Cardiovascular and Thoracic Surgery

ALERT BAR

Coronary Artery Bypass Graft Surgery & Vein Harvesting 

Coronary Artery Bypass Graft (CABG) Surgery

Most commonly referred to as simply "bypass surgery," this surgery is often performed in people who have angina (chest pain) and coronary artery disease (where plaque has built up in the arteries). During the surgery, a bypass is created by grafting a piece of a vein above and below the blocked area of a coronary artery (see vein harvesting, below), enabling blood to flow around the obstruction. Veins are usually taken from the leg, but arteries from the chest or arm may also be used to create a bypass graft.

Bypass surgery is used to divert blood around blocked arteries in the heart. This surgery uses a healthy blood vessel taken from your leg, arm, or chest and connects it to the other arteries in your heart so that blood is bypassed around the diseased or blocked area.

Conventional Coronary Artery Bypass Graft (CABG) Surgery, also referred to as “open heart” surgery. In open heart surgery, the heart is stopped. A heart-lung machine is used to circulate and oxygenate the blood while the surgeon works on the stopped heart. The heart is accessed by dividing the patient's sternum with a 10-12" long incision on the patient's chest.

After the bypasses are complete, the heart is restarted until it is beating normally, and the patient is removed from the heart-lung machine. A wire suture is used to close up the sternum, and sutures or clips are used to close up the chest and leg wounds. The sternum may also be repaired using a metal plate, which is favorable for some high risk patients and also helps reduce complications improve healing (performed using minimally invasive surgery—see Rib and Sternal Repair.)

While bypass surgery works well, it's also more invasive. For certain candidates, a minimally invasive approach to CABG can have many benefits. 

Minimally Invasive Vein Harvesting

Patients who have veins harvested using minimally invasive endoscopic removal experience less pain and swelling post-procedure. They are also up and moving more quickly than patients who undergo traditional vein harvesting—approximately two days sooner.

Minimally Invasive Coronary Artery Bypass Graft (MIDCAB) Surgery

Minimally invasive coronary artery bypass (MIDCAB) surgery is an option for some patients who require a left internal mammary artery (LIMA) bypass graft to the left anterior descending (LAD) artery or bilateral mammary artery (BIMA) bypass graft surgery.

The advantages of Minimally Invasive Surgery over traditional open heart surgery are numerous. During a minimally invasive procedure:

  • The incisions are significantly smaller, which means there is also a reduced blood loss and a lower risk of infection.
  • There is no need to divide the breastbone (sternotomy) during the robotically-assisted procedure. Research shows that there is no known significant difference in patient outcomes whether or not a sternotomy is performed; however, having not opened the chest, healing time is shortened, there is less pain, less bleeding and a lower infection rate. Patients who undergo minimally invasive procedures have been found to be much healthier 30 days after the procedure than those who undergo traditional open heart surgery.
  • There is also no need to stop the heart during the procedure during minimally invasive heart surgery. While there is no significant difference in outcomes when a patient is placed on- or off-pump during their procedure, off-pump is considered a good option for high-risk patients, such as those with extensive ascending aortic atheromatous or calcific changes which might preclude safe aortic instrumentation.
  • Generally, patients who undergo minimally invasive heart procedures have a shorter hospital stay after surgery, with an average stay of 3 to 5 days after minimally invasive surgery, compared to an average of 7 to 10 days after traditional heart surgery.
  • Overall recovery time is shortened with minimally invasive surgery; healing time ranges from 1 to 4 weeks, while the average recovery time after traditional heart surgery is 6 to 8 weeks.
  • UTMB employs an “aortic no-touch technique” using a “heart string” device that eliminates the need for partial clamping of the diseased aortae. When this technique is combined with the advantages listed above, the risk of stroke is reduced both during and following surgery. Patients experience superior outcomes over other techniques in experienced hands.

LIMA-LAD

Coronary Arteries of the Heart - LIMA-LADThe left anterior descending artery branches off the left coronary artery and supplies blood to the front of the left side of the heart. Single-vessel disease of the left anterior descending (LAD) coronary artery may be surgically revascularized by grafting to the left internal mammary artery (LIMA). This is considered the “gold standard” (best survival rate) graft in Coronary Artery Bypass Graft Surgery.

Most surgeons consider using minimally invasive CABG in patients with isolated proximal left anterior descending (LAD) coronary artery disease and occasionally with LAD and proximal right coronary artery disease.

Large observational studies have shown  that the use of an internal mammary artery graft to the left anterior descending (LAD) coronary artery improves survival and reduces the incidence of late myocardial infarction (heart attack), recurrent angina (chest pain), and the need for further cardiac interventions.

A minimally invasive approach to this procedure is associated with a lower incidence of postoperative complications (approximately 2 percent), lower reintervention rates (2.9 percent), a reduced risk of stroke, overall better long-term outcomes and lower mortality rates (2 percent) than conventional surgery.

*Based on an observational study of 274 patients


Bilateral Internal Mammary Artery Grafting (BIMA)

bimaMost patients require grafting of the three main native coronary arteries. For the last 15 years, the "standard" operation has achieved this using a single internal mammary artery and supplemental vein grafts performed with cardiopulmonary bypass. Although this procedure achieves excellent short and medium term outcome, and over 70 percent of patients are alive 12 years after surgery, the long term results are limited by progressive vein graft failure.

A bilateral internal mammary artery (BIMA) graft approach is superior over single internal mammary artery grafting in select populations. Although more research is necessary, three recent studies suggest BIMA are favorable, and appear to have significant survival advantages in a wide range of aged patients. In a study published in 1999 by the Cleveland clinic group they reported better survival and reintervention–free survival after 10 years when BIMA was used.

  • BIMA surgery is considered highly compatible, if not preferred, to be performed in a minimally invasive manner.
  • It is particularly beneficial for elderly and diabetic patients and enhances their survival

Hybrid Surgery is a state-of-the-art procedure, combining the use of stents (angioplasty) with minimally invasive robotic surgery (LIMA to LAD MIDCAB)

  • Superior outcomes at 18 months follow-up
  • Combines the survival benefit of the LIMA to LAD graft and the less invasive nature of percutaneous coronary intervention (PCI)
  • The hybrid procedure requires a slightly longer operative time, but results in a shorter intensive care stay and shorter in-hospital stay. There is typically also less chest tube drainage and blood loss. At a follow-up of 18 months, patients who underwent hybrid procedures saw greater freedom from major adverse cardiac or stroke-related events.