From the Guidelines
Coronary Artery Bypass Grafting (CABG) is indicated for patients with significant coronary artery disease, particularly those with left main coronary artery stenosis, multivessel disease, or complex coronary anatomy, as well as those with refractory angina or ischemia despite maximal medical therapy. The primary indications for CABG include:
- Left main coronary artery stenosis greater than 50% 1
- Three-vessel coronary artery disease, especially in patients with reduced left ventricular function 1
- Two-vessel disease involving the proximal left anterior descending artery 1
- Failed or unsuitable percutaneous coronary interventions 1
- Patients with diabetes mellitus and multivessel disease 1
- Patients with complex coronary anatomy or diffuse disease 1
- Patients experiencing ongoing ischemia despite maximal medical therapy, including antiplatelet agents, beta-blockers, statins, and nitrates 1
The decision for CABG should be made by a heart team considering the patient's clinical status, coronary anatomy, comorbidities, and preferences 1. CABG provides more complete revascularization compared to percutaneous interventions in complex disease, potentially offering better long-term outcomes and reduced need for repeat procedures in selected patients 1.
Some key considerations for CABG include:
- Ejection fraction (EF) less than 35%, where CABG is recommended 1
- EF between 35-50%, where CABG is recommended with a class IIa indication 1
- Ischemic cardiomyopathy, where CABG may be indicated to improve survival and reduce symptoms 1
- Heart Team discussion is recommended for patients with complex disease or uncertain indications for CABG 1
Overall, CABG is a valuable treatment option for patients with significant coronary artery disease, and the decision to proceed with CABG should be individualized based on the patient's unique clinical characteristics and preferences.
From the Research
Indications for Coronary Artery Bypass Grafting (CABG)
The indications for CABG are based on various studies and guidelines. Some of the key indications include:
- Patients with severe left main coronary artery disease, particularly those with high surgical risk or complex anatomy 2
- Patients with triple vessel coronary artery disease, especially those with left ventricular dysfunction or diabetes 3
- Patients with single-vessel disease, particularly those with isolated proximal left anterior descending artery stenosis, who have failed or are not candidates for percutaneous transluminal coronary angioplasty (PTCA) 4
- Patients with chronic, severe angina refractory to medical therapy who cannot be completely revascularized with either PTCA or CABG, who may be candidates for transmyocardial laser revascularization (TMR) as sole therapy or as an adjunct to CABG 5
- Patients with diffuse, advanced coronary artery disease, who may benefit from incomplete CABG surgery, resulting in significant clinical improvement and acceptable graft occlusion rates at 1 year 6
Patient Selection
Patient selection for CABG relies on both predicting mortality with CABG from clinical characteristics using the Society of Thoracic Surgeons (STS) risk score and anatomical complexity, using the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score 2. A multidisciplinary heart team is recommended to help individualize revascularization decisions.
Graft Selection
The choice of graft material, such as radial artery or saphenous vein, is also an important consideration in CABG. Recent data suggest that the use of the radial artery, rather than the saphenous vein, is associated with improved cardiac outcomes and better survival 3. The internal mammary artery (IMA) grafts have been shown to have a lower occlusion rate compared to saphenous vein grafts, particularly in the left anterior descending artery (LAD) territory 6.