CABG

(CORONARY
ARTERY BYPASS
GRAFT)

CABG
is a surgical procedure in which a blood vessel is grafted to an occluded
coronary artery so that blood can flow beyond the occlusion.
is a surgery that increases blood flow to the heart by creating a detour and
re-routing the blood flow around the blocked portion of the artery.

is a surgical procedure performed to relieve angina and reduce the risk of

death from coronary artery disease. Arteries or veins from elsewhere in the
patients body are grafted (internal thoracic arteries, radial arteries and
saphenous) 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 .

Number of 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 :
double bypass means two coronary arteries are bypassed (e.g. the left
anterior descending (LAD) coronary artery and right coronary artery (RCA)
triple bypass means three arteries are bypassed (e.g. LAD, RCA, left
circumflex artery (LCX)
quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX,
first diagonal artery of the LAD) Bypass of more than four coronary arteries
is uncommon.

Purposes

 Restore blood flow to the heart

Relieves chest pain and ischemia
Improves the patients quality of life
Enable the patient to resume a normal lifestyle
Lower the risk of a heart attack

Indications For CABg

Patients with blockages in coronary arteries
Patients with angina
Patients who cannot tolerate PTCA (Percutaneous transluminal coronary
angioplasty ) and do not respond well to drug therapy

Contraindications For CABG

Aneurysms
Valvular diseases
Congenital diseases
diseases of blood

Angina Pectoris - is recurring acute chest pain or discomfort

resulting from decreased blood supply to the heart muscle(myocardial
ischemia). Angina occurs when the hearts need for oxygen increases beyond
the level of oxygen available from the blood nourishing the heart. Angina is a
common symptom for coronary heart disease (CHD)

Types of Angina
Stable angina- predictable and consistent pain that occurs on exertion and is
relieved by rest and/or nitroglycerin.
Unstabale angina-also called preinfarction angina or cresendo angina)
sysmptoms increase in frequency and severity;may not be relieved with rest
or nitroglycerin.
Intractable or refractory angina-severe incapacitating chest pain
Variant angina-also called Prinzmetals angina pain at rest with reversible ST
segment elevation; thought to be caused by coronary artery vasospasm.
Silent angina-objective evidence of ischemia(such as electrocardiographic
changes with a stress test), but patient reports no pain.

RISK FACTORS FOR ANGINA

Advanced age
Coronary artery disease
Hypertension
Increased serum glucose levels (diabetes)
Increased serum lipoprotein levels
Obesity
Smoking
Type A personality

INITIATING FACTORS OF AN ATTACK

Cold weather
Emotions
Heavy meals
Hypoglycemia
Pain
Smoking

Chest pain (Severe chest discomfort (heaviness, pressure,

tightness, choking, squeezing)
SOB
Pallor
Diaphoresis
Cool clammy skin
Nausea & Vomiting
Light-headedness
Anxiety
T waves inversion

S/S

MEDICAL MANAGEMENT
The objectives of the medical management of angina are:

To decrease the oxygen demand of the myocardium

To increase the oxygen supply

Medically these objectives are met through pharmacologic therapy and

control risk factor.
Alternately reperfusion procedures may be used to restore blood
duupply to myocardium these include CABG

Greater Saphenous Vein (GSV)

The Greater Saphenous Vein (GSV) of the lower extremity is the best choice.
GSV is harvested in two different ways:
1.Directly through multiple incisionsDirectly through multiple incisions
tunnelling over the vein along the medial thigh and leg.
2.Endoscopic vein harvest two small incisions are made, one above the
knee, and the second upper thigh for this type of harvest.

Surgical Procedure
An endotracheal tube is inserted and secured by the anaesthetist and
mechanical ventilation is started. General anaesthesia is maintained by
a continuous very slow injection of Propofol.
The chest is opened via a median sternotomy and the heart is
examined by the surgeon involves creating a 6 to 8 inch incision in the
chest (a thoractomy) .
The bypass grafts are harvested frequent conduits are the internal
thoracic arteries, radial arteries and saphenous veins. When harvesting
is done, the patient is given heparin to prevent the blood from clotting.
"on-pump", the surgeon sutures cannulae into the heart and instructs
the perfusionist to start cardiopulmonary bypass (CPB). Once CPB is
established, the surgeon places the aortic cross-clamp across the aorta
and instructs the perfusionist to deliver cardioplegia to stop the heart
and slow its metabolism

One end of each graft is sewn on to the coronary arteries beyond the

blockages and the other end is attached to the aorta

Chest tubes are placed in the mediastinal and pleural space to drain
blood from around the heart and lungs.
The sternum is wired together and the incisions are sutured closed.
The patient is moved to the intensive care unit (ICU) to recover.
Nurses in the ICU focus on recovering the patient by monitoring
blood pressure, urine output and respiratory status as the patient is
monitored for bleeding through the chest tubes. If there is chest tube
clogging, Thus nurses closely monitor the chest tubes and under take
methods to prevent clogging so bleeding can be monitored and
complications can be prevented.

 After awakening and stabilizing in the ICU (approximately one day),

the person is transferred to the cardiac surgery ward until ready to go
home (approximately four days).

PATIENT HEALTH EDUCATION

For post operative care: Wound care

Do not wet the wound (first 3 weeks after surgery).
Keep forearm / leg wounds dry.
If wound get wet, immediately dap with dry towel.
Use antiseptic soap when bath (after 3 weeks)
Discharge Planning & Teaching

What to expect at home?

Pain in your chest around the incision area
Swelling in the leg at harvest site
Itchiness or tingling feeling at incision site
Weakness
Cardiac rehabilitation
Lifestyle & diet modification
Smoking cessation Cardiac diet (Low salt, low cholesterol, low
fat)
Activity
No driving for at least 4 to 6 weeks
Walking / climbing stairs are good exercise
Light household chores (folding clothes, setting tables
Self care
Self care Shower & wash incision gently with soap and water.
Do not use hot tubs until incision is completely healed.
Adhere to all medication regimen Have someone stay with you in
your home for at least first 1-2 weeks.