Talk:Coronary artery bypass surgery

Graft patency
Anyone have a good reference for graft patency rates? The numbers I have are only for SVG grafts and I don't have a proper reference for where I got the numbers from. :-( Ksheka 14:23, 29 August 2006 (UTC)
 * Here are some reference articles for graft patency. I don't time (at the moment to sift through them, but 50% patency in 10-15 years sounds about right: 1 2 3 4. Ksheka 15:20, 29 August 2006 (UTC)
 * 50% is what I remember off the top of my head. The important thing is really the comparison to arterial grafts, particularily the ITA--which has patency rate of something like 90% at 10 years. Surprising is-- there doesn't seem to be a meta-analysis on this (I spent a bit of time searching PubMed). Nephron  T|C 03:42, 30 August 2006 (UTC)
 * From what I recall in the PCI talks, there is some debate about how good ITA grafts really are. Patency of the graft itself is excellent.  However, there are issues with stenosis at the anastamosis site.  Definitely need some hard facts on this. Ksheka 15:33, 3 September 2006 (UTC)
 * That grafts fail at the distal anastomosis is fairly well known:
 * Ojha M, Leask RL, Johnston KW, David TE, Butany J. Histology and morphology of 59 internal thoracic artery grafts and their distal anastomoses. Ann Thorac Surg. 2000 Oct;70(4):1338-44.
 * Leask RL, Butany J, Johnston KW, Ethier CR, Ojha M. Human saphenous vein coronary artery bypass graft morphology, geometry and hemodynamics. Ann Biomed Eng. 2005 Mar;33(3):301-9.
 * Nephron T|C 18:49, 3 September 2006 (UTC)

The patency rates are as follow (in decending order): If I find time to track down references for this, I will insert in in the article.
 * LIMA
 * RIMA
 * Free LIMA
 * Free RIMA
 * Radial - should quote the RAPS study by Desai, Fremes et. al. in NEJM (2005 I think). Radial grafts historically got a bad rap due to improper handling - the patency is excellent when handled with the same regard as the IMA's.
 * SVG


 * So, what happens after 15 years, when the the grafts fail? Are they replaced? --89.56.190.194 (talk) 16:36, 2 April 2008 (UTC)


 * Sometimes. There is re-do CABG.

Patency also depends on the quality of the outflow tract (downstream from the distal anastomosis). For this reason, a LIMA to LAD graft has the highest patency of any configurations. BakerStMD T&#124;C 18:16, 9 January 2015 (UTC) --- First of all... surprised that the talk page had more info than the article itself.

Second: I am working on my thesis on graft patency and I have my references on this handy. May as well put them here so someone else can work them into the article.

Third: Its not that after 15 years the graft all fail. But when they do, its the question of whether the patient is symptomatic or not. If the patient is coping well and not showing any symptoms, then we leave them alone. If they cannot stand up without feeling angina pain, then we operate on them again. Chances are, with people operated on being about 70-80 years old anyway, 15 years post-surgery most of them would have died by other cause (cancer most likely).

Ok, so here are the current recommendations:

For Left Coronary System: (i.e. the Left Anterior Descending Artery and the Circumflex Artery) Ref1: Taggart DP, D’Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 2001;358(September(9285)):870-5. Ref2: Lytle B, Blackstone E, Sabik JF, Houghtaling P, Loop FD, Cosgrove DM. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Trial awaiting Result: Taggart DP, Lees B, Gray A, Altman DG, Marcus F, Channon K, ART investigators. Arterial Revascularisation Trial (ART). A randomised trial to compare survival following bilateral versus single internal mammary grafting in coronary revascularisation [ISRCTN46552265]. Trials. 2006; 7: 7. doi: 10.1186/1745-6215-7-7.
 * Bilateral in-situ Internal Thoracic Arteries (i.e. both LITA and RITA used together)

This is the accepted norm (at least in the US and European Countries) for the moment

For the Right Coronary System: (i.e. the Right Coronary Artery, the Left Ventricular Branches of the RCA and in most cases the Posterior Descending Artery) Ref1: Glineur D, D'hoore W, El Khoury G, Sondji S, Kalscheuer G, Funken JC, Rubay J, Poncelet A, Astarci P, Verhelst R, Noirhomme P, Hanet C. Angiographic predictors of 6-month patency of bypass grafts implanted to the right coronary artery a prospective randomized comparison of gastroepiploic artery and saphenous vein grafts. J Am Coll Cardiol. 2008 Jan 15;51(2):120-5. Ref2: Hayward PA, Hadinata IE, Hare D, Moten S, Rosalion A, Seevanayagam S, Buxton B, Matalanis G. Choice Of Conduit For The Right Coronary System: An 8-year Analysis From The Radial Artery Patency And Clinical Outcomes Trial. Proceedings of the 2009 Society For Cardiothoracic Surgery In Great Britain and Ireland Annual Meeting BIC; 2009 Mar 22-24; Bournemouth, United Kingdom. (Abstract available online - Manuscript publication pending) ***EDIT: The paper is now published. The correct reference is: Hadinata IE, Hayward PAR, Hare DL, Matalanis GS, Seevanayagam S, Rosalion A, Buxton BF. Choice of Conduit for the Right Coronary System: 8-Year Analysis of Radial Artery Patency and Clinical Outcomes Trial. Ann Thorac Surg 2009;88:1404–9*** Ignatius Eric Hadinata (talk) 15:38, 8 January 2010 (UTC)
 * Use the Radial Artery or the Saphenous Vein, not the Gastro-eplipoic Artery

Yes, I am one of the authors of that last reference. I admit that not everyone will agree with what I have written above, especially if you research publications older than 2008. Older surgeons also tend not to agree with newer research. Not every country has adopted the bilateral ITA approach. This method is new and still debated. The randomised controlled trial to prove it is not finished yet, but there is enough evidence to convince the majority of surgeons to adopt it.

P.S: The study by Dr. Fremes (mentioned in the comment above) was started before the theory of the bilateral ITA was put forward. It studies the difference between Saphenous vein (SV) and Radial Artery (RA) in the same patient. Basically he randomises each patient to either receive an SV or RA to the circumflex artery. If the patient receives SV to the circumflex, then he puts the RA to the right coronary artery and vice versa. He then follows up those patients over 10 years (I believe) and compares the patencies of the RA and SV.

Ignatius Eric Hadinata (talk) 05:27, 21 April 2009 (UTC)

on-pump, off-pump
"Two alternative techniques are also available allowing CABG to be performed on a beating heart either without using the cardiopulmonary bypass deemed as "off-pump" surgery or performing beating surgery using partial assistance of the cardiopulmonary bypass called as "on-pump beating" surgery. The latter gathers the advantages of the on-pump stopped and off-pump while minimizing their respective side-effects."

Hello, as a non-expert, I am having difficulty parsing these two sentences. Let me give it a try. The following is what I think this text may be saying: Two alternative techniques are also available allowing CABG to be performed on a beating heart, 1) without using cardiopulmonary bypass at all, this is called "off-pump surgery", and 2) using partial assistance from the cardiopulmonary bypass, this is called "on-pump beating surgery". The latter combines the advantages of cardiopulmonary bypass (on-pump) and off-pump surgery while minimizing their respective side-effects.

My problem with the original is that I'm not sure if the 'deemed as' refers to cardiopulmonary bypass itself, or 'without using cardiopulmonary bypass', because the word pump does not appear in connection with cardiopulmonary bypass in the preceding text. In the second sentence, 'on-pump stopped' also leaves me bewildered.

As an aside, is aortic no-touch technique something that deserves mention in wikipedia? Papafrancis (talk) 18:01, 17 September 2015 (UTC)

NEJM review
10.1056/NEJMra1406944 JFW &#124; T@lk  05:01, 19 May 2016 (UTC)

Donor vessel
Shouldn't there be a section on the donor vessel in the article? Which vessels are being used as donor vessel? Why that vessel or those vessels? This with some good pictures would improve the article. I am insufficiently knowledgable on the subject to do it myself so I simply address it. 145.132.75.218 (talk) 16:19, 22 October 2019 (UTC)

Section "Complications"
Complications section (see current version) shouldnt be an indiscriminate list of various complications that might appear. Rather we should be describing the most common and dangerous (ie graft failure, heart failure, infection, sepsis, renal failure, Stroke and maybe some more), so reader should put things into the right perspective. Cinadon36 09:16, 19 September 2022 (UTC)

Section Procedure
Section procedure should have just two subsections, on and off Pump (criticism for current version. Cinadon36 09:19, 19 September 2022 (UTC)

Copy editing comments
I'll try to do a good copy edit. From a glance, there are a lot of exotic medical terms used here that will really need context and glossing, especially for such an important article like this one, which should be broadly accessible. I will note those as applicable and gloss the few I'm familiar enough with. I would pretend like you are writing for a 16 year old, with a basic understanding of the body as might be learned in high school. It's much better to be slightly imprecise or informal ("heart attack" instead of "myocardial infarction") than to make an article impenetrable to anyone not already immersed in the subject. Ovinus (talk) 01:29, 17 December 2022 (UTC)


 * Hi @Ovinus and thank you for taking up this difficult task. I will try to be as helpful as possible. Cinadon36 09:31, 17 December 2022 (UTC)
 * Thanks for the help. Ovinus (talk) 15:39, 22 December 2022 (UTC)

Terms that need to be defined
A list of terms that (in my opinion) must be defined or simply not used. (in progress)


 * Ones I tried to do myself
 * ischemic, anastomosis, stenotic, lesion, angina, myocardial infarction, graft
 * Ischemic: (USA english) or ischaemic (UK english) roughly means that a territory gets less blood than needed to survive.
 * Anastomosis: Anastomosis is a connection of two vessels. It is made by surgeons. Usually they open a hole in the side of one vessel and, using sutures, they attach the other vessel to it, so blood can flow from one vessel to another.
 * stenotic: Partially obstructed.
 * Lesion: an abnormality
 * Stenotic lesion in a vessel. A point where the normal wall of a vessel has been modified, most commonly because of accumulated fat. This fat causes the diameter of the vessel to become smaller and smaller. It is called a stenotic lession. The tissue that depends on the vessel becomes ischaemic.
 * Angina (or more formally angina pectoris) is the chest pain that is caused by heart that receives less blood than it needs to survive. Ischaemic heart disease causes angina.
 * Myocardial infraction: Roughly, no blood is supplied to a territory of the heart. A stenotic lesion has become totally occluded for some reason, or thrombus has been created (because of the stenotic lesion) that wont let blood flow towards the rest of the heart tissue.
 * Graft: Graft in the context of cardiac surgery, is a tube that is used to overpass a stenotic lesion and thus protect the heart from an infraction. Grafts used in CABG are other body vessels, either veins or arteries.


 * Ones I have no clue about
 * left internal mammary artery (maybe elaboration isn't necessary for this one, but the link doesn't make sense to me)
 * Each important artery in our body has a name. Now, in most cases, there are two pairs of each artery, one in each side of our body. Left kidney artery, right kidney artery. Left testicular artery, right testicular artery. So Left IMA is the IMA on the left side of our body. In many cases, there are two arteries suppling a tissue or an organ. There are various ways to qualify them, one of them is being exterior or interior to another structure. In this case, since the location of the specific artery is within the rib cage, it is called interior. (There is another artery that is called external mammary artery). Mammary signifies that it mostly supplies mammaries, mammaries are the breasts we have. So the artery that runs parallel and somewhat left to our sternum, inside of the ribs, is called  left internal mammary artery or LIMA. There is another one in the right side, it is called Righ internal mammary artery (RIMA). To make things more confusing, some decades ago, it was known as Left internal Thoracic Artery (LITA) and RITA. But now the word mammary is more commonly used. Are you still perplexed? Any questions? Dont hesitate, please ask! Cinadon36 09:41, 17 December 2022 (UTC)
 * That all makes sense. My question is why the link is to Anatomy of the human heart; is there a more appropriate place we could link to? Left internal mammary artery doesn't seem to exist... Ovinus (talk) 15:39, 22 December 2022 (UTC)
 * Maybe it should exist as a separate article, but since it does not, I had to link it somewhere. Should I dare create a new article? why not. Gimme a minute. <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 17:16, 22 December 2022 (UTC)
 * I created a redirect page. . There s an article on ITA after all. <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 17:19, 22 December 2022 (UTC)
 * Great! If you want to expand the left internal mammary artery part then that article seems like a good place to do so. Ovinus (talk) 18:04, 22 December 2022 (UTC)
 * Thanks that is tempting but I prefer spending my time in few articles, not to expand too much. Maybe later. <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 19:32, 22 December 2022 (UTC)
 * dobutamine stress echocardiography
 * Echocardiography, or echo, is a scan of the heart. Basically, you can check how heart contracts, and also how valves are working. It is widely used to examine all kinds of patients, either they are having symptoms or not (ie young athletes). It examines the heart when patient is resting. Sometimes, a CAD does not have any echographic manifestations when patient is at rest. So what cardiologists do to overcome this issue? Instead of walking in a treadmill (as it happens with cardiac stress test), they inject dobutamine to the patient. dobutamine is a drug that makes heart work as if patient is exercising. Then cardiologists can see how heart is functioning and valves work, under stress. This examination is called dobutamine stress echocardiography. It is considered more advanced than echocardiography.
 * Could we find a suitable place to wikilink this? And could we introduce it in the "Coronary artery disease" section instead of "stable patients"? I've removed the parenthetical in "Stable patients" containing a list of noninvasive procedures, since that should be redundant with the section above. Ovinus (alt) (talk) 21:04, 19 January 2023 (UTC)
 * LV function
 * Function of Left Ventricle
 * LM disease
 * CAD disease spotted in the Left Main Artery (LM). It is considered more significant that stenosis in some other branch of cardiac arteries. LM has two branches LAD and Cx
 * LAD.
 * Left Ascending Artery. The most significant vessel of the heart, after Left Main Artery. It supplies large part of Left Ventricle.
 * Cx
 * Circumflex artery. A branch of the LM.
 * RCA
 * Right Coronary Artery. Supplies the right ventricle (roughly speaking)

Continuing

 * Is "atheromatic" or "atheromatous" more common? Our article atheroma seems to use the latter. Ovinus (alt) (talk) 21:04, 19 January 2023 (UTC)
 * Atheromatous is more common
 * "Patients at risk of ongoing ischemia" Aren't all patients with acute coronary syndrome at risk of ongoing ischemia? Ovinus (alt) (talk) 21:04, 19 January 2023 (UTC)
 * Yes, they are.
 * "six hours in cases of non-transmural MI, and three days in cases of transmural MI" Can you reword this to avoid the term "transmural"? Ovinus (alt) (talk) 21:04, 19 January 2023 (UTC)
 * Hm, I will try to think of something during the weekend.
 * What is "valve disease"? Ovinus (alt) (talk) 21:04, 19 January 2023 (UTC)
 * "Valve disease" refers to a disease of a heart valve of heart. See Valvular heart disease. Most commonly, it affects aortic valve or mitral valve and the lession can be either stenotic or regurgitation.

Thanks for your ongoing effort to improve the article. <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 08:48, 20 January 2023 (UTC)


 * If you could think of a better way to define or explain "pseudo-lumen", that would be appreciated. Ovinus (talk) 22:25, 23 January 2023 (UTC)
 * In dissection, the internal layer of the aorta is teared (Aorta has 3 layers). After the tear, the two layers (internal and the "middle one") separate because of the blood pressure's force. A space is created that resembles a lumen. This illustration from Radiopedia may help you visualize what a false is . AoDissect Schema 01a.png ]]


 * "runoff of LM is not protected by a patent graft since previous CABG operation" what is a runoff? I don't understand Ovinus (talk) 22:25, 23 January 2023 (UTC)
 * Runoff is the vascular bed after a given point. For example the runoff of Left Main is the left anterior descending (LAD) and Circumflex artery (Cx). So lets say a patients has a lesion at LM, then in case of occlusion, the branches (LAD and Cx) will have no blood flowing through them. Now, had a patient had a CABG (with an anastomosis to LAD), and subsequently developed an LM lesion, there will be less risk for him since blood will still be delivered. Thus, in the former case, it is said that the patient has an "unprotected LM", while in the latter case, he has "protected LM"
 * "branch of the conduit insufficiently sealed or from the sternum" What does this mean? (The vessel is attached to the sternum during the procedure?) Ovinus (talk) 22:25, 23 January 2023 (UTC)
 * Maybe it needs an oxford comma. Common sites of surgical bleeding in cases of CABG include a) the sternum and b)a branch of a graft-conduit that has not been sealed properly.
 * Gotcha
 * "optimization of pre- and afterload" What are these? Ovinus (talk) 04:41, 25 January 2023 (UTC)
 * Think as if load means "work has to be done". Pre-load, means the work has to be done for issues that are "before" heart. The more blood there is in the venous systems, the more the work heart has to do in order to circulate it. Afterload, is the work that has to be done for issues that lies "ahead" of the heart. Lets say the arteries constrict for a reason and thus blood pressure rises. So, heart will spend more energy to move 100 ml of blood from its champers to the circulation. In such cases, we say "there is increased afterload". Going back to the article, when writing "optimization of pre- and afterload" I mean we make sure there is adequate but not excessive fluid within the veins and the blood pressure is not too high. Look, I know pre-load and afterload are not easy meanings to grasp. If there are any questions, pls ask. <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 08:22, 25 January 2023 (UTC)
 * "either technical or patient factors" What is a technical factor? Ovinus (talk) 04:41, 25 January 2023 (UTC)
 * An infraction may occur because of technical factor (bad anastomosis technique, kinking of the graft, too much tension of the graft, rotation of the graft) or a patient factor (commonly: too much coronary artery disease) <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 08:25, 25 January 2023 (UTC)
 * "New ECG features as Q waves and/or US documented alternation of cardiac wall motions are indicative." Indicative of what? Ovinus (talk) 04:41, 25 January 2023 (UTC)
 * Indicative of the Myocardial Infraction.<b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 08:26, 25 January 2023 (UTC)
 * "Inflammation caused by CPB, hypoperfusion or cerebral embolism." What are we saying about the inflammation? Ovinus (talk) 04:41, 25 January 2023 (UTC)
 * Oh, ok, makes no sense. Fixed that. <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 08:28, 25 January 2023 (UTC)
 * "hypoperfusion" What does this mean in context? Ovinus (talk) 04:41, 25 January 2023 (UTC)
 * It means that brain does not adequate blood (and oxygen). Most common it is because of technical factors (aortic cannula that delivers blood to the body during CPB has been misplaced)<b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 08:30, 25 January 2023 (UTC)

Pre-GAN note
This page has two tags that really should be resolved immediately. Sammi Brie (she/her • t • c) 19:49, 24 August 2023 (UTC)


 * Not any more! Thanks <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 20:40, 24 August 2023 (UTC)

Recent edits
Recent edits by Wpntm have tried to increase the prominence of René Favaloro in the history section; while that might be a worthy goal, I'm not really sure that was the best way of going about it so I reverted them. The sources they used were good as far as these things go, but are not as comprehensive as the Head (2013) reference that's already in the article; I don't know much about the topic but I doubt there's a much better source than Head (2013), which also gives a little more prominence to Favaloro than we do ... although not in a very encyclopedic way. Also see the conversation about this on Wpntm's talk page, but further comments should probably go here. Pinging Cinadon36, the main writer of this page. Graham87 (talk) 15:49, 17 October 2023 (UTC)


 * Totally agree with you @Graham87. I just want to add that sources from the NHS fail WP:MEDRS. Sources have to be published works at peer reviewed journals and books of the same level. <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 18:06, 17 October 2023 (UTC)
 * Thank you both for your comments. I'll review the literature again and get back to you. Wpntm (talk) 09:42, 18 October 2023 (UTC)
 * Hi @Graham87 and welcome to WP! Allow me to give you an advice, since you are a new editor here:
 * Backward editing: "Here is what the article should say, now let's find sources to support each fact..."
 * Forward editing: "Here are three good sources about this topic, now let's summarize them..."
 * (From 's userpage). Choose the Forward editing. It will save you time and it is much more rewarding. Cheers! <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 21:27, 18 October 2023 (UTC)
 * I think you meant to address this to Wpntm, but I'd never encountered that link myself either; I entirely agree with its sentiments. Graham87 (talk) 04:04, 19 October 2023 (UTC)
 * Also this user debated characterisation of them as a newby on their talk page ... but it's only your record as a registered editor that really counts here. It's impossible to verify any claimed contributions as an unregistered user except in unusual circumstances, anyhow. Graham87 (talk) 04:20, 19 October 2023 (UTC)
 * Hi @Graham87. My bad, it was not meant for you. Thanks for pinging the right editor. <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 21:25, 19 October 2023 (UTC)
 * Also this user debated characterisation of them as a newby on their talk page ... but it's only your record as a registered editor that really counts here. It's impossible to verify any claimed contributions as an unregistered user except in unusual circumstances, anyhow. Graham87 (talk) 04:20, 19 October 2023 (UTC)
 * Hi @Graham87. My bad, it was not meant for you. Thanks for pinging the right editor. <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 21:25, 19 October 2023 (UTC)

Removing internal link to endoscopic harvesting
I removed two recently added internal links to endoscopic harvesting. Not all, or even most, harvesting is done endoscopically. Moreover, sources are not saying such a thing. So, I believe it should not be added again. . <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 08:53, 27 November 2023 (UTC)
 * Have restored previous edits but have changed the linked page name to Vessel harvesting. Thanks --Iztwoz (talk) 10:57, 27 November 2023 (UTC)
 * "Vessel harvesting" is much more appropriate, thanks. Note, linking once is sufficient, to avoid the "sea of blue" <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 12:40, 28 November 2023 (UTC)
 * You removed all links so have replaced one in lead and one in harvesting subsection known as a local link. It's usual to use links in captions too. Have also replaced the refs that you removed as nonMEDRS - Pages from websites of renowned organisations are constantly used usually providing up to date info. Have a look at the references sections of almost any medical/anatomy page. Examples from Good articles are found on Malaria, COPD, and Tuberculosis. CDC, NIH, NCBI, American Cancer Society, WHO factsheets and reports, NCI and more are all in use.--Iztwoz (talk) 22:19, 28 November 2023 (UTC)
 * Definitely failing MEDRS the links you added. I will remove them again. I wont be looking at other article, I will be looking at the guideline and stick to it. We need peer reviewed articles or books. <b style="display:inline; color:#008000;">Cinadon</b><b style="display:inline; color:#c0c0c0;">36</b> 15:23, 6 December 2023 (UTC)