, MBChB [6]

Synonyms and keywords: Coronary artery bypass grafting, and colloquially heart bypass, bypass, bypass surgery, open heart surgery, or CABG (pronounced like cabbage), aortocoronary bypass (ACB). The term Coronary Artery Graft Surgery (CAGS) is often used outside the United States and should not be confused with Coronary Angiography (CAG). OPCAB refers to Off-pump coronary artery bypass, a procedure during which the patient is not placed on extracorporeal circulation ("the pump").

Overview

Coronary artery bypass surgery (CABG) is a surgical revascularization procedure that is used to circumvent or bypass blockages in the epicardial coronary arteries associated with acute coronary syndromes (including ST elevation MI, non ST elevation MI, unstable angina) and stable angina. The technique was pioneered by Argentine cardiac surgeon René Favaloro at the Cleveland Clinic in the late 1960s. As part of the procedure, arteries or veins from elsewhere in the patient's body are grafted from the aorta to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass. However, recent advances allow the procedure to be performed with the heart beating and through smaller incisions. Currently, about 500,000 Coronary artery bypass surgery (CABG) are performed in the United States each year.

Pathophysiology

Saphenous Vein Graft Disease | Other Non-Atherosclerotic Saphenous Vein Graft Diseases

Indications for CABG

CABG in Patients with Acute MI | CABG in Patients with Ventricular Arrhythmias | Emergency CABG after Failed PCI | CABG in Association with Other Cardiac Procedures | Heart Team Approach to Revascularization Decisions | Revascularization of Left Main CAD to Improve Survival | Revascularization of Non-Left Main CAD to Improve Survival | Revascularization to Improve Symptoms | CABG in Left Ventricular Dysfunction

Prognosis

Imaging in the patient undergoing CABG

Chest x-ray | Coronary Angiography | CT Angiography | MRI Angiography | Trans-Esophageal Echocardiography | Epiaortic Ultrasound

Goals of Treatment

Perioperative and Intraoperative Management

Aspirin and Clopidogrel | Beta-Blockers | ACE Inhibitors/ARBs | Management of Hyperlipidemia | Management of Mediastinitis/Perioperative Infection | Percutaneous Coronary Intervention (PCI) To Treat Saphenous Vein Graft Failure | Maintaining Glucose Level | Coronary artery bypass surgery bleeding/transfusion | Management of Dysrhythmias | Smoking Cessation | Perioperative Management of Myocardial Dysfunction | Perioperative Carotid Artery Noninvasive Screening

Perioperative and Intraoperative Monitoring

Electrocardiographic Monitoring | Pulmonary Artery Catheterization | Central Nervous System Monitoring

Surgical Procedure

Anesthetic Considerations | The Traditional Coronary Artery Bypass Grafting Procedure (Simplified) | Minimally Invasive CABG | Conduits Used for Bypass | Videos on Saphenous Vein-Graft Harvesting | Videos on Coronary Artery Bypass Surgery | Cardiopulmonary Bypass

Post-Operative Care and Complications

Postoperative Antiplatelet Therapy

Special Scenarios

Anomalous Coronary Arteries | Chronic Obstructive Pulmonary Disease/Respiratory Insufficiency | Existing Renal Disease | Concomitant Valvular Disease | Previous Cardiac Surgery | Menopause | Carotid Disease Evaluation Before Surgery

Related Chapters

External Links

References


Template:WikiDoc Sources

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