What are the indications for Coronary Artery Bypass Grafting (CABG)?

From the Guidelines

Coronary Artery Bypass Grafting (CABG) is indicated for patients with significant coronary artery disease, particularly those with complex 3-vessel disease, left main coronary involvement, or multivessel disease with diabetes mellitus.

Indications for CABG

• Patients with significant (>70% diameter) stenoses in 2 major coronary arteries with severe or extensive myocardial ischemia, or target vessels supplying a large area of viable myocardium 1
• Patients with mild-moderate left ventricular systolic dysfunction (ejection fraction 35% to 50%) and significant (>70% diameter) multivessel CAD or proximal LAD coronary artery stenosis, when viable myocardium is present in the region of intended revascularization 1
• Patients with complex 3-vessel CAD (eg, SYNTAX score >22) with or without involvement of the proximal LAD artery, who are good candidates for CABG 1
• Patients with multivessel CAD and diabetes mellitus, particularly if a left internal mammary artery graft can be anastomosed to the LAD artery 1
• Patients with left main coronary involvement or multivessel coronary artery involvement, where more complete revascularization can be achieved with CABG 1

Key Considerations

• The use of arterial grafts, such as the left internal mammary artery, is preferred due to their superior patency rates compared to saphenous vein grafts 1
• Off-pump surgery may be considered in select patients with good target vessels and significant co-morbidity, although its benefits are still debated 1
• The adoption of new techniques and technologies in CABG is crucial to optimize outcomes, but may be limited by factors such as familiarity with existing techniques and the need for additional equipment and training 1

From the Research

Indications for Coronary Artery Bypass Grafting (CABG)

The indications for CABG include:

• Multivessel disease, particularly in patients with diabetes and higher coronary disease complexity 2, 3, 4
• Left main and three-vessel disease 2
• Patients with comorbid conditions, such as left ventricular dysfunction 2
• Obstructive coronary artery disease, particularly in patients with multivessel disease or diabetes 3
• Acute coronary syndromes, including non-ST-elevation ACS (NSTE-ACS) and ST-elevation myocardial infarction (STEMI), especially in patients with complex anatomy or failed percutaneous coronary intervention (PCI) 4

Patient Selection and Graft Selection

Patient selection and graft selection are crucial in determining the outcomes of CABG:

• A surgical approach individualized to the patient's clinical and anatomic characteristics, and surgeon and team experience, is key to excellent outcomes 5
• Multiple arterial grafting, especially if associated with anaortic techniques, might provide the best longer-term outcomes 5
• The use of left internal thoracic artery to bypass the left anterior descending artery is considered the "golden standard" 6
• More arterial grafts are recommended in young patients for better long-term results 6

Current Evidence and Recommendations

Current evidence and recommendations for CABG include:

• CABG remains the standard of care for obstructive coronary artery disease, particularly for patients with multivessel disease or diabetes 3
• A multidisciplinary approach, including surgeons with a special interest in CABG, is recommended to optimize treatment selection and outcomes 3
• Good quality control with flow meter during surgery, fast track post-operatively, and intensive anti-platelets therapy along with second prevention may further decrease perioperative mortality and increase long-term graft patency rate 6
• The choice between PCI and CABG depends on the complexity of coronary disease and patient comorbidities 4