CABG
Summary
Coronary Artery Bypass Grafting (CABG) is a surgical procedure that reroutes blood around narrowed or blocked coronary arteries using grafts, typically to treat severe coronary artery disease (CAD). Common grafts include the left internal mammary artery (LIMA), saphenous vein, and radial artery. Indicated for left main disease, triple-vessel disease, or CAD with reduced LVEF, especially in diabetics.
Detail
CABG improves myocardial perfusion by bypassing atherosclerotic obstructions in coronary arteries. The internal mammary artery (usually left, LIMA) is preferred for grafting to the LAD due to superior long-term patency (>90% at 10 years) compared to saphenous vein grafts (~50-60% at 10 years) due to resistance to atherosclerosis. Indications per ACC/AHA guidelines include: left main coronary artery stenosis >50%, three-vessel disease (especially with diabetes or reduced ejection fraction), two-vessel disease with proximal LAD involvement, and failed PCI or unsuitable anatomy for stenting. CABG is generally preferred over PCI in diabetic patients with multivessel disease (per FREEDOM trial) and in patients with complex disease (high SYNTAX score). Surgical approaches include on-pump (with cardiopulmonary bypass and cardioplegic arrest) and off-pump (beating heart) techniques. Post-CABG complications include atrial fibrillation (most common, ~30%), perioperative MI, stroke, mediastinitis, graft occlusion, and post-pericardiotomy syndrome. Long-term management includes aspirin, statins, and risk factor modification. Compared to PCI, CABG offers more durable revascularization in complex multivessel disease but carries higher perioperative risk.
Sources
- First Aid for the USMLE Step 1
- Harrison's Principles of Internal Medicine
- ACC/AHA Guidelines for Coronary Artery Revascularization
- UpToDate: Coronary artery bypass graft surgery
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