Coronary artery bypass grafting (CABG) is one of the worldwide most successful surgical procedures. Despite the impressive progress in the field of percutaneous coronary interventions (PCI), i.e. balloon dilatation and implantation of stents (especially in the acute coronary syndrome / myocardial infarction), coronary surgery remains a main pillar in the treatment of advanced coronary artery disease.
The indications and choice of the most suitable and reasonable procedure for the individual patient are discussed within the interdisciplinary Heart Team (invasive and non-invasive cardiologists, cardiac surgeons). These collegial discussions can take place if needed during coronary angiography (calling and discussing with the cardiac surgeons in the catheterization suite), as well as in a more formal manner during the weekly Heart Team Meeting.
Although every operation carries the same title (i.e. CABG), surgical planning and decision making is highly individualized and tailored to each patient’s needs. Many factors are important in this context: age, gender, current state of health, other co-existing diseases, the precise anatomy of the coronary arteries and their lesions. Generally, we are strongly in favor of the use of as many arterial grafts as possible (mammary arteries, radial arteries). In effect, our proportion of use of more than one arterial graft is higher than the average in Europe and continuously increasing. There are, however, many anatomical and medical considerations, that favor the use of vein grafts as additional grafts to the left mammary artery (which is always used). Such conditions can be ad example not critical but significant stenosis in branches of secondary coronary arteries or poorly controlled diabetes mellitus and / or obesity and / or peripheral artery disease. To counteract the major drawback of venous grafts, which is the high proportion of diseased or occluded grafts after 10-15 years, we are participating in common efforts (studies) with other institutions in Europe and in the United States to add specific treatments to the venous grafts to improve their resistance to graft disease in the long term.
In most of the patients, surgery is performed through longitudinal division of the breast bone for getting access to the heart (median sternotomy).
Normally we perform these operations with the Heart-Lung-Machine, either on the arrested or on the beating heart (on pump coronary bypass, ONCAB). When indicated, we adopt the so-called “off pump” surgery (OPCAB) without extracorporeal circulation. Sometimes and in selected patients, surgery can be performed in a minimal invasive technique (called MIDCAB), through a small incision at the left lateral chest wall (called “mini-thoracotomy”) without the use of the Heart-Lung-Machine.
One of the most important aspects of our surgical planning is the prevention of complications during and after coronary surgery, such as neurologic adverse events, acute graft occlusion and wound infections.
There are several surgical techniques, which are all part of our armamentarium, to reduce or prevent neurological adverse events (stroke). To name a few: careful evaluation of the aorta, the central blood vessel, to which bypass graft are connected, which occurs with direct ultrasound on the vessel during surgery, reduction of its manipulation by means of the use of specific devices (Heartstring, PAS-Port), use of composite arterial grafts to avoid any need to manipulate the aorta.
All grafts are evaluated carefully during surgery by real time flow measurements and revised if needed. This strategy allows us to counteract timely situations, which could lead to acute graft failure.
Wound infections are a recognized complication after coronary surgery. One specific factor, that increases the odds of sternal wound infections is that blood delivery to the breast bone is diminished, when one or both mammary arteries are harvested and used as bypass conduits. Active prevention and surveillance programs are ongoing (conceived and executed by an interdisciplinary task force and supervised by Swissnoso) to prevent and reduce these complications. We ask our patients to help us and to see this as a common effort to eliminate those complications by complying with the measures preceding their admission to surgery.
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