What are best practices in the performance of coronary artery bypass grafting (CABG)?

Updated: Dec 04, 2019
  • Author: Rohit Shahani, MD, MS, MCh; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

Either arteries or veins may be used as conduits for coronary artery bypass grafting (CABG). The survival benefits of grafting the left internal thoracic (mammary) artery to the left anterior descending coronary artery was established many years ago in a landmark paper from the Cleveland Clinic. [24]  This remains true; in fact, bilateral internal thoracic (mammary) artery grafting, if possible, confers a significant long-term survival benefit. Robust evidence suggests that the use off an additional arterial graft rather than a vein graft is associated with further improvement in late outcomes. [25] The greater saphenous vein and, very rarely, the short saphenous vein are the most commonly used vein grafts, whereas the internal thoracic (mammary) artery is the most commonly used artery graft. The radial artery graft was reintroduced into clinical practice in the 1990s and continues to show high patency rates of 80% or higher at 10 years follow-up, especially if the target vessel stenosis was greater than 90%. [26]

The disadvantage of saphenous vein grafts is their declining patency with time: 10-20% are occluded 1 year after surgery because of technical errors, thrombosis, and intimal hyperplasia. [1] Another 1-2% of vein grafts occlude every year from 1-5 years after surgery, and 4-5% occlude every year from 6-10 years after surgery. Vein graft occlusion that occurs 1 or more years after CABG is due to vein graft atherosclerosis with developing neointimal hyperplasia. At 10 years after surgery, only 50-60% of saphenous vein grafts are patent, and only half of these are free of angiographic atherosclerosis. [1] As part of appropriate secondary prevention, patients should receive life-long antiplatelet therapy, most commonly with daily low-dose (81 mg) aspirin.

Unlike saphenous vein grafts, internal thoracic (mammary) artery grafts exhibit stable patency over time. [1] At 10 years, more than 90% of internal thoracic (mammary) artery grafts are patent. The left internal thoracic (mammary) artery should be the conduit used when the left anterior coronary artery is bypassed.


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