Coronary Artery Bypass Grafting

RS Kramer, JR Morton, RC Groom, and DL Robaczewski, Maine Medical Center, Portland, ME, United States
© 2018 Elsevier Inc. All rights reserved.

Introduction 700
Background 700
Embryology and Anatomy 701
Atherogenesis 701
The CABG Era 705
The Vineberg Procedure 705
Coronary Angiography: The Beginning 706
Peripheral Vascular Surgery Foreshadowed CABG 706
The First CABGs 706
Indications and Selection for CABG Surgery, Shared Decision-Making, and the Heart Team 708
Coronary Angioplasty and Stenting 711
Cardiopulmonary Bypass 712
Pumps 714
Oxygenators 716
CABG Technique 717
Saphenous Vein Graft: Its Position as Conduit of Choice in CABG Surgery 717
The Saphenous Vein Graft: An Imperfect Yet Remarkable Conduit 717
The Internal Mammary Artery: The Physiology of Arterial Grafting 719
The Radial Artery 720
Conduct of the CABG Operation 721
Conduct of the CABG Operation 722
CABG Using Cardiopulmonary Bypass 724
CABG Without Cardiopulmonary Bypass: Off-Pump CABG (OPCAB) 725
Perioperative Management, Complications 726
Summary 726
References 726

Introduction

The purpose of this article is to give the reader, a scientist or a scientist in training, an overview of coronary artery bypass grafting
from the clinician’s point of view. Accordingly, it is written and edited with that in mind explaining some of the clinical terms in
what is close to lay terms, while taking liberties at times with some of the fascinating science behind the clinical events, using terms
more familiar to scientists. The article starts with a brief look at the embryology of the human heart, a description of the anatomy,
especially with regard to the myocardial circulation, and the coronary arteries. After an introduction to the pathophysiology of
coronary artery disease, specifically atherosclerosis, the discussion of CABG begins, starting with the history of CABG, cardiopul-
monary bypass, current thinking about the evidence for indications and selection, some basic science aspects of vascular biology
that support decision-making, the technique of CABG, and an overview of perioperative management.

Background

Over the past half century, restoring the circulation to the heart (myocardial revascularization) has evolved into a standard of care
that has changed and saved and improved the lives of millions of people worldwide. In the context of the changes in the practice of
medicine since the industrial revolution, restoring the circulation to the heart when the myocardial blood supply has been
compromised has been one of the pivotal advances in medicine and surgery. One tool in that armamentarium has been coronary
artery bypass grafting (CABG). While the acronym for this procedure, CABG (pronounced “cabbage”), has been decried by some as
degrading as it is the name of a common vegetable, it has stuck and has been accepted over its nearly 50 year history.

700 Encyclopedia of Cardiovascular Research and Medicine https://doi.org/10.1016/B978-0-12-809657-4.99754-0

Embryology and Anatomy

The heart is a four-chambered dual pump (Fig. 1). It is a double pump responsible for blood flow to both the lungs (the pulmonary
circulation for gas exchange) and the rest of the body (the systemic circulation primarily for delivery of oxygen and nutrients).
Embryologically, in keeping with the concept that ontogeny recapitulates phylogeny, the human heart begins with a tube (much
like that of a fish) that eventually folds and compartmentalizes into two separate hearts (Fig. 2). Those two hearts ultimately fuse
into a four-chambered interdependent muscular pump supplying two separate and connected circulations, pulmonary and
systemic. In cardiac hemodynamics, this tandem arrangement is truly interdependent, as the flow through the pulmonary
circulation (right side of the heart) in the normal healthy person must equal that of the systemic circulation (left side of the heart).
The right side of the pump generates flow to the pulmonary circulation, while the left side pumps to the systemic circulation.
Approximately five liters of blood each minute courses through this double pump as it generates blood flow through both the
pulmonary and systemic circuits. The left (systemic) side of the heart pumps oxygen (O2)-rich blood through the arterial system to
the tissues of the body to support aerobic metabolism. Having delivered its load of O2, the deoxygenated red blood cells along with
a plasma load of dissolved carbon dioxide return to the right (pulmonic) side of the heart to be pumped to the lungs for gas
exchange then return to the left heart to repeat the process (Fig. 3).
While this huge volume of blood courses through the chambers of the heart each minute, the heart’s share of that blood is
delivered to the myocardium, the heart muscle, via its own circulation, the coronary arteries. The coronary arteries are so named as
they course over the top and sides of the surface of the heart much like a crown named by the early anatomists who used the Latin
for crown (corona). While the anatomical pattern is generally consistent, there is usually normal and occasionally abnormal
variability (Fig. 4).

Atherogenesis

The coronary arteries in some individuals develop atherosclerosis, commonly called hardening of the arteries. In fact, calcified
atherosclerotic plaques feel hard to the touch. Touching of the heart was limited to postmortem examinations in early days, and
since the advent of cardiac surgery, expanded to the operating room.

Fig. 1 The four chambers of the heart and the tandem nature showing the direction of blood flow and depicting the chambers and vessels with oxygenated blood
in red and those with deoxygenated blood in blue.
702 Coronary Artery Bypass Grafting

Fig. 2 Embryogenesis from days 21 to 28: (A) The cardiac loop is formed. The heart tube is folded into an S-shaped dextro-ventral convexity. (B) The atria are
partitioned. The septum primum (in brown) grows from the inferior part of the atria to the top, leaving a foramen called the ostium primum. The septum
secundum (in orange) comes from the top. The ostium primum will be closed at the end of the fifth week by an expansion of tissue coming from the endocardial
cushions (in yellow). (C) The conus and the truncus are partitioned. The dextrodorsal and sinistroventral conus ridges, which are isolated in the first picture,
partition the conus by a helical outgrowth into two cavities: the subpulmonary and the subaortic coni. The truncus is partitioned from the bottom upward
from aorticopulmonary swellings, leading to the formation of the aorta and pulmonary arteries. Reproduced with permission from Wolters Kluwer Health Inc.
Schleich, J.-M. and Dillenseger, J.-L. (2001). Circulation 104, e134.

Fig. 3 This illustration depicts the two circulations supplied by the tandem heart, showing the four cambers, direction of flow, and colors representing oxygenated
and deoxygenated blood. From Pearson Education (Copyright 2010).

The term atherosclerosis is derived from Latin and Greek roots meaning “gruel or pasty” (athero) and hard (scler), ultimately
gaining acceptance as the lay term, “hardening of the arteries.” The deposition of this pasty material in the coronary arteries, a
consequence of the metabolism of some types of cholesterol, ultimately becomes calcified with time, and becomes firm or hard.
In its early stages atheromas consist of soft plaque that can rupture and promote thrombosis, occluding the coronary artery,
interrupting myocardial blood supply, and potentially causing a myocardial infarction (heart attack). In its more chronic and
progressive form, the atheromatous plaque results in coronary insufficiency, a supply-demand problem, where the blood supply
through narrowed coronary arteries to a segment of the heart is not adequate to meet metabolic demands (Figs. 5 and 6).
 Coronary Artery Bypass Grafting 703

Fig. 4 This illustration depicts the usual distribution of the coronary arteries. Note that the major vessels are epicardial, coursing over the surface of the heart,
making them easily accessible to the cardiac surgeon for revascularization. From daviddarling.info.

Fig. 5 Plaque is shown beneath the lining of the artery, showing how the artery’s lumen is accordingly narrowed, and the lining of the vessel is still intact.

Fig. 6 Plaque rupture is shown from the vantage point of the cellular elements coursing through the artery with platelets aggregating at the rupture site to begin
the formation of a clot. From Crystalgraphics.
704 Coronary Artery Bypass Grafting

The clinical presentations of coronary artery disease range from patients who are virtually asymptomatic to those who experience
sudden death with little or no warning. On one end of the spectrum, patients may present with chest discomfort (angina) with
exertion or at rest to more extreme acute coronary syndromes, including myocardial infarction. Treatment that consisted of medical
management with rest and medications such as nitroglycerine was all there was to offer to these patients until the late 1960s and
early 1970s, the time when CABG surgery was conceived and implemented. During the first half of the 20th century, innovative
surgical strategies to restore blood supply to those hearts were suboptimal. By the early 1960s there were a few reports of success
surgically bypassing occluded and stenotic (narrowed) vessels. The advent of a reliable method to visualize the coronary artery
anatomy (coronary angiography) in that decade led to the beginning of the CABG era.
Diseases addressed by cardiac surgery are divided into two main categories: congenital/genetic and acquired. Congenital and
genetic cardiac disorders are driven by events that result in structural abnormalities that become apparent very early in life, even
in utero, or genetically acquired defects that may effect cardiac and great vessel structure later in life. Clarity in categorizing diseases
is often challenging because of overlap. While coronary artery disease (CAD) is considered to be in the category of acquired cardiac
disease, there is a clear genetic component with offspring of parents with premature CAD (Khurram et al., 2007) having a higher
predilection for acquiring CAD than others. The multifactorial etiology of CAD is apparent as atherogenesis is driven by multiple
factors: genetics, lifestyle (smoking, diet, and exercise), and metabolism (such things as diabetes and obesity).
Atherogenesis (the formation of atherosclerosis from the root “gen,” meaning to form) is a disorder of the artery wall that may be
the result of a chronic inflammatory fibroproliferative process that has become excessive and in its excess this protective response
becomes the disease state, a maladaptive response. The process starts with the adhesion of monocytes and lymphocytes (white
blood cells) to the luminal side of the endothelial cell lining of the coronary arteries. Those monocytes migrate into the
subendothelial space and differentiate into macrophages. Once those macrophages ingest low-density lipoproteins (LDL), the
LDL is modified in such a way (such as oxidation) that cholesterol esters accumulate inside and form “foam cells,” which are really
dead macrophages engorged with LDL. When foam cells combine with T lymphocytes the fatty streak is formed, the beginning of
the atherosclerotic plaque is formed by migration of vascular smooth muscle cells from the media of the vessel to the intima.
Eventually a fibrous cap is formed, completing the plaque. Ironically, the body’s effort to manage this fatty endovascular deposition
results in the proliferation of atherosclerotic plaques. This exuberant response is regulated by inflammatory cytokines released by
the foam cells and growth regulatory peptides released by platelets, and in the case of coronary artery disease, the body’s protective
intent becomes the disease (Ross and Agius, 1992) (Fig. 7).

Fig. 7 Atherosclerosis occurs at sites in the arterial tree where laminar flow is disrupted. A lesion begins as a fatty streak (A) and can develop into an intermediate
lesion (B), and then into a lesion that is vulnerable to rupture (C) and, finally, into an advanced obstructive lesion (D). A more detailed description of this process is as
follows: (A) Atherogenic lipoproteins such as low-density lipoproteins (LDLs) enter the intima, where they are modified by oxidation or enzymatic activity and
aggregate within the extracellular intimal space, thereby increasing their phagocytosis by macrophages. Unregulated uptake of atherogenic lipoproteins by
macrophages leads to the generation of foam cells, which are laden with lipid. The accumulation of foam cells leads to the formation of fatty streaks, which are often
present in the aorta of children, the coronary arteries of adolescents, and other peripheral vessels of young adults. Although they cause no clinical pathology, fatty
streaks are widely considered to be the initial lesion leading to the development of complex atherosclerotic lesions. (B) Vascular smooth muscle cells—either
recruited from the media into the intima or proliferating within the intima—contribute to this process by secreting large amounts of extracellular-matrix components,
such as collagen. The presence of these increases the retention and aggregation of atherogenic lipoproteins. In addition to monocytes, other types of leukocyte,
particularly T cells, are recruited to atherosclerotic lesions and help to perpetuate a state of chronic inflammation. As the plaque grows, compensatory remodeling
takes place, such that the size of the lumen is preserved while its overall diameter increases. (C) Foam cells eventually die, resulting in the release of cellular debris
and crystalline cholesterol. In addition, smooth muscle cells form a fibrous cap beneath the endothelium, and this walls off the plaque from the blood. This process
contributes to the formation of a necrotic core within the plaque and further promotes the recruitment of inflammatory cells. This nonobstructive plaque can rupture
or the endothelium can erode, resulting in the exposure of thrombogenic material, including tissue factor that stimulates the formation of a thrombus in the lumen.
If the thrombus is large enough, it blocks the artery, which causes an acute coronary syndrome or myocardial infarction (heart attack). (D) Ultimately, if the plaque
does not rupture and the lesion continues to grow, the lesion can encroach on the lumen and result in clinically obstructive disease. Above quoted from the following
article and illustration taken from Rader, D. J. and Daugherty, A. (2008). Translating molecular discoveries into new therapies for atherosclerosis. Nature 451,
904–913. https://doi.org/10.1038/nature06796.
 Coronary Artery Bypass Grafting 705

The CABG Era

Currently, CABG surgery is performed on over 400,000 patients in the United States annually, and since its inception has provided
myocardial revascularization world-wide to millions. During the first half of the 20th century, strategies to restore cardiac blood
supply were manifold and included scarifying the surface of the heart or applying muscle flaps or omentum to induce collateral
vessel ingrowth, cervico-dorsal sympathectomy, coronary sinus constriction or arterialization, and internal mammary artery (IMA)
ligation. Some of these procedures would occasionally bring symptomatic relief of angina, encouraging proponents, but following
an historic randomized trial comparing IMA ligation with a control sham operation of sternotomy alone, the procedure of IMA
ligation was shown to be ineffective (Cobb et al., 1959).

The Vineberg Procedure

In 1945, Arthur Vineberg, MD, from Montreal, noting the sinusoidal microcirculation peculiar to the myocardium, postulated that a
systemic artery, imbedded in the myocardium, might find adequate runoff into these sinusoids to remain patent and to increase
blood flow to the myocardium (Vineberg, 1958) (Fig. 8).
During the next four years, he pursued his idea in the animal lab and discovered that, if he rendered the myocardium ischemic by
obstructing the flow in the principle artery to the left ventricle (left anterior descending coronary artery or LAD), the implanted left
internal mammary artery (LIMA) would not only maintain flow and remain open, but would, over time establish connections to
arterial branches of the coronary circulation. In 1950, he performed this procedure for the first time on a patient with severe
coronary insufficiency. The patient survived the procedure but died a short time later, before the effect of the procedure could be
ascertained. The procedure was repeated on a second patient who lived for ten years and was significantly improved. Dr. Vineberg
continued to perform these operations and many of his patients enjoyed dramatic improvement. Many of his colleagues around the
world remained skeptical, doubting that meaningful connections were actually being formed to the coronary arteries. There were
some advocates of this procedure, including Dr. Bigelow in Toronto and Dr. DeBakey in Houston, who were able to show flow in
the heart muscle from Vineberg’s operation by using the then new technology of coronary angiography (Bigelow et al., 1966). At this
point in history, cardiac surgeons were on the cusp of the CABG era when direct anastomoses of both the mammary artery and
saphenous vein graft became feasible and successful, with instant revascularization. The knowledge from coronary angiography that
the Vineberg procedure did actually revascularize the myocardium came late and was eclipsed by CABG surgery and has remained so
since (Thomas, 1999).

Fig. 8 Drawing of implanted internal mammary artery in left ventricle with opening on one side of vessel. Blood escapes from internal mammary artery into
myocardial sinusoids, which is why the implanted vessel remain open until its own branches join the coronary arterioles. From Vineberg, A. (1958). Coronary
vascular anastomoses by internal mammary artery implantation. Canadian Medical Association Journal78, 871–879. Copyright © by the Canadian Medical
Association.
706 Coronary Artery Bypass Grafting

Coronary Angiography: The Beginning

In 1958, pediatric cardiologist, Mason Sones, at the Cleveland Clinic, while performing a heart catheterization on a 27-year-old
patient with rheumatic heart disease, accidentally injected a bolus of dye into his right coronary artery, an error known to be fatal.
The result was cardiac arrest and a beautiful picture of the coronary artery. The heart was restarted with a cough, and coronary
angiography was born, albeit in the face of vigorous opposition from others in the cardiac field who thought the technique was
ethically irresponsible (Sones et al., 1959). Sones and his cardiology fellow, Earl Shirley, perfected the technique and began
performing angiograms on hundreds of patients from all over the country, including many patients who had had previous Vineberg
procedures, many of which showed dramatic flow from the implanted IMAs into the branches of blocked coronary arteries. These
findings stimulated renewed interest in the Vineberg procedure, particularly at the Cleveland Clinic, and in 1968, they published a
report on 1100 IMA implants, 92% of which were open and 54% had significant visible connections to the coronaries (Fergusson
et al., 1968; Cineangiography, n.d.; Effler et al., 1963).

Peripheral Vascular Surgery Foreshadowed CABG

Beginning in the 1950s, great advances were made in arterial surgery, stimulated by the wartime injuries of WWII and the Korean
conflict. Led largely by the advances of Michael DeBakey (DeBakey et al., 1958) in Houston, artificial arterial substitutes were
created out of nylon and later Dacron and PTFE (Teflon), and used to replace arterial aneurysms and to bypass occluded or stenotic
vessels. Initially, most arterial obstructions were treated by endarterectomy, in which the obstructing cholesterol-laden plaque was
surgically removed from the artery. This technique worked well when the obstruction was localized to a short segment of an artery
but was less effective when the occlusive disease involved longer arterial segments. For these situations, DeBakey developed the
arterial bypass technique, in which an artificial tube graft was connected to the side of the obstructed artery above and below the
obstruction, thus increasing blood flow distally while leaving the native circulation intact, in the event that the artificial graft failed
and became occluded.
The technique was used first to bypass obstructed iliac arteries, using a bifurcated Dacron graft from the aorta to the common
femoral arteries. Later, obstructed superficial femoral arteries were bypassed with Dacron bypass grafts from the common femoral to
the popliteal artery. Grafts to these smaller arteries and particularly to those below the knee did not remain open consistently, and
surgeons began using the long saphenous vein (from the patient’s leg) for the graft, with much better results. While the greater
saphenous vein that is harvested for use in CABG, the rest of the venous system that is left in place is more than adequate to provide
venous drainage to the leg.
Over time, as surgical techniques improved, vein bypasses were constructed to smaller and smaller arteries further down the leg.
These were reasonably successful until, close to the ankle, the recipient artery was no more than 2–3 mm in diameter, and then the
graft would usually not stay open. That was, therefore, considered the size limit for a saphenous bypass graft. For this reason, at that
time, bypassing the coronary arteries was not considered feasible.

The First CABGs

Between 1962 and 1967, human CABG using autogenous saphenous vein grafts were performed by Sabiston (1962), Garrett
(1964), Kahn (1966), and Favaloro (1967). In 1964, surgeon Edward Garrett, working with Dr. Michael DeBakey in Houston,
encountered a patient with a relative large, but severely stenotic LAD coronary artery (Cooke, 2015). He performed a vein bypass
graft from the ascending aorta to the obstructed artery and it remained open and relieved the patient of his angina (Fig. 9).
Subsequent follow-up showed that the graft remained open for at least ten years. At the time, Garrett believed that this was an
unusual and lucky case and that it was unlikely that it could be repeated reliably and did not justify the risk, which was then
considerable, of subjecting these clinically fragile patients to the hazards of cardiopulmonary bypass. He did not publish a report of
this case. It was not appreciated at the time that the patency of these grafts was more dependent on blood flow through the graft as
well as the size of the recipient vessel. A few years later, Rene Favaloro, at the Cleveland Clinic, performed the same procedure, in a
similar situation to a large right coronary artery, which was also a success. He subsequently reported on his series and ignited an
industry (Favaloro et al., 1969).
In the late 1960s, Dr. Favaloro was a cardiothoracic surgery fellow at the Cleveland Clinic. Before he published the series of cases
where he was able to revascularize the heart using saphenous veins from patients’ legs, many preceding events had to occur and
come together for this relatively straightforward solution to evolve. These events included technologic advances in cardiac surgery,
peripheral vascular surgery, and diagnostic cardiology. By the 1960s, the heart–lung machine or cardiopulmonary bypass (CPB) was
in common use, having been invented in the early 1950s. At the beginning of the CABG era, CPB had improved to the point where it
was being used regularly in cardiac surgery centers for congenital heart surgery and valve surgery. In addition, the Sones technique of
coronary angiography allowed practitioners to see precisely where occlusions and stenoses were in the coronary arteries. At that
point in history, cardiovascular surgeons had much experience in peripheral arterial surgery, in particular, restoring circulation to
extremities by using the patient’s own veins (autologous) to bypass occluded peripheral vessels, particularly in the legs. With the
 Coronary Artery Bypass Grafting 707

Fig. 9 Images of first coronary artery bypass performed by Doctors Ed Garrett and Jimmy Howell. Image and description from DeBakey, M. E. (2015). Houston
hearts: A history of cardiovascular surgery and medicine at Houston Methodist Debakey Heart & Vascular Center. The Methodist DeBakey Cardiovascular Journal 11
(3 Suppl.), 5–17.

experience of operating on the heart using the heart–lung machine, the knowledge that vessels could be bypassed with autologous
vein, and having a roadmap supplied by the angiographer, CABG became feasible (Fig. 10).
Cardiologists and vascular surgeons were poised and ready for this long-awaited step in the discovery process, and coronary
surgery virtually exploded across the western world. Initially, bypass grafts were done to only the largest coronaries with localized
proximal disease in relatively young patients. For each distal anastomosis of the vein to the coronary artery, the ascending aorta was
cross-clamped and the heart allowed to stop from ischemic arrest. The vein was then carefully sewn to an opening in the side of the
coronary artery using magnifying loupes, after which the clamp was removed from the aorta to allow the heart to recover. After a few
minutes of recovery time, the process was repeated for the next distal anastomosis to a second coronary, using another segment of
vein. When the last distal attachment had been completed, a partially occluding clamp was placed on the ascending aorta (Fig. 11),
and the opposite ends of the vein grafts (proximal) were sewn to small openings made in the wall of the aorta. Over time, many

Fig. 10 The roadmap: Frames from cineangiography of normal coronary arteries. (A) Radiocontrast dye has been injected from the catheter positioned in the root
of the aorta at the origin of the right coronary showing a view of a normal vessel and its branches. (B) The dye has been injected into the left main coronary
artery revealing its branches, the left anterior descending, and circumflex coronary arteries. From: © Copyright Policy—open-access Open-i service of the National
Library of Medicine enables search and retrieval of abstracts and images (including charts, graphs, clinical images, etc.) from the open source literature,
and biomedical image collections. Searching may be done using text queries as well as query images. Open-i provides access to over 3.7 million images from
about 1.2 million PubMed CentralW articles; 7,470 chest x-rays with 3,955 radiology reports; 67,517 images from NLM History of Medicine collection; and 2,064
orthopedic illustrations.
708 Coronary Artery Bypass Grafting

Fig. 11 This illustration depicts the application of a partially occluding clamp on the ascending aorta allowing flow through the native vessel while giving the
surgeon the opportunity to occlude part of it to sew a proximal anastomosis to the depressurized segment of the aorta. From Royse, A. and Royse, C. (2009).
Epiaortic ultrasound assessment of the thoracic aorta in cardiac surgery. Best Practice & Research Clinical Anaesthesiology 23, 335–341.

improvements were made in all phases of the procedure, including local and systemic cooling, myocardial preservation, more
precise suturing techniques, and improvements in cardiopulmonary bypass equipment and technology.
The concept of temporarily inducing cardiac arrest with cold potassium rich solution injected antegrade into the coronary
arteries was introduced in the late 1970s. This solution, coined “cardioplegia” (literally meaning to paralyze the heart muscle) was
infused into the coronaries to arrest the heart, literally causing the cells of the heart to hibernate, preserving its function. The high
concentration of potassium in the solution literally paralyzes the cells by influencing its electrical properties (by eliminating the
potential difference across the cell membrane), and the low temperature induced decreases the metabolic demands of the cells, the
combination of which is termed “myocardial preservation” (Yamamoto and Yamamoto, 2013). The surgeon could now work on
these tiny vessels in a still, bloodless field. With these improvements, it was possible to do all the distal anastomoses during a single
cross clamping of the aorta and significantly shorten the length of the procedure and the time on the heart lung machine. This was
particularly important since over time, as surgical techniques were improving, the patients were getting older with more advanced
disease, and the number and difficulty of the grafted arteries was increasing.
In 1968, shortly after the onset of the beginnings of coronary bypass surgery, Kolessov, in Russia performed the first bypass from
the left internal mammary artery (LIMA) to the left anterior descending coronary artery (Kolessov, 1967). Initially this did not attract
much attention, because the vein grafts were quicker and easier and seemed to work as well, at least in the short term. Green, at NYU,
was the first in the United States to perform and publish about the use of the LIMA. Over the years, evidence began mounting that
the vein grafts were slowly developing atherosclerotic obstructions of their own, and the LIMA grafts, which Green and about
5%–10% of the other surgeons preferred, were remaining free of disease and lasting longer. In 1985, a paper from Montreal reported
on a large series of coronary bypass patients who had follow up angiograms 10 years after their initial surgery (Bourassa et al., 1985;
Lytle et al., 1983). They found that about 30% of the vein grafts had occluded and that 95% of the LIMA grafts were open and free of
disease. These observations led to a dramatic increase in the use of LIMA grafts, particularly to the LAD coronary artery with a
noticeable improvement in short- and long-term results, regardless of the age of the patient or associated disease.
Concurrently, a number of surgeons extended this technique to include the right internal mammary (RIMA) and occasionally the
gastroepiploic artery anastomosed to the inferior or posterior coronary branches. The gastroepiploic artery courses along the surface
of the greater curvature of the stomach. By extending the median sternotomy incision inferiorly and opening the upper abdomen,
the stomach can be exposed, the gastroepiploic artery mobilized, and can be extended above the diaphragm to the heart, long
enough to reach vessels on the inferior surface of the heart. Radial artery grafts were also employed, particularly when satisfactory
veins are not available. To date, radial arterial grafts and free IMA grafts have not consistently demonstrated superiority over the
combination of LIMA and saphenous grafts, particularly in combination with cholesterol lowering drugs.

Indications and Selection for CABG Surgery, Shared Decision-Making, and the Heart Team

Modern management of ischemic coronary artery disease and the role of CABG surgery have been in a continual state of flux over
the past 50 years. Initial enthusiasm for the broad application of surgical revascularization was tempered by the results of three
important prospective randomized trials that were carried out from 1972 to 1979 (VA Coronary Artery Bypass Surgery Cooperative
Study Group, 1992; Varnauskas, 1988; Killip et al., 1985). In these studies, patient disease patterns and outcomes were compared
between medical and surgical therapy allowing for the stratification of patients with coronary artery disease into low-, medium-, and
high-risk groups. The impact of surgical revascularization on these groups proved a clear benefit for CABG in patients with severe left
main coronary artery and three-vessel coronary artery disease, while the benefits of CABG surgery were shown in patients with
double- and single-vessel disease only if the proximal LAD was involved. In patients with double- and single-vessel coronary artery
disease not involving the LAD, medical management was found to be equal to or superior to CABG. As surgical management
became standard for specific disease patterns, new medications as well as interventional technologies (percutaneous balloon
 Coronary Artery Bypass Grafting 709

angioplasty, bare metal, and drug-eluting stents) were introduced and dramatically impacted decision-making for patients with
ischemic heart disease. The RITA, BARI, and SYNTAX Trials provided the evidence for this decision-making (Henderson et al., 1998;
Investigators, 2007; Serruys et al., 2009).
The development of the Society of Thoracic Surgeons (STS) database in 1989 (Shroyer, 2015) has further aided surgeons in
determining patient risk for CABG and allowed for refinement of individual patient treatment plans based on both the degree of
coronary disease and the severity of a number of comorbidities. With the sophistication of current medical, interventional, and
surgical options that are available today, a multidisciplinary heart team approach that allows for regular communication between
the primary cardiologist, interventionalist (cardiologist that is trained to do interventions such as angioplasties and stents), and
cardiothoracic surgeon provides the best opportunity for optimal patient management.
The technological advancements in CABG surgery over the past 50 years have also provided today’s surgeon with a number of
options in surgical planning. These range from the performance of a standard “on-pump” procedure with a combination of differing
conduits to “off-pump” techniques and or hybrid approaches that combine surgical and interventional technologies. The cardio-
pulmonary bypass machine is often referred to as the “pump.” The proper selection from these many operative choices is predicated
upon a high-quality, systematic, preoperative assessment of the patient. Such a process is greatly aided by the deployment of a team
of supporting nurses, physician assistants, residents, and/or fellows under the guidance of the attending surgeon. The modern reality
of practicing medicine in the age of electronic medical records allows providers rapid access to not only the historical details of the
patient as documented by their referring physicians during any number of prior encounters but also to their laboratory and imaging
studies. The obvious goal of such a record has been to give the provider an efficient source of information that should theoretically
decrease the time required to thoroughly evaluate and formulate a proper plan for his or her patient. Though this often works out
quite nicely, electronic medical records are only as good as the data that has been uploaded into them and thus are not impervious
to collecting inaccurate or incorrect patient information. With that in mind, the most efficient use of the consultant’s time is to first
thoroughly review the imaging and laboratory studies in the contest of the patient’s historical and physical findings.
After reviewing the recent history and physical and progress notes, it is imperative that the consulting surgeon confirm with the
patient the details of their history and conduct a thorough review of systems and physical examination. It is incumbent upon the
operating surgeon to perform his or her own cardiovascular physical examination with close attention to the presence or absence of
cardiac murmurs and vascular bruits, clinical signs of heart failure, discrepancies in brachial (arm) blood pressures, character of
peripheral pulses, and the quality of potential primary and secondary conduit choices (greater or lesser saphenous veins and radial
arteries). With this approach, the surgeon can confidently determine the patient’s angina and heart failure scores, confirm the
presence of serious comorbidities, potentially identify missed diagnoses, calculate the risk for CABG surgery (STS or EuroScore)
(Shahian et al., 2009; Roques et al., 1999; Roques et al., 2003), and start formulating the surgical plan tailored to the patient’s health
status, including the patient and family in a shared decision-making process (Lin and Fagerlin, 2014).
Failure to prepare in this manner can result in suboptimal operative planning, avoidable complications, avoidable deaths, and
the performance of operations on patients who would have been better off with medical or interventional management. Once the
decision for surgery has been made, the details of the operative plan are formulated including selection of arterial targets, grafting
strategy, determination of the cardiac support plan, and selection of conduit. In general, the selection of target arteries is based on
findings of the coronary angiogram (a cine radiograph of coronary arteries injected with radio-opaque dye through a catheter) in
combination with information from any viability scans (imaging using markers that indicate the presence of living myocardial cells
in a nonfunctioning area of the heart) that may have been performed. The cardiac support plan is generally based upon the
surgeon’s preference, status of the ascending aorta, and the presence or absence of major comorbidities.
The most commonly used plan for cardiac support during CABG continues to be cardiopulmonary bypass with cardioplegic
arrest. The next most common technique is Off-Pump CABG (OPCAB) in which coronary anastomoses are performed on the
beating heart with the aid of special stabilizing devices and occasional intracoronary shunts. In the mid-1990s, as a response to
advances in percutaneous revascularization, surgeons developed several different strategies to make direct coronary bypass surgery
less invasive. The first was coined Minimally Invasive Direct Coronary Artery Bypass or MIDCAB. In this technique, the LIMA was
harvested and anastomosed to the LAD via a left anterior thoracotomy incision through the fourth intercostal space with or without
cardiopulmonary bypass support. Though this technique had many successes, revascularization was limited to the LAD, pain from
the thoracotomy incision was significant, hemodynamic instability with need for conversion to full sternotomy was not uncom-
mon, and inadvertent grafting of the LAD at the wrong site occurred (Vicol, 2003).
Around the same time, an Off-Pump approach via a full sternotomy with mechanical stabilization techniques (OPCAB) was
developed that allowed for complete revascularization with a lower incidence of grafting errors. Both techniques had the goal of not
exposing patients to the deleterious effects of CPB. Over time, some centers practicing both techniques reported OPCAB to be the
superior method. Several prospective randomized studies have proven the safety of OPCAB, and there are a number of surgeons
who prefer OPCAB as their primary method of CABG. Other surgeons feel that their ability to perform a sutured anastomosis is far
superior while On-Pump with cardioplegic arrest and selectively utilize Off-Pump CABG in cases of a “porcelain aorta” (an
ascending aorta that has so much dense, calcified atheromatous plaque that it feels as firm as porcelain, risky to manipulate for
fear of breaking of particles and causing embolic strokes) or severe pulmonary disease. Conflicting inferiority/superiority outcomes
from several studies allow for the support of both positions (Hattler et al., 2012; Lamy et al., 2012; Puskas, 2009; Diegeler, 2013;
Bakaeen and Puskas, 2014; Taggart et al., 2016).
Over the nearly 50 years of the “CABG Era,” evidence has been gathered through these databases, observational analyses, and
trials that has, in the aggregate, provided the surgeon with guidance as to what the indications are for surgery and who should be
710 Coronary Artery Bypass Grafting

selected as each patient provides a different context depending on age, comorbidities, and other factors. Armed with the evidence
provided by these studies, the first management decision would be to decide whether to offer the patient medical therapy, CABG or
“PCI” a percutaneous intervention (angioplasty and stenting). The major drivers of that decision include the patient’s coronary
anatomy, the presence of diabetes mellitus, the clinical syndrome (stable angina, acute coronary syndrome, acute myocardial
infarction (STEMI or NSTEMI)), and left ventricular dysfunction and mitral valve disease. The terms “STEMI” or ST-segment
elevation myocardial infarction or “NonSTEMI” define electrocardiographic features of myocardial infarctions that have been
found to distinguish the extent of injury and treatment decisions in the context of the coronary anatomy and the other features
outlined in Fig. 12. These evidence-based factors and decision points are well summarized by Alexander and Smith from their 2016
review article on CABG surgery (Alexander and Smith, 2016).

Fig. 12 A summary of the indications for CABG surgery from Alexander JH, Smith PK. Coronary-Artery Bypass Grafting N Engl J Med 2016;374:1954-64. The
SYNTAX scoring system, developed as part of the Synergy between PCI with Taxus and Cardiac Surgery study, classifies the extent and complexity of coronary artery
disease, with a score of 22 or lower indicating low complexity, a score of 23 to 32 indicating intermediate complexity, and a score of 33 or higher indicating high
complexity. CABG denotes coronary–artery bypass grafting, LAD left anterior descending, PCI percutaneous coronary intervention, and STEMI ST-segment elevation
myocardial infarction (Ong et al., 2006; Sianos et al., 2005). From: Yusuf, S. et al. (2016). Cholesterol lowering in intermediate-risk persons without cardiovascular
disease. New England Journal of Medicine 374, 2021–2031.
 Coronary Artery Bypass Grafting 711

Coronary Angioplasty and Stenting

In 1977, Andreas Gruentzig, a German cardiologist living in Zurich, first employed a balloon on the end of a cardiac catheter
(Matthias et al., 2014; Gruentzig et al., 1979) (Fig. 13) to dilate a stenotic lesion in a patient’s LAD coronary artery.
Later that year, Dr. Gruentzig presented the results this technique of four such successful balloon angioplasties at the American
Heart Association Meeting, which led to widespread acknowledgement of this procedure, and, with successive refinements in
technique and devices, by 1990, percutaneous angioplasty became a commonly used method of treating coronary disease by
revascularization. Unfortunately, a significant number of these dilated arteries developed recurrent stenosis due to reaccumulation
of plaque a few months to a year after balloon angioplasty, requiring another angioplasty or a bypass graft. During the next decade,
an expandable wire stent was developed to prevent restenosis of the vessel. Later these stents were coated with antiproliferative drugs
to slow or prevent plaque growth (Fig. 14).
Several large randomized clinical trials, most notably the SYNTAX Trial (Gulati et al., 2009; Serruys et al., 2009), have helped to
define the relative effectiveness of the various revascularization techniques currently available in different situations and, in

Fig. 13 Illustration depicting a balloon angioplasty where a tiny catheter with an integrated balloon is guided into a coronary artery, the balloon positioned into the
area of stenosis, inflated, thereby improving blood flow through that segment. This original procedure has subsequently been enhanced by the addition of drug-
eluting stents that discourage restenosis of the vessel. From: MedicineNet.com.

Fig. 14 This is an example of a drug-eluting stent. It is the TAXUS Express Paclitaxel-Eluting Coronary Stent System, which releases paclitaxel, the stent that was
used in the SYNTAX Trial. From: Food and Drug Administration—http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/
DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm081189.htm, Public Domain, https://commons.wikimedia.org/w/index.php?curid¼973844.
712 Coronary Artery Bypass Grafting

particular, which patients are better served by surgery versus balloon angioplasty. Long-term results have shown that diabetic
patients and those with multiple coronary blockages appear to do better with coronary surgery, where grafts can be constructed to
three or more coronary branches at once, often creating multiple distal anastomoses with a single vein graft. Revascularization is
more frequent with stents as opposed to CABG, while strokes are more common with CABG. At this writing, 5-year results from
SYNTAX have been published and data on 10-year mortality is currently being analyzed.
As technology has evolved in both surgery and interventional cardiology, the cardiac surgeons who perform the CABG surgery
and the cardiologists who perform coronary angioplasties and place stents both have technologies that have been found to suit
different subsets of patients requiring coronary revascularization. This commonality has brought the two specialties closer together,
forming “Heart Teams” to address coronary revascularization and other complex cardiac issues such as advanced valve therapy and
heart failure.

Cardiopulmonary Bypass

The concept of cardiopulmonary bypass (CPB), commonly known as the heart–lung machine, became a reality in the early 1950s
when it was used in a succession of patients to correct congenital cardiac problems such as atrial septal defect, the failure of the
completion of the formation of a partition between the left atrium and the right atrium. CPB is a form of extracorporeal circulation,
meaning circulation outside of the body. Substituting a machine for the heart and lungs to pump the blood and provide gas
exchange allowed surgeons to stop the heart and stop ventilation so as to have an opportunity to open the heart and work on its
interior, correcting and reconstructing congenital defects. As CPB began to evolve and improve in the first decade of its use,
pioneering medical centers and surgical teams began to use it for acquired cardiac problems, such as valve surgery, in addition to
correcting congenital defects. By the 1960s, valve replacement surgery became a reality, and at the beginning of the CABG era in the
early 1970s, CPB was used as well.
With the ability of the surgeon to stop the heart and work on its interior during this era, the potential to apply lessons learned in
peripheral vascular surgery to the coronary arteries became real. The coronary arteries course over the surface of the heart
(epicardial) and are visible and palpable. The use of the principles of peripheral aterial bypass to the coronary arteries was applied
in the early days of CABG, and with CPB and cardioplegia, the surgeon was now able to work in a still, bloodless field, using familiar
techniques in this new setting.
The heart and lungs provide gas exchange and perfusion of more than 37 trillion living cells. The idea of designing a machine
that could take over the function of the heart and lungs was conceptualized in 1813 by Le Gallois; however, the first attempts to
actually apply the concept occurred in the early 1950s (Groom and Fitzgerald, 2017). The first successful use of cardiopulmonary
bypass was in 1953 by a surgeon, John H Gibbon Jr., and his team at Jefferson Hospital in Philadelphia, Pennsylvania (Stammers,
1997). Gibbon used his heart–lung machine to “perfuse the patient” allowing her heart to be stopped while he and his team opened
her right atrium and sutured closed her atrial septal defect. The early years following that landmark case were not so promising. Five
subsequent procedures at Jefferson Hospital where cardiopulmonary bypass was used by Gibbon were not successful as all five
patients did not survive, and he abandoned the use of the heart–lung machine. At least seventeen other cases were performed in the
early 1950s using some form of extracorporeal circulation, and only Dr. Gibbon’s patient survived. Nonetheless, his one successful
case served to inspire others, including John Kirklin at The Mayo Clinic, C. Walton Lillihei at the University of Minnesota, and Denis
Melrose at Hammersmith Hospital in London, to press with their research and application the heart–lung machine with CPB
techniques that were crude compared to today’s standards. (Fig. 15).

Fig. 15 The Mark-Clowes heart–lung machine with a membrane oxygenator in use at Maine Medical Center in 1959. Sixteen units of donor blood were needed to
prime this heart-lung circuit. With permission from Archives of Maine Medical Center.
 Coronary Artery Bypass Grafting 713

The accomplishments of these early pioneers in cardiac surgery have been described as being “one of the boldest and most
successful feats of man’s mind.” (Eloesser, 1970).
Since the 1950s, CPB has steadily improved in terms of survival and reduction in complications such as hemorrhage, stroke, and
kidney injury. CPB techniques are used for temporary or longer-term support, known as extracorporeal membrane
oxygenation (ECMO).
CPB has been designed as an integrated system that provides nutritive solutions with an appropriate hemodynamic driving force
to maintain whole-body homeostasis, protecting the patient from ischemic injury. Over the last three decades options for the use of
CPB for coronary artery revascularization have been developed such as percutaneous interventions (angioplasty and stenting), and
by surgical procedures not utilizing CPB, collectively called off-pump CABG surgery (OPCAB) and procedures using hybrid
miniaturized circuits to support the circulation during grafting.
The benefit of CPB was validated in a randomized clinical trial, the Randomized Off-pump or On BYpass (ROOBY) trial,
involving 2203 elective or urgent coronary artery bypass grafting (CABG) patients randomized to either off- or on-pump surgery is a
testament to the efficacy and safety of CPB as currently practiced. At one year, the on-pump group had significantly better composite
outcomes (death, myocardial infarction, or repeat revascularization) than the off-pump group (9.9% vs. 7.4%; P ¼ 0.04). The
overall rate of graft patency was lower in the off-pump group than in the on-pump group as well (82.6% vs. 87.8%; P < 0.01).
The ROOBY Trial and other trials demonstrated that off-pump CABG yielded no advantage in clinical outcomes and cost over
on-pump CABG (Shroyer et al., 2009). A metaanalysis which included 12 randomized clinical trials reported a 38% increased rate of
early revascularization with off-pump surgery (Takagi et al., 2013). Moller and colleagues published a systematic review including
over 15,000 subjects that reported no clinical benefit in mortality, stroke, or myocardial infarction or increased survival benefit of
OPCAB (Møller et al., 2012).
A cardiovascular perfusionist is a specialized healthcare professional who operates the heart–lung machine during cardiac
surgery and other surgeries that require cardiopulmonary bypass to manage the patient’s circulatory physiology (Fig. 16). After a
patient’s circulation is accessed thru large cannulae (tubing providing connection to the CPB circuit) in the right atrium in the
ascending aorta, the perfusionist, under the direction of the heart surgeon, has the ultimate aim of providing satisfactory gas
exchange and metabolic needs at the cellular level (Galletti and Brecher, 1962). CPB is being used to provide perfusion for about 1.4
million patients each year around the globe. It has become evident that efforts should be directed toward measuring the adequacy of
perfusion at the cellular level and at the end organ level is where we should be focusing our attention as we try to improve patient
support with CPB (Ranucci et al., 2005; Demers et al., 2000; de Somer et al., 2011).
The principal component of the Heart–lung machine includes pumps, reservoirs, tubing, and filters. The CPB circuit consists of a
number of components for gas exchange, temperature regulation, filtration, monitoring, and safety mechanisms. Fig. 17 is a
diagram of the various components of the CPB circuit (Kim et al., 2013).
Blood drains by gravity or with the use of gentle suction into the oxygenators venous reservoir labeled (B). (A) represents the
arterial pump that pumps the blood from the venous reservoir (B) and delivers blood to the membrane oxygenator which is
attached to the lower part of the venous reservoir. Once oxygen, carbon dioxide, and heat exchange have occurred the blood is
directed thru an arterial blood filter (C). A purge line to the upper most part of the filter and serves for the removal any microemboli
that may have been introduced into the blood during its passage through the circuit. The oxygenated blood is introduced back into
the patient’s circulatory system through a cannulae (a large tube connected to the circuit) placed in the ascending aorta. The line
attached to intravenous bags labeled (D) provides a method for priming the CPB circuit with electrolyte fluid or a port for adding
blood during bypass. Four roller pumps labeled (E) in the diagram are auxiliary pumps. The one on the far left is used to pump
cardioplegia solution with a mixture of blood and additives, labeled (H), used to arrest the heart. This solution is cooled with a
separate heat-exchanger labeled (F).

Fig. 16 S-5 Heart-lung machine (LivaNova, Houston, TX). The cardiovascular perfusionist operating the pump is seated at the lower left. With permission from RC
Groom, CCP, Director of Cardiopulmonary Perfusion, Maine Medical Center, Portland Maine, USA.
714 Coronary Artery Bypass Grafting

Fig. 17 Diagram of a cardiopulmonary bypass circuit. (A) Centrifugal pump, (B) reservoir and oxygenator, (C) solution, (E) heart–lung machine, (F) cardioplegia heat
exchanger, (G) manometer for the cardioplegia system, (H) del Nido cardioplegia solution. Reprinted with Permission J Extra Corp Technol 2014 46(4): 317–323.

Pumps

Two principle types of pumps are used to propel blood thru the extracorporeal circuit and into the patient’s circulation, roller
pumps, and centrifugal pumps. These pumps, unlike the heart, provide continuous flow rather than pulsatile flow. Numerous
studies over the past three decades have sought to determine if pulsatile flow improved organ perfusion and patient outcomes;
however, the evidence is inconclusive (Alghamdi and Latter, 2006; Likosky, 2009). Metaanalysis by Nam (Nam et al., 2015) and
Seivert (Sievert and Sistino, 2012) both showed improvements in renal function with pulsatile flow. Sievert further reported that the
studies with Intra Aortic Balloon Pump (IABP) generated pulsatile flow had the best results and also noted significant reduction in
lactate levels in the pulsatile groups. Zangrillo carried out a metaanalysis of preoperative use of IABP in 625 high-risk CABG patients
and reported a significant reduction in 30-day mortality (risk ratio 0.38 p for effect 0.004) (Zangrillo et al., 2015). More recently Lim
and colleagues undertook a metaanalysis to look at pulmonary function with pulsatile perfusion and found a significant
improvement in pulmonary function and ICU length of stay (Lim et al., 2015). Clearly pulsatile flow is an area ripe for future
study. Although the two types of pumps available for arterial blood pumping, the centrifugal pump and roller pump, are capable of
producing pulsatile flow, at this juncture pulsatile flow is not commonly utilized.
The dual roller pump is the most common type of pump used for cardiopulmonary bypass. It operates by occluding tubing
between a stationary raceway and rotating rollers (Fig. 18). The pumping mechanism is referred to as the “pump head,” and the
tubing that traverses the raceway is referred to as the “pump header.” Roller pumps were first proposed for use in cardiovascular
medicine in the 1930s by Gibbon (Gibbon, 1937). The mechanism for flow with the roller pump is the displacement of fluid, in a
progressive fashion, from suction to discharge, with the capacity of the displacement dependent both on the volume of the tubing
occluded by the rollers and on the number of revolutions per minute (rpm) of the roller. The volume displaced per revolution is
multiple times the revolutions/minute to calculate the estimated blood flow. This is displayed on a digital readout and is referred to
as the output (flow) of the pump. It is measured in liters per minute (Fig. 19).
Another common pump used for arterial blood flow is the centrifugal pump (Figs. 20 and 21). Although nearly all of the
randomized trials show significant benefit to systems designed with centrifugal pumps, it is difficult to separate the improved
performance conferred from other characteristics, such as lower prime volume, surface coating, more limited surface area, and
reduced air-to-blood contact. A metaanalysis that included 18 randomized, controlled trials comparing centrifugal and roller
pumps in adult cardiac surgery suggests no significant difference for hematological variables, postoperative blood loss, transfusions,
neurological outcomes, or mortality (Saczkowski et al., 2012).
Centrifugal pumps produce less blood damage; however, this improvement appears to be inconsequential. Nevertheless,
recently published Guidelines on Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery, endorsed by the
Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists state that, “It is not unreasonable to select a
 Coronary Artery Bypass Grafting 715

Fig. 18 Twin (dual) roller pump. Occlusiveness of the pump is adjusted by the thumb adjustment knob at the center of the roller assembly. Roller guides hold the
tubing in place in the pump race way. With permission from RC Groom, MS, CCP.

Fig. 19 Roller Pump control module displays flow (3.04 l/min) and Revolutions/Minute (117 RPM). With permission from RC Groom, MS, CCP.

Fig. 20 Disposable component for a centrifugal pump (Revolution by LivaNova, Houston, TX). A magnetic internal rotor is coupled to a motor that rotates the rotor
creating centrifugal force that propels the blood though the outlet of the disposable centrifugal head. With permission from RC Groom, MS, CCP.
716 Coronary Artery Bypass Grafting

Fig. 21 Centrifugal disposable head magnetically coupled to a motor to produce fluid flow. With permission from RC Groom, MS, CCP.

Fig. 22 Terumo FX Oxygenator Hollow fiber oxygenator. Exploded view shows hollow fibers where gas flows through the fiber and blood flows around the fiber.
Gas transfer occurs across the semipermeable hollow fiber membrane surface. The FX model has an integrated 32 mm filtration surface encapsulated into the
oxygenator. Reprinted with Permission Terumo Cardiovascular Inc. Ann Arbor, MI.

centrifugal pump rather than a roller but more so for safety reasons rather than blood conservation” (American Heart Association/
American College of Cardiology Class IIb level of evidence B) (Society of Thoracic Surgeons Blood Conservation Guideline Task
Force, 2011).

Oxygenators

Membrane oxygenators operate by diffusion of oxygen and carbon dioxide across a microporous hollow fiber bundle. The gas
exchange occurs by diffusion of the gases across microporous fiber surface, oxygen moving from the interior of the hollow fiber into
the blood and carbon dioxide diffusing from the blood cross into the interior of the fiber and swept away by the regulated gas flow
through the hollow fiber. Blood oxygenators have integrated heat exchangers that allow the circulating blood to be cooled or
warmed. The heat exchangers are comprised of stainless steel or polypropylene tubes that are not permeable. Water from a regulated
water supply flows through the fibers and heat is transferred from the blood flowing around the tubes into the circulating water.
While there have been major improvements in the materials and surfaces that the blood is exposed to in the extracorporeal circuit,
there remains hematological changes including the liberation of inflammatory mediators (Hammerschmidt et al., 1981; Cheno-
weth et al., 1981). Platelets and leukocytes that elicit a complex series of inflammatory and hemostatic reactions that ultimately
increase the risk for postoperative complications are activated.
The oxygenator (Fig. 22) represents the largest source of nonendothelialized surface area in the extracorporeal circuit, ranging in
size between 0.5 and 2.5 square meters. Other issues identified include the occurrence of gaseous microemboli during cardiac
 Coronary Artery Bypass Grafting 717

surgery with CPB (Dickinson et al., 2006; Likosky et al., 2009) that have been managed with in-line filters. These arterial line filters
significantly reduce the load of gaseous and particulate emboli. A dose–response relation between these emboli and subtle
neurologic injury has been reported, and some studies have demonstrated a protective effect of arterial line filtration on neurologic
outcomes. The use of a leukocyte-depleting arterial line filter has been shown to reduce cerebral embolic count and demonstrated a
trend toward improved postoperative psychometric test scores and should be used in CPB circuits. Transfer of volatile (inhalational)
anesthetic agents does not readily cross this membrane. The inhaled anesthetic during the course of CPB is delivered via the
membrane oxygenator, rather than the patient’s lungs that are not ventilated during the procedure. Noninhalational agents such as
narcotics adequately supplement the inhaled anesthetic during the conduct of the operation.
While many advances in CPB have been realized since the first successful procedure in 1953, there remains a vast areas of
research opportunities related to cardiopulmonary bypass including: (1) issues related to material–blood interaction specifically
inflammation and coagulation-related issues; (2) patient and organ system responses to cardiopulmonary bypass; (3) the use of
hypothermia, brain and myocardial protection; and (4) improving safety.

CABG Technique

As previously mentioned, the fundamental technique for performing CABG surgery was developed by peripheral vascular surgeons
who had developed procedures to replace or bypass vessels peripheral to the heart and great vessels. In particular, the ability to
bypass lower extremity vessels was developed using the greater saphenous vein. The venous component of the circulatory system is a
low-pressure system, while the arterial part of the circuit is pressurized by the contractions of the left side of the cardiac pump. The
venous circuit is necessary for the return of blood to the heart without a pump to pressurize it. Venous return to the heart relies on
other mechanisms for propulsion such as gravity, in the case of the head, and external muscle pumping, redundancy and valves, in
the case of the lower extremities. As seen in the illustration showing the deep and superficial venous circulation, the huge capacity of
the venous system allows for the return of as much blood each minute as is being pumped out, roughly five liters per minute. This
“forward flow,” under normal conditions, allows for adequate oxygen delivery and nutrients to end organs and other tissues.
The large capacity of the venous compartment creates redundancy allowing the reconstructive vascular and cardiac surgeons to
relocate some of these veins, the greater saphenous vein being a good example as a conduit for restoring blood flow to both the
heart the periphery such as the legs. While it was not designed to function as an artery, the saphenous vein, when reversed because of
its valves, provides a useful and readily available conduit for the surgeon. It is the right size, handles easily, and has no issues
regarding rejection or foreign body reaction, as it is the patient’s own tissue. Thus, with the advent of CABG surgery, the reversed
saphenous vein graft became the workhorse conduit of choice for the cardiac surgeon and has remained so after nearly 50 years. As it
is designed to work in a low-pressure system, graft patency and longevity is not ideal in this vein graft that was not originally
designed to function under such high internal pressures. Early in the experience of CABG surgery, it became apparent that the
internal mammary artery (LIMA) was a superior alternative. The LIMA became the favored choice for grafting the left anterior
descending coronary artery (Fig. 23)

Saphenous Vein Graft: Its Position as Conduit of Choice in CABG Surgery

During the early period of CABG surgery in the United States, the saphenous vein graft was the conduit of choice for coronary bypass
surgery. It soon became apparent that the saphenous vein graft was prone to progressive disease and eventual failure as illustrated
earlier. During the early experience with myocardial revascularization, no interventional techniques, such as balloon angioplasty,
were available to rescue a diseased graft territory, thus patients with early vein graft failure were at risk for a repeat CABG operation if
medical management was not successful. In an attempt to alleviate vein graft-related problems, cardiac surgeons adopted and
popularized the use of the left internal mammary artery (LIMA) with anastomosis to the left anterior descending coronary
artery (LAD).
Use of the LIMA remained a relatively controversial technique until the surgeons from Cleveland clinic (Loop et al., 1986; Loop,
1996; Cameron et al., 1996; Burfeind et al., 2004) and others published papers establishing the evidence that the LIMA was superior
to the saphenous vein graft when used in the LAD position in both freedom from recurrence of angina, myocardial infarction, and
death. In spite of these landmark papers, universal application was slow. By the early 2000s, the STS data showed still only 90% of
cases being done in the country were utilizing a LIMA. In the 1980s and 1990s, studies of the use of bilateral IMAs showed decreased
need for reoperation and improvements in survival. Currently, the use of the LIMA is now nearly universal with CABG surgery, while
utilization of bilateral IMAs has not been as widely adopted (Puskas et al., 2014; Lytle, 2001, 2013; Buxton et al., 2014; Taggart et al.,
2016; Lytle et al., 1985).

The Saphenous Vein Graft: An Imperfect Yet Remarkable Conduit

Though the use of the saphenous vein as a conduit has been shown to be inferior to the left internal mammary artery (Lytle et al.,
1985; Loop et al., 1986; Sabik et al., 2003, 2005) it remains a central part of the surgeons assortment of conduit choices in the
718 Coronary Artery Bypass Grafting

Fig. 23 A depiction of a left internal mammary (LIMA) graft to the left anterior descending coronary artery and saphenous vein grafts to the left marginal and right
coronary arteries. From: N Engl J Med 2016;374:1955.

performance of modern CABG surgery. In fact, it remains the most commonly utilized conduit by surgeons today (Alexander and
Smith, 2016). By the early 1970s, vein graft failure was already well recognized and a pathophysiologic process involving the intima
was being described. Endothelial injury that occurs during vein graft harvest followed by and/or additionally caused by exposure of
the vein graft to arterial pressure has been associated with platelet deposition, subsequent intimal hyperplasia, atherosclerotic
plaque formation, and eventual stenosis and closure. A series of studies over the past 40 years have proven the benefit of antiplatelet
therapy with low to intermediate dose aspirin as well as high-intensity statin therapy for lipid management in the interruption of
this pathophysiologic process and improvement in vein graft patency. Unfortunately, studies of agents that directly interrupt intimal
hyperplasia at the DNA level such as Edifoligide in the PREVENT IV study (2002–03) have not been as successful (Lopes
et al., 2012a).
Despite these adverse findings, there are a number of the greater saphenous vein characteristics that make it such a good conduit
and help to explain its continued status as workhorse in CABG surgery. These include its length, ease of use, ease of harvest,
reasonably matched size in comparison to the targeted coronary artery, immediate capacity for high flow to the target vessel,
capacity for sequential grafting, and suitability to the construction of a proximal anastomosis to the ascending aorta. During the
early experience with CABG surgery, vein harvesting was universally carried out with either a full open technique or via a series of
skip incisions. Dissatisfaction with the rate of wound complications/infections, delayed healing, pain, and cosmetics (appearance)
along with advances in minimally invasive surgery led to the development of endoscopic vein harvesting (EVH) techniques by the
mid to late 1990s.
Initially, EVH was criticized for a number of drawbacks including increased time of harvest, increased risk of conduit injury,
increased potential for retained clot in the harvested vein, increased risk of vein stenosis or graft occlusion, risk of CO2 (carbon
dioxide) embolism, and operator dependence for graft quality. Several prospective studies carried out from 2000 to 2009 produced
conflicting results regarding noninferiority of the endoscopically harvested vein graft. Other studies during this era revealed that the
clot formation associated with EVH is most likely a result of combined local trauma and stagnant blood (Lopes et al., 2009, 2012b;
Poston, 2006; Dacey et al., 2009, 2011). As a result of continued technological advances in operative equipment, increased surgical
 Coronary Artery Bypass Grafting 719

experience, earlier intraoperative use of heparin, and associated improvement in the quality of harvested veins, EVH has become the
preferred method of greater saphenous vein procurement over the past 10 years (Raja and Sarang, 2013).
During preoperative planning, the surgeon determines the use of conduits based on the number, size, and location of diseased
the coronaries. Generally speaking, the LIMA will be placed to the LAD. Based on patient comorbidities, severity of coronary
obstruction, acuity/severity of patient illness, and presence of adequate ulnar collateral flow, the surgeon will determine the
appropriateness of the use of secondary arterial grafts such as the RIMA as a pedicled (attached to its native source) or free graft,
and the left/right radial artery. If appropriate for a particular case, those conduits will be placed to the second or third tier target
vessels. Severity of stenosis of the native coronary has been associated with superior saphenous vein graft longevity over arterial
conduit choices due to the negative effects of competitive flow. In the case of the RIMA, SVG is superior when grafted to the distal
right coronary artery when the stenosis is less than 80–90% because of size compatibility and consequent flow characteristics.
Likewise, if the native stenosis is less than 70 or 80%, saphenous vein graft patency is superior to radial artery grafts (Yie, 2008;
Taggart, 2013; Athanasiou et al., 2011; Deb, 2012; Sabik, 2008). The practical result of such operative planning is that the distal
coronaries that are not going to be grafted by arterial conduits will need to be grafted with saphenous vein.

The Internal Mammary Artery: The Physiology of Arterial Grafting

The internal mammary artery grafted to the left anterior descending coronary artery is a major quality indicator in CABG surgery and
gives superior short- and long-term outcomes when compared with saphenous vein grafts (Hillis et al., 2011). Linguistically, the
Latin root of the word mammary is “mamma” or breast. Further underscoring the physiologic importance of the breast is the use of
the same root in Taxonomy, or the scientific classification of organisms. In this classification system, Mammals represent a major
Class within the Animal Kingdom. As the name of this Class implies, its members share a critical survival advantage: The ability to
sustain their offspring by providing nutrition in the form of milk from maternal mammary glands. Though the title “internal
thoracic artery” is admittedly more anatomically accurate, it can give the impression that the artery has the functional importance of
a redundant tributary vein from the superficial venous system of the leg or of a vestigial structure such as the appendix
(Conti, 1991).
The title “internal mammary artery” reinforces the concept that this artery serves as a critical support element of Mammalian
breast systems and by extension, species survival. Moreover, given the importance of this vascular structure in supporting the level of
lactation required for the continuing generation of mammalian species, it is not surprising to find that internal mammary arteries
have some unique characteristics when compared with other arteries in the body. From studies of human physiology, we know that
a nursing human mother forms about a liter and half of milk per day (Hall, 2016.). In order to support this rate of production, the
cardiovascular system provides arterial support to each breast from two main arteries: the internal mammary and the lateral thoracic
arteries. A recent study of the blood flow to the lactating human breast revealed that an average of 126 L of blood was supplied to
each breast over a 24-h period with 70% of that flow being derived from the left internal mammary artery the artery often destined
to revascularize the heart (Geddes et al., 2012). In pregnancy, such flow augmentation can present as a continuous murmur over the
front of the chest called the “mammary souffle of pregnancy” (Scott and Murphy, 1958). The capacity of the internal mammary
arteries to increase blood flow in response to end organ demand during the pregnant/lactating state has proven to be an excellent
conduit characteristic when providing blood flow to an ischemic myocardial zone.
In addition to the ability to increase blood flow, studies have shown that IMAs have specific anatomic and physiologic properties
that account for their superiority when used as a coronary bypass graft. These arteries have been shown to be impervious to the
transfer of lipoproteins. This characteristic seems consistent with its primary support role as a conduit for optimal oxygen and
nutrient delivery, especially lipoproteins, to the lactating breast for production of calorie dense milk and is also likely associated
with its remarkable resistance to the development of atherosclerosis. Anatomically, this resistance to the transfer of lipoproteins may
be related to an endothelial layer containing fewer fenestrations and lower intercellular junction permeability. Physiologically, IMA
endothelial cells (the cells that line the blood vessels) have continuing high levels of heparan sulfate, tissue plasminogen activator (a
protein involved in the breakdown of blood clots), and endogenous nitric oxide (a vasodilator) production (Osuka, 2013).
The internal mammary artery (IMA) graft’s superior long-term patency could also be partly attributed to the fact that the
endothelium of the IMA graft can release prostacyclin. Prostacyclin (also called prostaglandin I2 or PGI2) is a potent vasodilator that
can also inhibit platelet aggregation. Lin et al (Lin et al., 1991). demonstrated that endothelium of IMA grafts could release
prostacyclin either in a basal condition or upon stimulation of hypoxia. Subramian et al (Subramanian et al., 1986). found in vitro
that segments of the mammary artery (IMA) had a high capacity for PGI2 synthesis and diminished inhibition of PGI2 after aspirin
was demonstrated for IMA compared with saphenous vein tissue and may be a factor in the improved patency of IMA grafts.
Homolay (Homolay et al., 1993) studied the prostacyclin-producing capacity of the IMA using a platelet aggregation bioassay.
He concluded that the synthesis of prostacyclin was significantly higher in the internal mammary artery than that was in the
saphenous vein.
Many of the factors that contribute to the long-term patency of the LIMA graft are summarized in Fig. 24 (Bruce Ferguson, 2016).
The proinflammatory environment of the diseased heart is “normalized” as the graft stays open for many years by virtue of its
endothelial production of endogenous vasodilators (nitric oxide), prostacyclin (PGI2), along with the production of epoxyeicosa-
trienoic acids (EET). EETs are cardioprotective signaling molecules formed within various types of cells by the metabolism of
arachidonic acid.
720 Coronary Artery Bypass Grafting

Fig. 24 In a healthy heart, arteriolar endothelium produces NO (nitric oxide), prostacyclin (PGI2, and EETs) as well as low levels of hydrogen peroxide, which
support a quiescent nonproliferative state. With the onset of disease (A), flow through the microvasculature releases hydrogen peroxide, creating a proinflammatory
environment throughout the organ, potentially leading to hypertrophy, fibrosis, and atherosclerosis. In (B), with bypass grafting of ischemic myocardium, the
microvascular health of the myocardium is “normalized.” NO, nitric oxide; PGI2, prostacyclin; EET, epoxyeicosatrienoic acids. From: World J Cardiol 2016; 8(11):
623–637.

Fig. 25 Histologic changes observed in the internal mammary artery (IMA) graft as compared to the saphenous vein graft (SVG). (A, B). Histologic sections showing
IMA and SVG obtained from a 76-year-old man who underwent coronary artery bypass graft (CABG) surgery 2 years antemortem. IMA shows no or rare intimal
smooth muscle cells (SMCs), whereas SVG exhibits moderate neointimal growth with few SMCs but rich in matrix which consists of proteoglycans and collagen.
(C, D). Histologic sections showing IMA and SVG obtained from a 69-year-old man who underwent CABG surgery 6 years antemortem. Note the absence of
intimal thickening in IMA. (C) versus the presence of moderate neointimal thickening in SVG from SMCs and proteoglycan-collagenous matrix at the site
of anastomosis (arrow heads indicate suture sites) with left anterior descending artery (LAD) or left circum ex artery (LCX) (D). (E, F) IMA graft and SVG from a
77-year-old woman who underwent CABG surgery 12 years antemortem. While the IMA shows minimal intimal thickening, SVG exhibits moderate to severe
neointimal growth with proteoglycan–collagen matrix and angiogenesis (arrows). All sections were stained with Movat pentachrome. Illustration From: Osuka, F.
(2013). Why as the mammary artery so special and what protects it from atherosclerosis? Annals Cardiothoracic Surgery 2 (4), 519–526.

The combination of these attributes along with an ideal size match to target coronary arteries and associated decrease in
turbulent flow helps to account for the superior performance of the IMA as a bypass graft relative to the saphenous vein graft as
illustrated in Fig. 25.

The Radial Artery

The utilization of a radial artery free graft was first described by Dr. Alain Carpentier, in Paris, France, one of the pioneers of modern
cardiac surgery (Carpentier et al., 1973). After initial intense interest, reports of radial artery graft failures with profound narrowing
 Coronary Artery Bypass Grafting 721

Fig. 26 The radial artery (RA), harvested as a pedicle, is dissected through a skin incision starting 3 cm distal to the elbow crease lateral to the biceps tendon,
stopping 1 cm before the proximal crease at the wrist level, centered over the radial pulsation, between the flexor carpi radialis and the radial tubercle. Care is taken
to avoid damaging the lateral antebrachial cutaneous nerve (sensory), which crosses obliquely from medial to lateral. After incision of the skin and fatty tissue, the RA
can be seen in the distal third of the forearm beneath the fascial layer and is completely exposed by lateral mobilization of the brachioradialis. All side branches are
ligated and the artery is irrigated topically with dilute papaverine solution during the dissection. Compared with the LIMA, the RA has a much thicker muscular media
that likely contributes to its increased propensity to go into spasm. The RA may be proximally anastomosed to the LIMA, forming a composite graft, or to the
ascending aorta to bypass all coronary territories. Illustrated is the use of a free RA graft anastomosed proximally to the ascending aorta to bypass a lesion in the
right coronary artery, the LIMA anastomosed to the LAD, and a saphenous vein graft to the first obtuse marginal branch (OM). From: Verma et al Circulation.
2004;110:e40–e46.

of the graft (so-called angiographic string sign) discouraged utilization of the radial artery for CABG surgery. However, long-term
follow-up of these arteries revealed that vessels that had at one point shown a string sign showed with reassessment progression to
be widely patent (Verma et al., 2004). As arterial spasm might be a contributing factor, the use of the radial artery was resurrected
along with intraoperative and postoperative vasodilator therapy to decrease vasospasm in the vessel. As long-term vasodilator
therapy could result in atrophy of the muscular component of the radial artery, the vasodilators are given for a limited amount of
time (Verma et al., 2004). Fig. 26 depicts the harvesting and use of the radial artery.
In some centers, all arterial grafting has become the ideal operation, while others have not adopted that philosophy. In fact, most
patients do not receive all arterial grafts as most surgeons have not adopted all arterial grafting as a primary myocardial
revascularization strategy. These competing philosophies reflect one of the current major controversies in surgical myocardial
revascularization.

Conduct of the CABG Operation

Shortly after induction of general anesthesia, the greater saphenous veins are assessed and proposed incision sites are marked in the
leg(s). Ultrasound can be used to augment physical exam information and accurately predict sites of branching, varicosity, and
duplication. The patient is then “prepped” with a topical antiseptic from the chin down to the level of both ankles and then covered
with sterile drapes, leaving only the surgical incision sites exposed. A longitudinal midline sternotomy is made, aided by a surgical
saw, cutting in the midline of the sternum, allowing for a precise closure, securely repairing the bone and the rest of the wound at the
close of the procedure (Fig. 27). The midline has no muscle to cut through and at the completion of the procedure the sternum is
repaired with sternal wires or other methods of firm secure closure, allowing the bone to heal much like any other orthopedic repair
of bone with various types of hardware. The discomfort during healing is well tolerated in general and affords the patient less pain
than other major incisions such as thoracotomies (between the ribs) or laparotomies (large abdominal incisions)
722 Coronary Artery Bypass Grafting

Fig. 27 The sternotomy incision that is typically used in CABG surgery and other types of cardiac surgery. From www.surgery.usc.edu. IAC Publishing, LLC (“Ask”)
provides the Ask.com site (the “Site”) and the offered services and features (the “Services”) subject to these Terms of Service (“Terms of Service”).

Conduct of the CABG Operation

Shortly after induction of general anesthesia, the greater saphenous veins are assessed and proposed incision sites are marked in the
leg(s). Ultrasound can be used to augment physical exam information and accurately predict sites of branching, varicosity, and
duplication. The patient is then “prepped” with a topical antiseptic from the chin down to the level of both ankles and then covered
with sterile drapes, leaving only the surgical incision sites exposed. A longitudinal midline sternotomy is made, aided by a surgical
saw, cutting in the midline of the sternum, allowing for a precise closure, securely repairing the bone and the rest of the wound at the
close of the procedure (Fig. 27). The midline has no muscle to cut through and at the completion of the procedure the sternum is
repaired with sternal wires or other methods of firm secure closure, allowing the bone to heal much like any other orthopedic repair
of bone with various types of hardware. The discomfort during healing is well tolerated in general and affords the patient less pain
than other major incisions such as thoracotomies (between the ribs) or laparotomies (large abdominal incisions).
Once the sternum is opened, the mammary artery is harvested after which the sternum is separated with a sternal retractor
(Fig. 28), and the pericardium (sac around the heart) is exposed and divided. At this time the heart is exposed with all of its
structures, epicardial vessels, and the large veins leading to and great arteries exiting the pumping chambers.
If a radial artery is going to be harvested, the anesthesia team will start either a low dose of intravenous nitroglycerin or a calcium-
channel blocker to inhibit potential vessel spasm. The entire operation is performed under conditions of ideal illumination such as
an intense headlight, and magnification (surgical loupes that magnify 2.5 to 3.5 times). While the left internal mammary artery
(LIMA), right internal artery (RIMA), or both and/or radial arteries are being harvested, a small incision is made over the greater
saphenous vein either above or below the knee and eventually exposing the vein. Once the vein has been identified, the patient is
given a low dose of intravenous heparin. Endoscopic vein harvesting (EVH) equipment is then deployed to bluntly dissect out the
vein creating a carbon dioxide (CO2) insufflated tunnel that allows for a minimal touch technique, safe branch management, and
tunnel hemostasis (control of bleeding) (Fig. 29) (Accord and Maessen, 2011).
The near and far ends of the vein are accessed via additional small incisions and the vein is ultimately removed from the leg. It is
then reversed (as it has one-way valves) and flushed with a solution of heparin and saline in order to remove clots and to identify
branches, varicosities, defects, or injuries. If the vein is not felt to be adequate, remaining vein on the same leg the other leg is then
harvested. In general, branches are clipped or tied at the level of the vein though some surgeons prefer to preserve 2–3 mm of the
length on the larger branches for potential use when performing sequential distal anastomoses, allowing more than one coronary
artery to be grafted with one section of saphenous vein. Once the vein has been attended to, the leg wounds are inspected for
hemostasis, irrigated, and carefully closed in layers. If an inadequate length of vein conduit is available, then a backup plan for
harvesting the RIMA or radial arteries is activated. Alternatively, though not ideal, short segments of usable vein from each leg can be
sewn together end-to-end in order to create a composite graft of adequate length. A prognostic saphenous vein scoring system that
also takes into account the runoff status (size and quality with regard to the amount of atherosclerosis) of the target coronary artery
has been described (Sarzaeem et al., 2010). In circumstances in which a compromised vein conduit has to be used in CABG, and/or
 Coronary Artery Bypass Grafting 723

Fig. 28 The sternotomy has been performed and a sternal retractor has been inserted and spread to expose the pericardium with the dotted lines depicting the
planned typical pericardial incisions that will expose the heart. From ht.edwards.com. IAC Publishing, LLC (“Ask”) provides the Ask.com site (the “Site”) and the
offered services and features (the “Services”) subject to these Terms of Service (“Terms of Service”).

Fig. 29 Endoscopic vein harvesting. (A) The first step is the identification of the great saphenous vein (GSV) through a 3-cm incision near the knee. (B) The next
step is the dissection of the vein from the surrounding subcutaneous tissue. (C) After creating a tunnel by means of CO2 insufflation, all side branches of the GSV are
identified, coagulated using diathermy, and transected. (D) The final result is demonstrated, 35 cm of vein harvested through a 3-cm incision near the knee and a
3-mm counter-incision in the groin (arrow). From: https://www.hindawi.com/journals/crp/2011/813512.fig.001a.jpg Copyright © 2011 Ryan Accord and Jos
Maessen. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly cited.

the runoff is not ideal, antiplatelet therapy (medications such as aspirin or clopidogrel that decrease platelet aggregation or
“stickiness” to discourage the initiation on intraarterial clotting) is reasonable and evidence-based (Une et al., 2014).
A crucial aspect of long-term management of this newly create anatomy is termed “secondary prevention.” All of the efforts to
revascularize coronary arteries do not cure coronary artery disease, and a comprehensive postsurgical management program must be
instituted that includes high-intensity statins, antiplatelet medications such as low-dose aspirin, beta blockers, aldosterone
antagonists (if heart failure or left ventricular systolic dysfunction), angiotensin receptor blockers (if diabetes or left ventricular
systolic s dysfunction), and lifestyle changes that include regular aerobic exercise, a diet low in saturated fats and carbohydrates and
abstention from smoking (Kulik et al., 2015; Fihn et al., 2014).
Once all conduits are prepared and the patient is systemically heparinized, the heart and ascending aorta are inspected. Distal
coronary artery targets are confirmed and grafting sites can be marked. Once grafting sites are determined, the length of conduit that
will be required to reach the aorta is determined as well as the distance between any sequential anastomoses (the practice of using
one conduit for multiple distal connections). Once it is confirmed that adequate conduit is available, the surgeon may use natural
branches that may be available for sequential grafting or can fashion an arterial “Y” configured graft with a combination of arterial
724 Coronary Artery Bypass Grafting

or venous conduits. If there are any concerns about quantity or quality of the graft material, the surgical assistant can harvest more
saphenous vein as the surgeon initiates bypass and begins to perform distal anastomosis with conduit that has been deemed
adequate at this point in the procedure.

CABG Using Cardiopulmonary Bypass

If the CABG is going to be performed with CPB support and cardioplegic arrest as described in the section on CPB, aortic and right
atrial cannulation sutures are placed, after which aortic and right atrial cannulae are inserted and secured. A retrograde cardioplegia
cannula is inserted into the coronary sinus and an antegrade cannula is placed in the ascending aorta. Appropriate connections are
made with the tubing from the CPB and the patient is then placed “on bypass” and usually cooled (actively or passively) using
systemic hypothermia (cooling the entire body) while cardioplegia is being prepared. The distal ascending aorta is cross-clamped
between the aortic cannula and the antegrade cardioplegia line and induction antegrade/retrograde cardioplegia is delivered
(Fig. 30). Depending on surgeon preference, the metabolic rate of the myocardium can be further reduced with topically with
chilled saline or ice slush.
Once cardioplegia has been delivered, the heart is ready for grafting. With the heart now flaccid and cooled on CPB, each distal
coronary artery or branches thereof (targets) is adequately exposed, the visceral pericardium covering each vessel is dissected away,
and the vessel is opened. A bloodless, still, clear sewing field has been created, and the surgeon is now ready to sew the conduit to
the coronary artery at a point beyond the stenosis (narrowing) or obstruction. The appropriate conduit (vein or artery) is now
tailored to fit the opening in the recipient artery as sutured with a very fine monofilament suture using fine microvascular
instruments and intense lighting (headlight) and magnification (surgical loupes). Prior to completion, adequate patency is
confirmed, the conduit is deaired and tested for leaks which are repaired if present. More cardioplegia is now given, and this
cycle is repeated until each distal anastomosis is completed.
Rewarming of the patient is initiated using the heat exchanger on the CPB machine prior to the performance of the final
anastomosis and preparations are made for construction of the proximal anastomoses. Once all of the anastomoses have been
completed and with the aortic cross clamp having been removed, the heart begins to warm and regain its usual metabolism and
electromechanical properties. Once the patient is adequately rewarmed and the heart is recovered, the patient is weaned from CPB
with varying levels of inotropic/pressor support, decannulated, and the surgical wound closed. At this time, the team is dealing with
other details of weaning from CPB, primarily hemodynamic support, fluid, and electrolyte balance and management of coagulation
abnormalities when they arise. Graft flows are checked with flow probes for adequacy with Doppler flow signals, the most
commonly used being transit-time flow meters.

Fig. 30 This illustration depicts the heart with both antegrade (aortic) and retrograde (coronary sinus) catheters placed in the heart and ready to be attached to the
CPB circuit for administration of cardioplegia. From: criticalunit.com critical-care-medicine.becoming a better Clinician.
 Coronary Artery Bypass Grafting 725

CABG Without Cardiopulmonary Bypass: Off-Pump CABG (OPCAB)

If the operation is going to be performed off-pump, the room is kept warm and intravenous amiodarone (an antiarrhythmic) and
low-dose norepinephrine infusions are initiated. Temporary pacemaker wires are placed and tested. All of these measures are taken
in order to be prepared for rhythm and hemodynamic abnormalities that must be managed in the course of the operation as the
surgeon does not have the advantage of the mechanical support of CPB. Exposure and stabilizing devices are now deployed to
optimize exposure on a beating heart with blood continuing to flow in all of its vessels as opposed to the still, bloodless field
afforded by the use of CPB, and cardioplegic arrest. Exposure is gained with a combination of deep pericardial retraction sutures, an
apical suction universal retractor and judicious use of surgical pads. Communication between the anesthesiologist and the surgeon
regarding hemodynamic stability is a top priority to maintain safe conduct of the operation. The role of the cardiac anesthesiologist
is demanding and includes constant hemodynamic monitoring, transesophageal echocardiographic (TEE) assessment for ischemia,
and quick responses for maintenance of blood pressure and cardiac output and allows the surgeon to safely perform the distal
anastomoses. Once the target artery is exposed, it is immobilized with a stabilizing device(s), the visceral pericardium is dissected
away, and preparations are made to perform the distal anastomosis. Control of blood flow at the site of the intended anastomosis is
afforded by a proximal occlusion method. When the artery is opened, a clear anastomotic site is gained by a combination judicious
use of a device that blows CO2 in a gentle mist. In circumstances where hemodynamic stability is difficult to maintain because of
ischemia, an intracoronary shunt can be placed into the anastomosis to provide a blood free zone. Construction of the anastomosis
is the same as described in the on-pump CABG section. Once the anastomosis is completed, the conduit is flushed and the proximal
occlusion technique is released to ensure deairing and the suture line is tied down. This cycle is completed until all distal
anastomoses are performed.
The proximal anastomoses can be performed on the unclamped aorta with a device such as the Heartstring (Fig. 31) or with the
aid of a partial occlusion clamp. Bypass grafts can now be tested with a transit time flow probe (Doppler technology), and once
grafts are determined to be acceptable, protamine can be administered to reverse the effects of heparin, and the chest closed.
When surgeons are confronted with ischemic coronary beds that are not amenable to CABG due to poor distal targets, hybrid
techniques of managing those ischemic zones are available (Gosev and Leacche, 2014). For example, if numerous small branches
that arise from a larger artery that is amenable to more proximal percutaneous intervention populate the ischemic zone, then a
multidisciplinary approach of traditional CABG and PCI with a drug eluting stent can be performed simultaneously in a hybrid
operating room or as separate procedures utilizing both an OR and a cardiac catheterization laboratory.
When an ischemic zone has targets that are not amenable to either CABG or PCI, then transmyocardial laser revascularization
(TMR) can be utilized as an adjunct to CABG (Horvath, 2008; Bhimji and Sheridan, 2015). This technique utilizes a carbon dioxide
or YAG laser to create multiple full-thickness channels in an ischemic zone that cannot otherwise be revascularized. Though it was
initially hypothesized that the laser-created channels would develop into sinusoidal-type structures with direct perfusion of the
myocardium from the left ventricle, this has never been found to occur. The relief of angina may be due to an augmented
development of collaterals or to a local sympathectomy of the treated visceral epicardium and myocardium. The Society of Thoracic
Surgery recommendation is that such an approach is reasonable; however, further investigation is needed as several studies to date
have returned conflicting angina benefit and survival results (Bridges et al., 2004; Allen, 2000).

Fig. 31 The HeartstringW is an example of a novel device that allows the surgeon to sew a graft onto a hole created in the aorta for that purpose without having to
clamp or manipulate the aorta in a cast of beating heart surgery (OPCAB) or when the aorta is so diseased that minimal aortic manipulation is desired to minimize the
stroke risk from dislodging particulate matter from the aorta that could embolize (move from one place to another in the circulation). From: Boston Scientific
Corporation.
726 Coronary Artery Bypass Grafting

Controversy exists with regard to many aspects of the practice of medicine and surgery and the ideal technique for the
performance of CABG surgery is no exception, subject to conflicting evidence, longstanding practices, and beliefs. While different
practices have varying outcomes in different sets of hands, the evidence and the science behind it seem to be sending a message with
a common theme: With some exceptions, an all-arterial operation done on CPB is likely to achieve the best short- and long-term
outcomes (Puskas et al., 2014; Lytle, 2001; Buxton et al., 2014).

Perioperative Management, Complications

CABG surgery as described is performed in cardiac surgery centers with experienced teams and access to all of the supporting
multidisciplinary specialties to guide the patient safely through a defined pathway that is well described, frequently assessed, and
provides as much reliability as possible while reducing variability. Decision-making in this context is based upon checklists and
algorithms that are agreed upon by the team based on current evidence. Once the patient is referred to the system and placed on the
pathway, defined processes are initiated starting with a readiness for surgery checklist that includes everything from demographics,
socioeconomic factors, comorbidities, and evidence-based indications. Thinking as far ahead of postacute care considerations is
done at this point, especially with so-called complex discharges that may require skilled nursing facilities or rehabilitation. All
decisions cannot be based on checklists and algorithms alone and require more complex thinking, many times aided by the
multidisciplinary team, especially in the selection process. Checklists and algorithms help to drive preoperative orders that include
diagnostic tests such as laboratory studies and imaging. The results of those tests continue to be fed back into the decision-making
process. The involvement of family and patient is crucial in the informed consent as they develop an understanding of expectations
as best they can.
The care team is extensive, requiring the involvement of specialty nurses, outpatient and inpatient, advance practice providers
(nurse practitioners and physician assistants), physicians in training (residents), respiratory therapists, cardiopulmonary perfusion-
ists, physical and occupational therapists, pharmacists, registered dieticians, critical care specialists (surgeons and anesthesiologists),
care managers, and an extensive administrative support team usually in the context of a tertiary care hospital.
The CABG operation may take up to 4 or 5 h, including 1–2 h of CPB time and 5 or 6 days in the hospital before discharge to a
postacute care facility of home. Full recovery in an uncomplicated case can take up to 12 weeks. All of this timing is dependent on
whether there are complications or not. Nearly every feature of the process is carefully documented during the patients hospital-
ization in the electronic medical record and subsequently entered into an extensive database that is submitted to regional and
national databases allowing centers to see their teams’ performance compared with centers like theirs. Surgical site infections,
strokes, and mortality are key markers as well as each center’s ability to rescue patients from multiple other complications that
may arise.
In summary, patients are selected after shared decision-making in the context of evidence accumulated through many observa-
tional and randomized trials with this operation being done in the setting of an experienced center with a heart team and a
multidisciplinary team of caregivers. That center is constantly scrutinizing data compared with like centers in a national database.
Outcomes are fed back to front line workers in the multidisciplinary team, establishing and maturing pathways to minimize
variability in care and achieve the best outcomes possible.

Summary

CABG surgery has a central place in the effort to revascularize the myocardium, gained after over more than a 50-year history. The
knowledge gained by the world experience of cardiac surgeons performing millions of operations using evidence available to guide
appropriate selection of patients, the technologic advances gained by the cardiopulmonary perfusionists, understanding of
myocardial physiology, myocardial protection, vascular biology, secondary prevention, heart teams, and multidisciplinary teams
of perioperative caregivers has and will improve, save and prolong productive lives. As less invasive techniques evolve and
translational research leads us to a better understanding of the exuberant, maladaptive systemic inflammatory response with
strategies to mitigate it, CABG surgery will continue to evolve to be even safer and valuable.

References

Accord R and Maessen J (2011) Endoscopic vein harvesting for coronary bypass grafting: A blessing or a Trojan horse? Cardiology Research and Practice 2011: 813512. https://doi.
org/10.4061/2011/813512.
Alexander JH and Smith PK (2016) Coronary-artery bypass grafting. New England Journal of Medicine 374: 1954–1964.
Alghamdi AA and Latter DA (2006) Pulsatile versus nonpulsatile cardiopulmonary bypass flow: An evidence-based approach. Journal of Cardiac Surgery 21(4): 347–354.
Allen K (2000) Transmyocardial laser revascularization combined with coronary artery bypass grafting: A multicentric, blighted, prospective, randomized, controlled trial. Journal of
Thoracic and Cardiovascular Surgery 119: 540–549.
Athanasiou T, Saso S, Rao C, et al. (2011) Radial artery versus saphenous vein conduits for coronary artery bypass surgery: Forty years of competition—Which conduit offers better
patency? A systematic review and meta-analysis. European Journal of Cardio-Thoracic Surgery 40: 208–220.
Bakaeen FG and Puskas JD (2014) Trends in use of off-pump coronary artery bypass grafting: Results from the society of thoracic surgeons adult cardiac surgery database. Journal of
Thoracic and Cardiovascular Surgery 148(3): 856–864. discussion 863–4.
Bhimji S and Sheridan BC (2015) Transmyocardial laser revascularization: Overview, periprocedural care, technique. http://www.medscape.com/cardiology (accessed 07.31.15).
 Coronary Artery Bypass Grafting 727

Bigelow WG, Aldridge HE, and MacGregor DC (1966) Internal mammary implantation (vineberg operation) for coronary heart disease: Cineangiography and long-term follow up. Annals
of Surgery 164(3): 457–464.
Bourassa MG, Fisher LD, Campeau L, Gillespie MJ, McConney M, and Lesperance J (1985) Long-term fate of bypass grafts: The coronary artery surgery study (CASS) and montreal
heart institute experiences. Circulation 72(6 Pt 2): V71–V78.
Bridges CR, Horvath KA, Nugent WC, Shahian DM, Haan CK, Shemin RJ, Allen KB, Edwards FH, and Society of Thoracic Surgeons (2004) The Society of Thoracic Surgeons practice
guideline series: Transmyocardial laser revascularization. Annals of Thoracic Surgery 77: 1494–1502.
Bruce Ferguson T (2016) Physiology of in-situ arterial revascularization in coronary artery bypass grafting: Preoperative, intraoperative and postoperative factors and influences. World
Journal of Cardiology 8(11): 623–637.
Burfeind WR Jr., Glower DD, Wechsler AS, et al. (2004) Single versus multiple internal mammary artery grafting for coronary artery bypass: 15-year follow-up of a clinical practice trial.
Circulation 110: II27–II35.
Buxton BF, Shi WY, Tatoulis J, Fuller JA, Rosalion A, and Hayward PA (2014) Total arterial revascularization with internal thoracic and radial artery grafts in triple-vessel coronary artery
disease is associated with improved survival. Journal of Thoracic and Cardiovascular Surgery 148: 1238–1243. https://doi.org/10.1016/j.jtcvs.2014.06.056 discussion 1243-
1244.
Cameron A, Davis KB, Green G, et al. (1996) Coronary bypass surgery with internal-thoracic-artery grafts—Effects on survival over a 15-year period. New England Journal of Medicine
334: 216–219.
Carpentier A, Guermonprez JL, Deloche A, et al. (1973) The aorta-to-coronary radial artery bypass graft: A technique avoiding pathological changes in grafts. Annals of Thoracic
Surgery 16: 111–121.
Chenoweth DE, Cooper SW, Hugli E, et al. (1981) Complement activation during cardiopulmonary bypass. New England Journal of Medicine 304: 497.
Cineangiography introduced a whole new era of understanding coronary anatom and coronary arterydisease, and in its early years showed objective evidence that Dr Vineberg’s
operation provided revascularization for many people.
Cobb LA, Thomas GI, Dillard DH, Merendino KA, and Bruce RA (1959) An evaluation of internal-mammary-artery ligation by a double-blind technic. New England Journal of Medicine
260(22): 1115–1118.
Conti CR (1991) The mysterious, internal thoracic artery. Clinical Cardiology 14: 3–4.
Cooke JP (2015) Mechanisms of atherosclerosis: New insights and novel therapeutic approaches. Methodist DeBakey Cardiovascular Journal 1(3): 154–155.
Dacey LJ, Braxton JH, and Likosky DS (2009) Endoscopic versus open vein-graft harvesting. New England Journal of Medicine 361: 1907–1910. https://doi.org/10.1056/
NEJMc091645.
Dacey LJ, Braxton JH, Kramer RS, et al. (2011) Long-term outcomes of endoscopic vein harvesting after coronary bypass grafting. Circulation 123: 147–153.
de Somer F, Mulholland JW, Bryan MR, Aloisio T, Van Nooten GJ, and Ranucci M (2011) O2 delivery and CO2 production during cardiopulmonary bypass as determinants of acute
kidney injury: Time for a goal-directed perfusion management? Critical Care 15(4): R192.
Deb S (2012) Radial artery and saphenous vein patency more than 5 years after coronary artery bypass surgery: Results from RAPS. Journal of the American College of Cardiology
60: 28–35.
DeBakey ME, Cooley DA, Crawford ES, and Morris GC Jr. (1958) Clinical application of a new flexible knitted dacron arterial substitute. American Surgeon 24: 862–869.
Demers P, Elkouri S, Martineau R, Couturier A, and Cartier R (2000) Outcome with high blood lactate levels during cardiopulmonary bypass in adult cardiac operation. Annals of
Thoracic Surgery 70(6): 2082–2086.
Dickinson T, Riley JB, Crowley JC, et al. (2006) In vitro evaluation of the air separation ability of four cardiovascular manufacturer extracorporeal circuit designs. The Journal of Extra-
Corporeal Technology 38: 206–213.
Diegeler A (2013) Off pump versus on pump coronary artery bypass grafting in elderly patients. NEJM 368: 1189–1198.
Effler DB, Groves LK, Sones FM Jr., and Shirley EK (1963) Increased myocardial perfusion by internal mammary artery implantation: Vineberg’s operation. Annals of Surgery
158: 526–534.
Eloesser L (1970) Milestones in chest surgery. Journal of Thoracic and Cardiovascular Surgery 157.
Favaloro RG, Effler DB, Groves LK, Sheldon WC, and Riahi M (1969) Direct myocardial revascularization with saphenous vein autograft. Clinical experience in 100 cases. Diseases of
the Chest 56(4): 279–283.
Fergusson DJ, Shirey EK, Sheldon WC, and SonesFM Jr EfflerDB (1968) Left internal mammary artery implant-postoperative assessment. Circulation 38(4 Suppl.): 1124–1126.
Fihn SD, Blankenship JC, Alexander KP, et al. (2014) ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable
ischemic heart disease: A report of the American College of Cardiology/American Heart Association task force on practice guidelines, and the American Association for Thoracic
Surgery, preventive cardiovascular nurses association, society for cardiovascular angiography and interventions, and society of thoracic surgeons. Journal of the American College
of Cardiology 64: 1929–1949.
Galletti PM and Brecher GA (1962) Heart–lung bypass. Principles and techniques of extracorporeal circulation. New York: Grune and Stratton.
Geddes D, et al. (2012) Blood flow characteristics of the human lactating breast. Journal of Human Lactation 28(2): 145–152.
Gibbon H (1937) Artificial maintenance of circulation during experimental occlusion of pulmonary artery. Archives of Surgery 34: 1105.
Gosev Igor and Leacche Marzia (2014) Hybrid coronary revascularization: The future of coronary artery bypass surgery or an unfulfilled promise? Circulation 130: 869–871.
Groom RC and Fitzgerald D (2017) Cardiopulmonary bypass devices and techniques. Chapter in Kaplan’s cardiac anesthesia, 7th edn.
Gruentzig AR, Senning A, and Siegenthaler WE (1979) Nonoperative dilatation of coronary-artery stenosis: Percutaneous transluminal coronary angioplasty. New England Journal of
Medicine 301(2): 61–68. https://doi.org/10.1056/NEJM197907123010201.
Gulati R, Rihal CS, and Gersh BJ (2009) The SYNTAX trial a perspective. Circulation. Cardiovascular Interventions 2: 463–467.
Hall JE (2016) Guyton and Hall textbook of medical physiology, 13th edn. Jackson: University of Mississippi Medical Center p. 1069.
Hammerschmidt DE, Stroneck DF, Bowers TM, et al. (1981) Complement activation and neutropenia occurring during cardiopulmonary bypass. Journal of Thoracic and Cardiovascular
Surgery 81: 370.
Hattler B, Messenger JC, Shroyer AL, Collins JF, Haugen SJ, Garcia JA, Baltz JH, Cleveland JC Jr., Novitzky D, and Grover FL (2012) Veterans affairs randomized on/Off bypass
(ROOBY) study group. Off-pump coronary artery bypass surgery is associated with worse arterial and saphenous vein graft patency and less effective revascularization: Results from
the veterans affairs randomized on/Off bypass (ROOBY) trial. Circulation 125(23): 2827–2835. https://doi.org/10.1161/CIRCULATIONAHA.111.069260.
Henderson RA, Pocock SJ, Sharp SJ, et al. (1998) Long-term results of RITA-1 trial: Clinical and cost comparisons of coronary angioplasty and coronary-artery bypass grafting. Lancet
352: 1419–1425.
Hillis LD, Smith PK, Anderson JL, et al. (2011) ACCF/AHA guideline for coronary artery bypass graft surgery: A report of the American College of Cardiology Foundation/American Heart
Association task force on practice guidelines: Developed in collaboration with the American Association for thoracic surgery, society of cardiovascular anesthesiologists, and Society
of Thoracic Surgeons. Journal of the American College of Cardiology 58(24): e123–e210.
Homolay P, Bordánné Jenes E, Takács EI, and Péterffy A (1993) PGI2-like activity of the internal mammary artery and the saphenous vein used in coronary bypass surgery. Orvosi
Hetilap 134(14): 731–735.
Horvath K (2008) Transmyocardial laser revascularization. Journal of Cardiac Surgery 23(3): 266–276.
Investigators BARI (2007) The final 10-year follow-up results from the BARI randomized trial. Journal of the American College of Cardiology 49(15): 1600–1606.
Khurram N, Budoff MJ, Wong ND, et al. (2007) Family history of premature coronary heart disease and coronary artery calcification multi-ethnic study of atherosclerosis (MESA).
Circulation 116: 619–626.
Killip T, Passamani E, and Davis K (1985) Coronary artery surgery study (CASS): A randomized trial of coronary bypass surgery. Eight years follow-up and survival in patients with
reduced ejection fraction. Circulation 72(6 Pt 2): V102–V109.
728 Coronary Artery Bypass Grafting

Kim K, Ball C, Grady P, and Mick S (2013) Use of del nido cardioplegia for adult cardiac surgery at the cleveland clinic: Perfusion implications. The Journal of Extra-Corporeal
Technology 46: 317–323.
Kolessov VI (1967) Mammary artery-coronary artery anastomosis as method of treatment for angina pectoris. Journal of Thoracic and Cardiovascular Surgery 54: 535–544.
Kulik A, Ruel M, Jneid H, Ferguson TB, Hiratzka LF, Ikonomidis JS, Lopez-Jimenez F, McNallan SM, Patel M, Roger VL, Sellke FW, Sica DA, and Zimmerman L (2015) American heart
association council on cardiovascular surgery and anesthesia. Secondary prevention after coronary artery bypass graft surgery: A scientific statement from the American Heart
Association. Circulation 131(10): 927–964. https://doi.org/10.1161/CIR.0000000000000182.
Lamy A, et al. (2012) Off Pump versus on pump coronary artery bypass grafting at 30 days. NEJM 366: 1489–1495 Lamy. Five-year outcomes after off pump or on pump coronary
artery bypass grafting. N Engl J Med 2017; 376:894–895.
Likosky DS (2009) An Epidemiologist’s review of the case for pulsatile flow during cardiopulmonary bypass. Journal of ExtraCorporeal Technology 41: 30–32.
Likosky RC, Quinn DS, Lennon RD, Bracton P, Kramer JH, Weldner RS, Russo P, Chritie A, Taenzer A, Forest AH, Clark RJ, Welch C, Ross J, and Connor GT O (2009) Detection and
elimination of microemboli related to cardiopulmonary bypass groom. Circulation 2: 191–198.
Lim CH, Nam MJ, Lee JS, Kim HJ, Kim JY, Shin HW, Lee HW, and Sun K (2015) A meta-analysis of pulmonary function with pulsatile perfusion in cardiac surgery. Artificial Organs
39(2): 110–117. https://doi.org/10.1111/aor.12312.
Lin GA and Fagerlin A (2014) Shared decision making: State of the science. Circulation. Cardiovascular Quality and Outcomes 7: 328–334.
Lin PJ, et al. (1991) Endothelium-dependent production of prostacyclin in human internal mammary artery changgeng. Yi Xue Za Zhi 14(4): 222–229.
Loop FD (1996) Internal-thoracic-artery grafts. Biologically better coronary arteries. New England Journal of Medicine 334: 263–265.
Loop FD, Lytle BW, Cosgrove DM, et al. (1986) Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. New England Journal of Medicine
314: 1–6.
Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, Mehta RH, Gibson CM, Mack MJ, Kouchoukos NT, Califf RM, and Alexander JH (2009) Endoscopic versus
open vein-graft harvesting in coronary-artery bypass surgery. New England Journal of Medicine 361: 235–244. https://doi.org/10.1056/NEJMoa0900708.
Lopes RD, Williams JB, Mehta RH, Reyes EM, Hafley GE, Allen KB, Mack MJ, Peterson ED, Harrington RA, Gibson CM, Califf RM, Kouchoukos NT, Ferguson TB, Lorenz TJ, and
Alexander JH (2012a) Edifoligide and long-term outcomes after coronary artery bypass grafting: Project of ex-vivo vein graft engineering via transfection IV (PREVENT IV) 5-year
results. American Heart Journal 164: 379–386. https://doi.org/10.1016/j.ahj.2012.05.019.
Lopes RD, Mehta RH, Hafley GE, Williams JB, Mack MJ, Peterson ED, Allen KB, Harrington RA, Gibson CM, Califf RM, Kouchoukos NT, Ferguson TB, and Alexander JH (2012b)
Relationship between vein graft failure and subsequent clinical outcomes after coronary artery bypass surgery. Circulation 125: 749–756. https://doi.org/10.1161/
CIRCULATIONAHA.111.040311.
Lytle BW (2001) Skeletonized internal thoracic artery grafts and wound complications. Journal of Thoracic and Cardiovascular Surgery 121: 625–627. https://doi.org/10.1067/
mtc.2003.231.
Lytle BW (2013) Bilateral internal thoracic artery grafting. Annals of Cardiothoracic Surgery 2: 485–492.
Lytle BW, Loop FD, Cosgrove DM, Easley K, and Taylor PC (1983) Long- term (5-12 years) sequential studies of internal mammary artery and saphenous vein coronary bypass grafts.
Circulation 68(Suppl. Il): 1–14.
Lytle BW, Loop FD, Cosgrove DM, et al. (1985) Long-term (5 to 12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts. Journal of Thoracic and
Cardiovascular Surgery 89: 248–258.
Matthias B, Gruentzig J, Husmann M, and Rosch J (2014) Balloon angrioplasty—The legacy of andreas gruentzig, M.D. (1939-1985). Frontiers in Cardiovascular Medicine 1(15).
Møller CH, Penninga L, Wetterslev J, Steinbrüchel DA, and Gluud C (2012) Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease. Cochrane Database
of Systematic Reviews 3. CD007224https://doi.org/10.1002/14651858.CD007224.pub2.
Nam MJ, Lim CH, Kim HJ, Kim YH, Choi H, Son HS, Lim HJ, and Sun K (2015) A meta-analysis of renal function after adult cardiac surgery with pulsatile perfusion. Artificial Organs
https://doi.org/10.1111/aor.12452.
Ong AT, Serruys PW, Mohr FW, et al. (2006) The SYNergy between percutaneous coro- nary intervention with TAXus and cardiac surgery (SYNTAX) study: Design, ratio- nale, and run-
in phase. American Heart Journal 151: 1194–1204.
Osuka F (2013) Why as the mammary artery so special and what protects It from atherosclerosis? Annals of Cardiothoracic Surgery 2(4): 519–526.
Poston RS (2006) Role of procurement-related injury in early saphenous vein graft failure after coronary artery bypass surgery. Future Cardiology 2(4): 503.
Puskas (2009) Off pump coronary artery bypass disproportionately benefits high-risk patients. Annals of Thoracic Surgery 88: 1142–1147.
Puskas JD, Lazar HL, Mack MJ, Sabik JF, and Paul Taggart D (2014) State-of-the-art coronary artery bypass graft. Seminars in Thoracic and Cardiovascular Surgery 26: 76–94.
https://doi.org/10.1053/j.semtcvs.2014.03.002.
Raja SG and Sarang Z (2013) Endoscopic vein harvesting: Technique, outcomes, concerns & controversies. Journal of Thoracic Disease 5(Suppl. 6): S630–S637. https://doi.org/
10.3978/j.issn.2072-1439.2013.10.01.
Ranucci M, Romitti F, Isgro G, Cotza M, Brozzi S, Boncilli A, et al. (2005) Oxygen delivery during cardiopulmonary bypass and acute renal failure after coronary operations. Annals of
Thoracic Surgery 80(6): 2213–2220.
Roques F, Nashef SA, Michel P, et al. (1999) Risk factors and outcome in european cardiac surgery: Analysis of the EuroSCORE multinational database of 19030 patients. European
Journal of Cardio-Thoracic Surgery 15(6): 816–822 discussion 822–3.
Roques F, Michel P, Goldstone AR, and Nashef SA (2003) The logistic EuroSCORE. European Heart Journal 24(9): 882–883.
Ross R and Agius L (1992) The process of atherogenesis—Cellular and molecular interaction: From experimental animal models to humans. Diabetologia 35(Suppl. 2): S34–S40.
Sabik Blackstone (2008) Editorial comment—Coronary artery bypass graft patency and competitive flow. JACC: Heart Failure 51: 126–128.
Sabik JF 3rd, Lytle BW, Blackstone EH, et al. (2003) Does competitive flow reduce internal thoracic artery graft patency? Annals of Thoracic Surgery 76: 1490–1496 discussion 1497.
Sabik JF 3rd, Lytle BW, Blackstone EH, et al. (2005) Comparison of saphenous vein and internal thoracic artery graft patency by coronary system. Annals of Thoracic Surgery
79: 544–551 discussion 544-51.
Saczkowski R, Maklin M, Mesana T, Boodhwani M, and Ruel M (2012) Centrifugal pump and roller pump in adult cardiac surgery: A meta-analysis of randomized controlled trials.
Artificial Organs 36(8): 668–676.
Sarzaeem MR, Mandegar MH, Roshanali F, Vedadian A, Saidi B, Alaeddini F, et al. (2010) Scoring system for predicting saphenous vein graft patency in coronary artery bypass
grafting. Texas Heart Institute Journal 37(5): 525–530.
Scott JT and Murphy EA (1958) Mammary souffle of pregnancy: Report of 2 cases simulating patent ductus arteriosus. Circulation 18: 1038–1043.
Serruys PW, Morice M, Pieter Kappetein AP, et al. (2009) Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. New England
Journal of Medicine 360: 961–972.
Shahian DM, O’Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB, Normand SL, DeLong ER, Shewan CM, Dokholyan RS, Peterson ED, Edwards FH, Anderson RP, and Society of
Thoracic Surgeons Quality Measurement Task Force (2009) The society of thoracic surgeons 2008 cardiac surgery risk models: Part 1—Coronary artery bypass grafting surgery.
Annals of Thoracic Surgery 88(1 Suppl.): S2–S22. https://doi.org/10.1016/j.athoracsur.2009.05.053.
Shroyer ALW (2015) The society of thoracic surgeons adult cardiac surgery database: The driving force for improvement in cardiac surgery. Seminars in thoracic and cardiovascular
surgery. Seminars in Thoracic and Cardiovascular Surgery 27(2): 144–151.
Shroyer AL, Grover FL, Hattler B, et al. (2009) Veterans affairs randomized on/Off bypass (ROOBY) study group: On-pump versus off-pump coronary-artery bypass surgery. New
England Journal of Medicine 361: 1827–1837.
Sianos G, Morel M-A, Kappetein AP, et al. (2005) The SYNTAX score: An angiographic tool grading the complexity of coronary artery disease. EuroIntervention 1: 219–227.
Sievert A and Sistino J (2012) A meta-analysis of renal benefits to pulsatile perfusion in cardiac surgery. The Journal of Extra-Corporeal Technology 44(1): 10–14.
 Coronary Artery Bypass Grafting 729

Society of Thoracic Surgeons Blood Conservation Guideline Task Force (2011) 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists
blood conservation clinical practice guidelines. Annals of Thoracic Surgery 91: 944–982.
Sones FM Jr., Shirey EK, Proudfit WL, and Westcott RN (1959) Cine-coronary arteriography. Circulation 20: 773–774.
Stammers AH (1997) Historical aspects of cardiopulmonary bypass: From antiquity to acceptance. Journal of Cardiothoracic and Vascular Anesthesia 11: 266.
Subramanian VA, Hernandez Y, Tack-Goldman K, Grabowski EF, and Weksler BB (1986) Prostacyclin production by internal mammary artery as a factor in coronary artery bypass
grafts. Surgery 100(2): 376–383.
Taggart DP (2013) Current status of arterial grafts for coronary artery bypass grafting. Annals of Cardiothoracic Surgery 2(4): 427–430.
Taggart DP, Altman DG, Sc D, Gray Alastair M, Lees Belinda, Gerry Stephen, Benedetto Umberto, and Flather Marcus (2016) Randomized trial of bilateral versus single internal-
thoracic-artery grafts. New England Journal of Medicine 375: 2540–2549.
Takagi H, Mizuno Y, Niwa M, Goto SN, and Umemoto T (2013) ALICE (All-literature investigation of cardiovascular evidence) group. A meta-analysis of randomized trials for repeat
revascularization following off-pump versus on-pump coronary artery bypass grafting. Interactive Cardiovascular and Thoracic Surgery 17(5): 878–880.
Thomas JL (1999) The vineberg legacy: Internal mammary artery implantation from inception to obsolescence. Texas Heart Institute Journal 26: 107–113.
Une D, Al-Atassi T, Kulik A, Voisine P, Le May M, et al. (2014) Impact of clopidogrel plus aspirin versus aspirin alone on the progression of native coronary artery disease after bypass
surgery: Analysis from the clopidogrel after surgery for coronary artery disease (CASCADE) randomized trial. Circulation 130: S12–S18.
VA Coronary Artery Bypass Surgery Cooperative Study Group (1992) Eighteen-year follow-up in the Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery for stable
angina. Circulation 86(1): 121–130.
Varnauskas E (1988) Twelve-year follow-up of survival in the randomized european coronary surgery study. New England Journal of Medicine 319(6): 332–337.
Verma Subodh, Szmitko Paul E, Weisel Richard D, Bonneau Daniel, Latter David, Lee Errett, LeClerc Yves, and Fremes Stephen E (2004) Should radial arteries Be used routinely for
coronary artery bypass grafting? Circulation 110: e40–e46.
Vicol C (2003) Midterm results of beating heart surgery in single-vessel disease: Minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with full
sternotomy. The Heart Surgery Forum 6(5): 341–344.
Vineberg A (1958) Coronary vascular anastomoses by internal mammary artery implantation. Canadian Medical Association Journal 78: 871–879.
Yamamoto H and Yamamoto F (2013) Myocardial protection in cardiac surgery: A historical review from the beginning to the current topics. General Thoracic and Cardiovascular
Surgery 61(9): 485–496. https://doi.org/10.1007/s11748-013-0279-4.
Yie K (2008) Angiographic results of the radial artery graft patency according to the degree of native coronary artery stenosis. European Journal of Cardio-Thoracic Surgery 33(3):
341–348.
Zangrillo A, Pappalardo F, Dossi R, Di Prima AL, Sassone ME, Greco T, Monaco F, Musu M, Finco G, and Landoni G (2015) Preoperative intra-aortic balloon pump to reduce mortality in
coronary artery bypass graft: A meta-analysis of randomized controlled trials. Critical Care 19(1): 10.