Coronary artery bypass surgery: Difference between revisions

	Coronary Artery Bypass Surgery Microchapters
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Overview
Pathophysiology
Saphenous Vein Graft Disease
Other Non-Atherosclerotic Saphenous Vein Graft Diseases
Indications for CABG
Prognosis
Diagnosis
Imaging in the Patient Undergoing CABG
Chest X Ray
Angiography
CT Angiography
MRI Angiography
Trans-Esophageal Echocardiography
Treatment
Goals of Treatment
Perioperative Management
Perioperative Monitoring
Electrocardiographic Monitoring
Pulmonary Artery Catheterization
Central Nervous System Monitoring
Surgical Procedure
Anesthetic Considerations
Intervention in left main coronary artery disease
The Traditional Coronary Artery Bypass Grafting Procedure (Simplified)
Minimally Invasive CABG
Hybrid coronary revascularization
Conduits Used for Bypass
Videos on Spahenous Vein Graft Harvesting
Videos on Coronary Artery Bypass Surgery
Post-Operative Care and Complications
Pharmacotherapy in patients undergoing CABG CABG
Special Scenarios
Anomalous Coronary Arteries
COPD/Respiratory Insufficiency
Existing Renal Disease
Concomitant Valvular Disease
Previous Cardiac Surgery
Menopause
Carotid Disease evaluation before surgery
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Latest revision as of 06:26, 22 October 2022

For the WikiPatient page for this topic, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Mohammed A. Sbeih, M.D. [2]; Anahita Deylamsalehi, M.D.[3]; Cafer Zorkun, M.D., Ph.D. [4]; Varun Kumar, M.B.B.S. [5] Prince Tano Djan, BSc, MBChB [6]

Synonyms and keywords: Coronary artery bypass grafting, and colloquially heart bypass, bypass, bypass surgery, open heart surgery, or CABG (pronounced like cabbage), aortocoronary bypass (ACB). The term Coronary Artery Graft Surgery (CAGS) is often used outside the United States and should not be confused with Coronary Angiography (CAG). OPCAB refers to Off-pump coronary artery bypass, a procedure during which the patient is not placed on extracorporeal circulation ("the pump").

Overview

Coronary artery bypass surgery (CABG) is a surgical revascularization procedure that is used to circumvent or bypass blockages in the epicardial coronary arteries associated with acute coronary syndromes (including ST elevation MI, non ST elevation MI, unstable angina) and stable angina. The technique was pioneered by Argentine cardiac surgeon René Favaloro at the Cleveland Clinic in the late 1960s. As part of the procedure, arteries or veins from elsewhere in the patient's body are grafted from the aorta to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass. However, recent advances allow the procedure to be performed with the heart beating and through smaller incisions. Currently, about 500,000 Coronary artery bypass surgery (CABG) are performed in the United States each year.

Pathophysiology

Saphenous Vein Graft Disease | Other Non-Atherosclerotic Saphenous Vein Graft Diseases

Indications for CABG

CABG in Patients with Acute MI | CABG in Patients with Ventricular Arrhythmias | Emergency CABG after Failed PCI | CABG in Association with Other Cardiac Procedures | Heart Team Approach to Revascularization Decisions | Revascularization of Left Main CAD to Improve Survival | Revascularization of Non-Left Main CAD to Improve Survival | Revascularization to Improve Symptoms | CABG in Left Ventricular Dysfunction

Prognosis

Imaging in the patient undergoing CABG

Goals of Treatment

Perioperative and Intraoperative Management

Perioperative and Intraoperative Monitoring

Electrocardiographic Monitoring | Pulmonary Artery Catheterization | Central Nervous System Monitoring

Surgical Procedure

Post-Operative Care and Complications

Postoperative Antiplatelet Therapy

Special Scenarios

Related Chapters

External Links

Advances in Cardiovascular Surgery and Cardiothoracic Surgical Procedures
Cardiothoracic Surgery Notes an online interactive review developed by residents in cardiothoracic surgery
Contenidos de Enfermería y Cirugía Cardiaca
CTSNet: The Cardiothoracic Surgery Network
Curso de Enfermería y Cirugía Cardiaca
Heart Assist Devices
LVAD Simulator
Perfusion Line
The CardioThoracic Surgery Network: Residents Section
The Implantable Artificial Heart Project
The Virtual Textbook Of Extracorporeal Technology
Yale: Introduction to Cardiothoracic Imaging

References

Template:WikiDoc Sources

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-[[Image:Coronary artery bypass surgery Image_657C-PH.jpg|thumb|right|200px|Early in a '''coronary artery bypass surgery''' during vein harvesting from the legs (left of image) and the establishment of bypass (placement of the [[aorta|aortic]] [[cannula]]) (bottom of image).  The [[perfusionist]] and [[heart-lung machine]] (HLM) are on the upper right.  The patient's head (not seen) is at the bottom.]]
+'''For the WikiPatient page for this topic, click [[{{PAGENAME}} (patient information)|here]]'''
-[[Image:Coronary artery bypass surgery Image_657B-PH.jpg|thumb|right|200px|'''Coronary artery bypass surgery''' during mobilization (freeing) of the [[right coronary artery]] from its surrounding tissue, [[adipose tissue]] (yellow).  The tube visible at the bottom is the aortic cannula (returns blood from the [[Heart-lung machine|HLM]]).  The tube above it (obscured by the [[cardiac surgeon|surgeon]] on the right) is the venous cannula (receives blood from the body).  The patient's [[heart]] is stopped and the [[aorta]] is cross-clamped.  The patient's head (not seen) is at the bottom.]]
+{{Coronary artery bypass surgery}}
-{{SI}}
+{{CMG}}; '''Associate Editors-In-Chief:''' [[User: Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; {{Anahita}}; {{CZ}}; {{VK}} {{PTD}}
-{{CMG}}
+'''''Synonyms and keywords:''''' Coronary artery bypass grafting, and colloquially heart bypass, bypass, bypass surgery, open heart surgery, or CABG (pronounced like cabbage), aortocoronary bypass (ACB). The term Coronary Artery Graft Surgery (CAGS) is often used outside the United States and should not be confused with [[Coronary angiography|Coronary Angiography (CAG)]]. OPCAB refers to [[Off-pump coronary artery bypass]], a procedure during which the patient is not placed on extracorporeal circulation ("the pump").
-{{Editor Help}}
+==[[Coronary artery bypass surgery overview|Overview]]==
+[[Coronary artery bypass surgery]] ([[Coronary artery bypass surgery|CABG]]) is a [[surgery|surgical]] [[coronary revascularization|revascularization]] procedure that is used to circumvent or bypass blockages in the [[Epicardium|epicardial]] [[coronary arteries]] associated with [[acute coronary syndromes]] (including [[ST elevation MI]], [[non ST elevation MI]], [[unstable angina]]) and [[stable angina]]. The technique was pioneered by Argentine [[cardiac surgeon]] [[René Favaloro]] at the [[Cleveland Clinic]] in the late 1960s. As part of the procedure, [[artery|arteries]] or [[vein]]s from elsewhere in the [[patient]]'s body are [[medical grafting|grafted]] from the [[aorta]] to the [[coronary artery|coronary arteries]] to bypass [[atherosclerosis|atherosclerotic]] [[stenosis|narrowings]] and improve the [[blood]] supply to the [[coronary circulation]] supplying the [[myocardium]] ([[myocardium|heart muscle]]). This surgery is usually performed with the [[heart]] stopped, necessitating the usage of [[cardiopulmonary bypass]]. However, recent advances allow the procedure to be performed with the [[heart]] beating and through smaller [[incisions]]. Currently, about 500,000 [[Coronary artery bypass surgery]] ([[Coronary artery bypass surgery|CABG]]) are performed in the United States each year.
-[http://www.wikidoc.org/index.php/Cardiac_surgery See also: Cardiac surgery]
+==Pathophysiology==
+[[Coronary artery bypass surgery saphenous vein graft disease| Saphenous Vein Graft Disease]] | [[Coronary artery bypass surgery other non-atherosclerotic saphenous vein graft diseases|Other Non-Atherosclerotic Saphenous Vein Graft Diseases]]
-==Overview==
+==[[Coronary artery bypass surgery indications|Indications for CABG]]==
+[[Coronary artery bypass surgery in patients with acute MI|CABG in Patients with Acute MI]] | [[Coronary artery bypass surgery in ventricular arrhythmias|CABG in Patients with Ventricular Arrhythmias]] | [[Coronary artery bypass surgery after failed PCI|Emergency CABG after Failed PCI]] | [[Coronary artery bypass surgery in association with other cardiac procedures|CABG in Association with Other Cardiac Procedures]] | [[Coronary artery bypass surgery heart team approach to revascularization decisions|Heart Team Approach to Revascularization Decisions]] | [[Coronary artery bypass surgery of left main CAD to improve survival|Revascularization of Left Main CAD to Improve Survival]] | [[Coronary artery bypass surgery of non–left main CAD to improve survival|Revascularization of Non-Left Main CAD to Improve Survival]] | [[Coronary artery bypass surgery revascularization to improve symptoms|Revascularization to Improve Symptoms]] | [[Coronary artery bypass surgery CABG in left ventricular dysfunction|CABG in Left Ventricular Dysfunction]]
-'''Coronary artery bypass surgery''', also '''coronary artery bypass graft surgery''', and colloquially '''heart bypass''' or '''bypass surgery''' is a [[surgery|surgical procedure]] performed to relieve [[Angina pectoris|angina]] and reduce the risk of death from [[Coronary heart disease|coronary artery disease]]. [[artery|Arteries]] or [[vein]]s from elsewhere in the patient's body are [[medical grafting|grafted]] from the [[aorta]] to the [[coronary artery|coronary arteries]] to bypass [[atherosclerosis|atherosclerotic]] [[stenosis|narrowings]] and improve the [[blood]] supply to the [[coronary circulation]] supplying the [[myocardium]] (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of [[cardiopulmonary bypass]]. However, recent researches also shown that this surgery can be done with the heart still beating, by putting stabilizing devices on the heart.
+==[[Coronary artery bypass surgery prognosis|Prognosis]]==
-The technique was pioneered by Argentine [[cardiac surgeon]] [[René Favaloro]] at the [[Cleveland Clinic]] in the late 1960s.<ref>Captur G. Memento for Rene Favaloro. Tex Heart Inst J. 2004;31(1):47-60. PMID 15061628. [http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=15061628 Free Full Text].</ref>
+==Imaging in the patient undergoing CABG==
+[[Coronary artery bypass surgery X-ray|Chest x-ray]] | [[Coronary artery bypass surgery angiography|Coronary Angiography]]
+|  [[Coronary artery bypass surgery CT angiography|CT Angiography]]  |  [[Coronary artery bypass surgery mri angiography|MRI Angiography]] | [[Coronary artery bypass surgery TEE|Trans-Esophageal Echocardiography]] | [[Coronary artery bypass surgery epiaortic ultrasound|Epiaortic Ultrasound]]
-Currently, about 500,000 CABGs are performed in the United States each year.
+==[[Coronary artery bypass surgery goals of treatment|Goals of Treatment]]==
-==Terminology==
+==[[Coronary artery bypass surgery perioperative management|Perioperative and Intraoperative Management]]==
+[[Coronary artery bypass surgery aspirin and clopidogrel|Aspirin and Clopidogrel]] | [[Coronary artery bypass surgery use of beta-blockers|Beta-Blockers]] | [[Coronary artery bypass surgery use of ACE Inhibitors/ARBs|ACE Inhibitors/ARBs]] | [[Coronary artery bypass surgery management of hyperlipidemia|Management of Hyperlipidemia]] | [[Coronary artery bypass surgery management of perioperative infection|Management of Mediastinitis/Perioperative Infection]] | [[Coronary artery bypass surgery percutaneous coronary intervention (PCI) to treat saphenous vein graft failure|Percutaneous Coronary Intervention (PCI) To Treat Saphenous Vein Graft Failure]] | [[Coronary artery bypass surgery maintaining glucose level|Maintaining Glucose Level]] | [[Coronary artery bypass surgery bleeding/transfusion]] | [[Coronary artery bypass surgery management of dysrhythmias|Management of Dysrhythmias]] | [[Coronary artery bypass surgery smoking cessation|Smoking Cessation]] | [[Coronary artery bypass surgery perioperative management of myocardial dysfunction|Perioperative Management of Myocardial Dysfunction]] | [[Coronary artery bypass surgery perioperative carotid artery noninvasive screening|Perioperative Carotid Artery Noninvasive Screening]]
-There are many variations on terminology, in which one or more of 'artery', 'bypass' or 'graft' is left out.  The most frequently used acronym for this type of surgery is '''CABG''' (pronounced 'cabbage'),<ref>American Heart Association. Heart Bypass Surgery. URL: http://www.americanheart.org/presenter.jhtml?identifier=4484. Accessed on March 26, 2006.</ref> pluralized as '''CABGs''' (pronounced 'cabbages').  More recently the term '''aortocoronary bypass (ACB)''' has come into popular use.  '''CAGS''' (Coronary Artery Graft Surgery, pronounced phonetically) has been used (primarily outside the United States) and should not be confused with [[Coronary angiography|Coronary Angiography (CAG)]].
+==[[Coronary artery bypass surgery perioperative monitoring|Perioperative and Intraoperative Monitoring]]==
+[[Coronary artery bypass surgery electrocardiographic monitoring|Electrocardiographic Monitoring]] | [[Coronary artery bypass surgery pulmonary artery catheterization|Pulmonary Artery Catheterization]] | [[Coronary artery bypass surgery central nervous system monitoring|Central Nervous System Monitoring]]
-===Number of bypasses===
+==[[Coronary artery bypass surgery surgical procedure|Surgical Procedure]]==
+[[Coronary artery bypass surgery anesthetic considerations|Anesthetic Considerations]] | [[Coronary artery bypass surgery the traditional coronary artery bypass grafting procedure (simplified)| The Traditional Coronary Artery Bypass Grafting Procedure (Simplified)]] | [[Coronary artery bypass surgery minimally invasive CABG| Minimally Invasive CABG]] | [[Coronary artery bypass surgery conduits used for bypass|Conduits Used for Bypass]] | [[Coronary artery bypass surgery videos on spahenous vein graft harvesting| Videos on Saphenous Vein-Graft Harvesting]] | [[Coronary artery bypass surgery videos on Coronary artery bypass surgery|Videos on Coronary Artery Bypass Surgery]] | [[Coronary artery bypass surgery cardiopulmonary bypass|Cardiopulmonary Bypass]]
-The terms ''single bypass'', ''double bypass'', ''triple bypass'', ''quadruple bypass'' and ''quintuple bypass'' refer to the number of coronary arteries bypassed in the procedure.  In other words, a double bypass means two coronary arteries are bypassed (e.g. the [[left anterior descending|left anterior descending (LAD)]] coronary artery and [[right coronary artery|right coronary artery (RCA)]]); a triple bypass means three vessels are bypassed (e.g. LAD, RCA, [[left circumflex artery|left circumflex artery (LCX)]]); a quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagnonal artery of the LAD) while quintuple means five.  Less commonly more than four coronary arteries may be bypassed.
+==[[Coronary artery bypass surgery post-operative care and complications|Post-Operative Care and Complications]]==
+[[Coronary artery bypass surgery postoperative antiplatelet therapy|Postoperative Antiplatelet Therapy]]
+==Special Scenarios==
+[[Coronary artery bypass surgery in anomalous coronary arteries|Anomalous Coronary Arteries]] | [[Coronary artery bypass surgery in patients with COPD/respiratory insufficiency|Chronic Obstructive Pulmonary Disease/Respiratory Insufficiency]] | [[Coronary artery bypass surgery in patients with existing renal disease|Existing Renal Disease]] | [[Coronary artery bypass surgery in patients with valvular disease|Concomitant Valvular Disease]] | [[Coronary artery bypass surgery in patients with previous cardiac surgery|Previous Cardiac Surgery]] | [[Coronary artery bypass surgery in patients with menopause|Menopause]] | [[Coronary artery bypass surgery carotid disease evaluation before surgery|Carotid Disease Evaluation Before Surgery]]
-A greater number of bypasses does not imply a person is "sicker," nor does a lesser number imply a person is "healthier."<ref>{{cite journal |author=Ohki S, Kaneko T, Satoh Y, ''et al'' |title=[Coronary artery bypass grafting in octogenarian] |language=Japanese |journal=Kyobu geka. The Japanese journal of thoracic surgery |volume=55 |issue=10 |pages=829–33; discussion 833–6 |year=2002 |pmid=12233100 |doi=}}</ref>  A person with a large amount of [[coronary artery disease|coronary artery disease (CAD)]] may receive fewer bypass grafts due to the lack of suitable "target" vessels.  A coronary artery may be unsuitable for bypass grafting it if it is small (< 1 mm or < 1.5 mm depending on surgeon preference), heavily calcified (meaning the artery does not have a section free of CAD) or intramyocardial (the coronary artery is located within the heart muscle rather than on the surface of the heart).  Similarly, a person with a single [[stenosis]] ("narrowing") of the [[Left coronary artery|left main]] coronary artery requires only two bypasses (to the LAD and the LCX).  However, a left main lesion places a person at the highest risk for death from a cardiac cause.
+==Related Chapters==
-The surgeon reviews the [[coronary angiogram]] prior to surgery and identifies the lesions (or "blockages") in the coronary arteries.  The surgeon will estimate of the number of bypass grafts prior to surgery, but the final decision is made in the operating room upon examination of the heart.
+* [[CABG]]
+* [[Hybrid bypass]]
-==Indications for CABG==
+* [[Off-pump coronary artery bypass surgery|Off-Pump Coronary Artery Bypass Surgery (OPCAB)]]
+* [[Minimally invasive direct coronary artery bypass surgery]] ([[MIDCAB]])
-Several alternative treatments for coronary artery disease exist. They include:
-* Medical management ([[statins]], [[antihypertensive]]s, [[smoking cessation]], tight [[blood sugar]] control in [[diabetes mellitus|diabetics]])
-* [[Percutaneous coronary intervention]] (PCI)
-Both PCI and CABG are more effective than medical management at relieving symptoms,<ref name=rihal>{{cite journal |author=Rihal C, Raco D, Gersh B, Yusuf S |title=Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable angina: review of the evidence and methodological considerations |journal=Circulation |volume=108 |issue=20 |pages=2439-45 |year=2003 |pmid=14623791}} [http://circ.ahajournals.org/cgi/content/full/108/20/2439 Full Free Text].</ref> (e.g. [[Angina pectoris|angina]], [[dyspnea]], [[fatigue (medical)|fatigue]]), but repeat procedures are required more frequently after PCI.<ref name=rihal/>
-CABG is the preferred treatment with:<ref name=rihal/>
-* Disease of the [[left main coronary artery]] (LMCA). LMCA disease is associated with [[sudden death]]; therefore, lesions of the LMCA are sometimes referred to as ''widow makers''.
-* Disease of all three coronary vessels ([[left anterior descending|LAD]], [[circumflex artery|LCX]] and [[right coronary artery|RCA]]).
-* Diffuse disease not amendable to treatment with a PCI.
-CABG is the likely the preferred treatment with other high-risk patients such as those with severe ventricular dysfunction (i.e. low [[ejection fraction]]), or [[diabetes mellitus]].<ref name=rihal/>
-==Prognosis==
-Prognosis following CABG depends on a variety of factors, but successful grafts typically last around 10-15 years. In general, CABG improves the chances of survival of patients who are at high risk (meaning those presenting with angina pain shown to be due to ischemic heart disease), but statistically after about 5 years the difference in survival rate between those who have had surgery and those treated by drug therapy diminishes. Age at the time of CABG is critical to the prognosis, younger patients with no complicating diseases have a high probability of greater longevity. The older patient can usually be expected to suffer further blockage of the coronary arteries.
-==Complications==
-People undergoing coronary artery bypass are at risk for the same complications as any surgery, plus some risks more common with or unique to CABG.
-===CABG associated===
-*[[Postperfusion syndrome]] (pumphead), a transient neurocognitive impairment associated with [[cardiopulmonary bypass]].  Some research shows the incidence is initially decreased by [[Off-pump coronary artery bypass]], but with no difference beyond three months after surgery.  A neurocognitive decline over time has been demonstrated in people with coronary artery disease regardless of treatment (OPCAB, conventional CABG or medical management).
-*[[Nonunion]] of the [[sternum]]; [[internal thoracic artery]] harvesting devascularizes the sternum increasing risk.
-*[[Myocardial infarction]] due to hypoperfusion, early graft occlusion, or graft failure.
-*Late graft [[stenosis]], particularly of [[Great saphenous vein|saphenous vein]] grafts due to [[atherosclerosis]] causing recurrent [[Angina pectoris|angina]] or [[myocardial infarction]].
-*[[Acute renal failure]] due to hypoperfusion.
-*[[Stroke]], secondary to aortic manipulation or hypoperfusion.
-===General surgical===
-*[[Infection]] at incision sites or [[sepsis]].
-*[[Deep vein thrombosis]] (DVT)
-*[[Anesthesia|Anesthetic]] complications such as [[malignant hyperthermia]].
-*[[Keloid]] scarring
-*[[Chronic pain]] at incision sites
-*[[Chronic stress]] related illnesses
-*[[Death]]
-==Procedure (Simplified)==
-#The patient is brought to the [[operating room]] and moved onto the operating table.
-#An anesthetist places a variety of [[intravenous]] lines and injects an induction agent (usually [[propofol]]) to render the person unconscious.
-#An [[endotracheal tube]] is inserted and secured by the anesthetist or a [[respiratory therapist]] and [[mechanical ventilation]] is started.
-#The chest is opened via a [[median sternotomy]] and the heart is examined by the surgeon.
-#The grafts are harvested - frequent conduits are the [[internal thoracic artery|internal thoracic arteries]], [[radial artery|radial arteries]] and [[saphenous vein]]s.
-#The surgeon stops the heart and initiates [[cardiopulmonary bypass]]; or in the case of "off-pump" surgery, places devices to stabilize the heart.
-#One end of each graft is sewn onto the [[coronary artery|coronary arteries]] beyond the [[coronary artery disease|blockages]] and the other end is attached to the [[aorta]].
-#The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In some cases, the Aorta is partially occluded by a C shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating. This reduces time spent on the heart lung machine.
-#The [[sternum]] is wired together and the incisions are [[suture]]d closed.
-#The person is moved to the [[intensive care unit]] (ICU) to recover.  After awakening and stabilizing in the ICU (approximately 1 day), the person is transferred to the cardiac surgery unit until ready to go home (approximately 4 days).
-==Conduits used for bypass==
-The choice of conduits is highly surgeon and institution dependent.  Typically, the left [[internal thoracic artery]] (LITA) (previously referred to as ''left internal mammary artery'' or ''LIMA'') is grafted to the [[Left Anterior Descending]] artery and a combination of other arteries and veins is used for other coronary arteries.  The right internal thoracic artery (RITA), the [[great saphenous vein]] from the leg and the [[radial artery]] from the forearm are frequently used.  The [[right gastroepiploic artery]] from the [[stomach]] is infrequently used given the difficult mobilization from the [[abdomen]].
-===Graft patency===
-Grafts can become diseased and may occlude in the months to years after bypass surgery is performed.  Patency is a term used to describe the chance that a graft remain open.  A graft is considered patent if there is flow through the graft without any significant (>70% diameter) stenosis in the graft.
-Graft patency is dependent on a number of factors, including the type of graft used (internal thoracic artery, radial artery, or great saphenous vein), the size or the coronary artery that the graft is anastomosed with, and, of course, the skill of the surgeon(s) performing the procedure.  Arterial grafts (e.g. LITA, radial) are far more sensitive to rough handling than the saphenous veins and may go into spasm if handled improperly.
-Generally the best patency rates are achieved with the in-situ (the proximal end is left connected to the [[subclavian artery]]) left internal thoracic artery with the distal end being anastomosed with the coronary artery (typically the left anterior descending artery or a diagonal branch artery).  Lesser patency rates can be expected with radial artery grafts and "free" internal thoracic artery grafts (where the proximal end of the thoracic artery is excised from its origin from the subclavian artery and re-anastomosed with the ascending aorta).  Saphenous vein grafts have worse patency rates, but are more available, as the patients can have multiple segments of the saphenous vein used to bypass different arteries.
-Veins that are used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft. LITA grafts are longer-lasting than vein grafts, both because the artery is more robust than a vein and because, being already connected to the arterial tree, the LITA need only be grafted at one end.  The LITA is usually grafted to the [[left anterior descending coronary artery]] (LAD) because of its superior long-term patency when compared to saphenous vein grafts.<ref>Kitamura S, Kawachi K, Kawata T, Kobayashi S, Mizuguchi K, Kameda Y, Nishioka H, Hamada Y, Yoshida Y. [Ten-year survival and cardiac event-free rates in Japanese patients with the left anterior descending artery revascularized with internal thoracic artery or saphenous vein graft: a comparative study] Nippon Geka Gakkai Zasshi. 1996 Mar;97(3):202-9. PMID 8649330.</ref><ref>Arima M, Kanoh T, Suzuki T, Kuremoto K, Tanimoto K, Oigawa T, Matsuda S. Serial Angiographic Follow-up Beyond 10 Years After Coronary Artery Bypass Grafting. Circ J. 2005 Aug;69(8):896-902. PMID 16041156. [http://www.jstage.jst.go.jp/article/circj/69/8/896/_pdf Free Full Text].</ref>
-==Minimally Invasive CABG==
-Alternate methods of minimally invasive coronary artery bypass surgery have been developed in recent times.  [[Off-pump coronary artery bypass surgery|Off-pump coronary artery bypass surgery (OPCAB)]] is a technique of performing bypass surgery without the use of [[cardiopulmonary bypass]] (the heart-lung machine).  Futher refinements to OPCAB have resulted in [[Minimally invasive direct coronary artery bypass surgery|Minimally invasive direct coronary artery bypass surgery (MIDCAB)]] which is a technique of performing bypass surgery through a 5 to 10 cm incision.
-==See also==
-* [[Angioplasty]]
 * [[Cardiothoracic surgery]]
 * [[Dressler's syndrome]]
 * [[Hybrid bypass]]
-* [[Off-pump coronary artery bypass surgery|Off-pump coronary artery bypass surgery (OPCAB)]]
-* [[Minimally invasive direct coronary artery bypass surgery]] (MIDCAB)
-==References==
-{{reflist}}
-==External links==
+==External Links==
 *[http://www.texheartsurgeons.com/ Advances in Cardiovascular Surgery and Cardiothoracic Surgical Procedures]
 *[http://www.ctsnet.org/residents/ctsn/ Cardiothoracic Surgery Notes] an online interactive review developed by residents in cardiothoracic surgery
@@ Line 123: / Line 60: @@
 *[http://info.med.yale.edu/intmed/cardio/imaging/ Yale: Introduction to Cardiothoracic Imaging]
+==References==
-{{Cardiac surgery}}
+{{Reflist|2}}
-{{SIB}}
 [[Category:Cardiac surgery]]
 [[Category:Cardiology]]
-[[Category:Emergency medicine]]
+[[Category:mature chapter]]
+[[Category:Surgery]]
+[[Category:Surgical procedures]]
+[[Category:Overview complete]]
+[[Category:Template complete]]
-[[de:Koronararterien-Bypass]]
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-[[fi:Sepelvaltimon ohitusleikkaus]]
 [[fr:pontage aorto-coronarien]]
-[[he:ניתוח מעקפים]]
-[[mk:Бајпас операција]]
-[[nl:CABG]]
 [[ja:冠動脈大動脈バイパス移植術]]
 [[pl:CABG]]
 [[pt:Cirurgia cardiovascular]]
-[[uk:Коронарне шунтування]]
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