Coronary artery bypass

Coronary artery bypass surgery (CABG) is a surgical procedure performed to treat ischemic cardiopathy.

This disease causes a narrowing of the coronary arteries, i.e. the coronary arteries that transport oxygen and nutrients to the heart muscle.
Ischemic cardiopathies are caused by an accumulation of plaques on the inner walls of the arteries. Fat deposition causes a narrowing of the inner diameter of the artery and limits blood flow to the heart muscle.

Often there are two narrowed coronary arteries, the surgeon can also apply a triple or quadruple bypass.
The main trunk is the first section of the coronary arteries. If there are plaque formations here that hinder blood circulation in this vessel, the situation is particularly serious.
There are small coronary secondary vessels that have the function of a natural bypass, as they connect the coronary arteries, expand when necessary, thus allowing blood circulation.

When to operate?

Bypass surgery is performed to treat occlusion or narrowing of one or more coronary arteries and thus restore sufficient blood flow to the heart.

Symptoms of the condition include:

• Chest pain
• Fatigue
• Palpitation
• Arrhythmia
• Shortness of breath

Coronary disease does not cause warning symptoms, rather the process progresses until blockage of the artery provokes the first discomfort.
If the blood flow to the heart muscle continues to decrease, a myocardial infarction can occur.
Blood circulation must be restored quickly, otherwise part of the heart muscle will die.

What arteries are used for a coronary graft?

The surgeon decides which blood vessel to use depending on the location of the problem, the amount of tissue affected, and the size of the patient’s coronary arteries.

Internal chest wall arteries: These blood vessels are the most commonly used grafts because they give the best long-term results.
During surgery, the chest arteries are sutured with the coronary arteries below the closed area.
This blood vessel is located in the chest and is accessible at the first incision during surgery.

Saphena: The saphenous vein is removed from the leg and used to connect the aorta to the blocked (narrowed) coronary artery. The removal of the saphenous vein is only slightly invasive, causes no visible scars and allows the patient a speedy recovery.

Radial artery: There are two arteries on the forearm, the ulnar artery and the radial artery. Most people have adequate blood flow through the ulnar artery and there are no negative effects when the radial artery is removed and used as a graft.
Careful preoperative and intraoperative tests show whether the radial artery can be used. If the patient suffers from diseases such as Raynaud’s disease, carpal tunnel syndrome, etc., this artery can not be used for the procedure. The incision in the blood vessel on the forearm begins 2 cm below the elbow and ends 1 cm above the wrist.
After this type of bypass, the doctor prescribes taking a calcium channel blocker for the following six months. The active ingredient serves to keep the radial artery open. Some patients have a numb wrist after surgery.

The gastroepiploic artery of the stomach and the inferior epigastric artery of the lower abdominal wall are used less frequently as grafts (grafts).

How is the operation performed?

Coronary bypass surgery – intervention in case of cardiac arrest (with heart-lung machine)

1. The heart is stopped so that the doctor can perform the operation: suturing the grafts on the small coronary arteries is a very delicate process.
   The blood is pumped through the body during bypass surgery through a special heart-lung machine.
2. The blood is drained into the machine and the heart is stopped by injecting a cold solution.
3. The doctor connects one end of the vein to a small opening in the aorta, then unites the other end after a small incision with the coronary artery immediately after occlusion.
   If the inner chest wall artery is used, only an incision is made and the artery is implanted after narrowing.
4. Depending on the number and location of the blocked arteries, several bypasses can be placed.
5. At the end of the bypass operation, the blood circulating through the heart-lung machine re-enters the heart and the machine tubes are removed. The doctor restores the heart function.
6. The doctor may insert a stimulator and temporary electrodes into the heart. These cables are connected to a pacemaker (heart stimulator) and shock stimulates the heart during the first postoperative beats.

Coronary bypass – procedure on the beating heart (without heart-lung machine)

1. The incision is made in the chest, the inner area around the affected artery is prepared with a special instrument.
2. The rest of the heart continues its function, pumping blood throughout the body.
3. The doctor implants one end of the vein graft (or chest wall artery) into the aorta and the other end into the coronary artery just below the occlusion.
4. You can place several bypasses, depending on how many closures are present and where they are located.
5. Before closing the chest, the doctor checks the grafts and their correct functioning.

The completion of the procedure for both methods

1. The doctor returns the sternum to its position and connects it to the other components.
2. The doctor sutures the skin over the sternum.
3. The surgeon inserts drainage tubes to drain the blood. This system is connected to a suction device so that no fluid accumulates in the area of the heart.
4. Finally, the wound is protected with a sterile or medicamentous dressing.

Minimally invasive technique
Minimally invasive coronary bypass surgery is one option in which the left inner chest wall artery is used.
Other minimally invasive surgical techniques include endoscopic laparoscopy techniques or robot-assisted surgery.
The advantages of minimally invasive surgery are very small scars and shorter incisions (only 12 cm long instead of 18 cm as in traditional surgery).
Benefits also include reducing the risk of infection, less bleeding, less pain and shorter hospital stay (3 days).
The surgical team weighs the advantages and disadvantages of minimally invasive surgery against traditional surgery.

What are the risks and complications?

The percentage of short-term survival rate is high, the postoperative death rate is about 1%. Complications include:

1. Internal bleeding
2. Infection
3. Stroke
4. Myocardial infarction
5. Atrial fibrillation
6. Renal failure
7. Respiratory insufficiency
8. Death

Angioplasty is a minimally invasive procedure that restores blood flow in a blocked artery.
The cardiologist inserts a catheter through an arm or inguinal vein and uses it to penetrate to the occlusion.
Once it has reached the affected coronary artery, a balloon is inflated, which leads to the widening of the artery. After that, a stent (a cylindrical metal mesh) is inserted to keep open.
Compared to the bypass, coronary angioplasty is less dangerous, since the patient’s chest does not need to be opened.
However, the durability of the stent compared to the coronary bypass is shorter (rarely 15 years are exceeded).
A study published in the New England Journal of Medicine shows that outcomes are better with coronary bypass in diabetics.
In 18.7% of cases, diabetics who underwent coronary bypass surgery had a stroke, a heart attack or died in the 5 following years. In comparison, this was true for 26.6% of diabetics who underwent angioplasty.

How long does the procedure take?
The operation takes between 3 to 5 hours, depending on the number of arteries that need to be bridged.

Postoperative course and recovery times

After coronary bypass surgery, the duration of hospitalization is about 7 days. At this stage, the doctor can monitor the healing.
A feeling of postoperative discomfort and lightheadedness is normal, but the doctor will prescribe anti-inflammatories to relieve the pain. If the pain increases or there is heavy bleeding, the doctor intervenes.
Recovery after such a procedure takes a lot of time, but each patient recovers at different rates.

The person concerned should be able to:

1. to sit on a chair after a day,
2. to leave after three days,
3. to climb stairs after five or six days.

Convalescence after surgery lasts between 6 and 12 weeks.

At home
To relieve the pain, it is recommended to continue taking painkillers at home for a few weeks and wear loose and comfortable clothes.
During the first 3 – 6 weeks, the patient still feels very tired because the body uses a lot of energy for the healing process.
In case of high fever, the doctor should be notified.
After six weeks you should be able to perform light everyday activities, three months after the operation, the person concerned should be fully recovered.

Activities
The medical team recommends which activities to perform or avoid.
In the following days after discharge, the following activities can be carried out:

• short walks,
• Cook
• play card and board games,
• pick up light objects.

After about six weeks, you can increase physical activity, for example:

1. Motoring
2. carry heavier objects,
3. Cleaning the house,
4. Make love.

Once the convalescence has ended and the patient has no other complaints, he can return to the activities he carried out before the operation and also do sports again.
Older people, especially in the case of complications, may need rehabilitation that requires at least a week of bed rest for the patient.

Side effects after surgery

After discharge from the hospital, you might experience some side effects of the surgery. These include:

1. Loss of appetite
2. Constipation
3. Swelling and tingling at the graft collection sites
4. Muscle
5. Fatigue
6. Insomnia
7. Mood

The prognosis

Life expectancy depends on several factors, including:

1. Postoperative complications,
2. clinical picture of the patient,
3. Age
4. Conditions of the heart.

• Coronary angioplasty
• Intestinal infarction: symptoms and therapy
• Ischemic or hemorrhagic stroke – rehabilitation