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Coronary Artery Bypass Grafting (CABG): Procedure, Recovery & Outcomes

CABG revascularizes the heart by grafting conduits beyond coronary stenoses. It remains the gold standard for complex multivessel disease.

Indications (Guideline-Driven)

  • Left main disease >50%
  • Three-vessel disease (esp. with diabetes, reduced EF)
  • Two-vessel disease with proximal LAD + diabetes or EF<40%
  • Failed PCI / unsuitable anatomy
  • Mechanical complications post-MI (VSR, papillary muscle rupture)

Conduits

  • Left Internal Mammary Artery (LIMA) → LAD: Gold standard; 10-yr patency >90%.
  • Radial Artery: Second arterial conduit; better patency than SVG.
  • Saphenous Vein Graft (SVG): Most common venous; 10-yr patency 50–60%. "No-touch" harvest improves.
  • Right IMA, Gastroepiploic, Arterial Composite (Y/T-grafts): For total arterial revascularization.

Operative Steps (Standard Sternotomy)

  1. Median sternotomy; heparinization.
  2. Conduit harvest (LIMA, radial, vein).
  3. Cardiopulmonary bypass (CPB) — on-pump; or off-pump (OPCAB) on beating heart.
  4. Cardioplegic arrest (on-pump) or stabilization (off-pump).
  5. Distal anastomoses (graft → coronary beyond stenosis).
  6. Proximal anastomoses (graft → aorta or in situ LIMA).
  7. De-air, wean CPB, protamine.
  8. Chest closure (sternal wires, thoracostomy tubes).

Recovery Milestones

  • ICU: 24–48 hrs (extubation <6–8 hrs target).
  • Step-down: telemetry, mobilization, chest tube removal.
  • Discharge: Day 4–7 (uncomplicated); longer if complications.
  • Cardiac Rehab: Phase II (outpatient) starts 2–4 wks; 36 sessions covered.
  • Sternal precautions: 6–8 wks (no push/pull >10 lbs, no driving).
  • Full recovery: 3–6 months.

Outcomes

  • Operative mortality: 1–2% (elective), 5–10% (emergent).
  • 5-yr survival: 85–90% (age/comorbidity adjusted).
  • Symptom relief (angina): 85–95% at 1 yr.
  • Repeat revascularization: 3–5%/yr (SVG) vs. <1%/yr (LIMA).

Modern Advances

  • Minimally invasive direct CABG (MIDCAB) — small thoracotomy, LIMA-LAD.
  • Hybrid (CABG + PCI) — LIMA-LAD + stenting non-LAD.
  • Robotic-assisted (totally endoscopic).
  • Endoscopic vein harvest (EVH) — standard.

CABG durability relies on arterial grafts, risk factor control, and cardiac rehab adherence.

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