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coronary artery bypass graft surgery

Coronary artery bypass graft (CABG)
this factsheet is for people who are planning to have a coronary artery bypass graft (CABG) or who would like information about it.

A CABG is ‘open-heart’ surgery to treat coronary artery disease. A CABG uses a blood vessel (called a graft) taken from your chest, leg or arm to bypass a narrowed or blocked coronary artery.

Your care will be adapted to meet your individual needs and may differ from what is described here. So it’s important that you follow your surgeon’s advice.

About CABG
If you have coronary artery disease, your coronary arteries become narrowed or blocked, restricting the supply of oxygen and nutrients. This starves the heart of oxygen, which causes angina. Angina is the feeling of chest pain, chest tightness and sometimes breathlessness or choking.

A CABG can bypass the blocked arteries so that blood can flow more easily. A new blood vessel (a graft) is attached from your aorta (your main artery) to a point in the coronary artery beyond the blockage. Your graft(s) can be created from blood vessels taken from your chest wall, leg or arm.

A CABG won’t cure coronary artery disease so it’s possible for blockages to recur in both the grafts and other blood vessels, but it does improve symptoms such as angina.

What are the alternatives to CABG?
Depending on the condition of your arteries you may be offered a different treatment, such as percutaneous transluminal coronary angioplasty (PTCA). This flattens the material blocking your artery so blood can flow again.

Your surgeon will advise you which treatment is most suitable for you.

Preparing for your CABG
Your surgeon will explain how to prepare for your operation. For example if you smoke you will be asked to stop, as smoking increases your risk of getting a wound infection and slows your recovery.

A CABG usually requires around a week in hospital. The operation is usually done under general anaesthesia. This means you will be asleep during the operation.

You will be asked to follow fasting instructions. Typically you must not eat or drink for about six hours before a general anaesthetic. However, some anaesthetists allow occasional sips of water until two hours beforehand.

At the hospital your nurse may check your heart rate and blood pressure, and test your urine.

Your surgeon will usually ask you to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.

You may be asked to wear compression stockings to help prevent blood clots forming in the veins in your legs.

About the operation
The procedure takes around three hours, but may take longer depending on how many grafts need to be done.

If blood vessels from your leg or arm are being used for grafts, your surgeon will remove and prepare these first.

Your surgeon will then make a cut, about 25cm (10 inches) long, down the middle of your breastbone (sternum) and will open your ribcage to reach your heart.

Your surgeon may attach the new grafts while your heart is still beating, but it’s more common to temporarily stop your heart. Your blood is then diverted to a heart-lung (bypass) machine. This takes over from your heart and lungs to add oxygen to your blood and maintain your circulation.

The grafts will be attached and your heart will be restarted. Your sternum will be rejoined using wires and the skin on your chest will be closed with dissolvable stitches.

Keyhole surgery
The operation can also be done using keyhole (or minimally invasive) surgery. Instead of a large cut down the sternum, the operation is done through small cuts. Special instruments are passed through the cuts and the surgeon looks at a monitor to see inside your chest. Keyhole surgery isn’t suitable for everybody – your surgeon will advise you if it’s appropriate for you.

What to expect afterwards
After a CABG, you will be taken to the intensive care unit (ICU) and will be closely monitored for about 24 hours before you go back to your ward.

When you wake up you will be connected to machines that record the activity of your heart, lungs and other body systems. These might include a ventilator machine to help you breathe.

You may need pain relief to help with any discomfort as the anaesthetic wears off.

You may have a catheter to drain urine from your bladder into a bag. You may also have fine tubes running out from the wound. These drain fluid into another bag and are usually removed after a day or two.

You will be encouraged to get out of bed and move around as this helps prevent chest infections and blood clots in your legs.

A physiotherapist will usually visit you every day to guide you through exercises designed to help your recovery.

When you are ready to go home, you will need to arrange for someone to drive you home. You should try to have a friend or relative stay with you for the first 24 hours.

Your nurse will give you some advice about caring for your healing wounds before you go home. You may be given a date for a follow-up appointment.

The wires holding your sternum together are permanent. Dissolvable stitches will disappear in seven to 10 days on their own.

Recovering from CABG
If you need pain relief, you can take over-the-counter painkillers such as paracetamol. Do not take ibuprofen if you are taking aspirin. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice.

The sternum takes about six weeks to heal but a full recovery can take two to three months. Your surgeon will give you advice about how soon you can return to work.

Follow your surgeon’s advice about driving. You shouldn’t drive until you are confident that you could perform an emergency stop without discomfort. This is usually about four weeks after the operation. If you drive a lorry or a bus you need to notify the DVLA about your operation. You will be disqualified from driving for three months and you will need to take an exercise test before driving again.

What are the risks?
CABG is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.

Side-effects
These are the unwanted, but mostly mild and temporary effects of a successful treatment, for example feeling sick as a result of the general anaesthetic.

After a CABG you will usually feel some discomfort and have some swelling around the wound areas for a few weeks.

You’re likely to have permanent scars on your chest and in the area from where your graft is taken. These may fade over time.

You may suffer from poor memory and concentration, this usually wears off gradually within six months.

Complications
This is when problems occur during or after the operation. Most people are not affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT).

Specific complications of a CABG are rare but can include:

a heart attack
a stroke
death – it’s important to consider that having no treatment, or having an alternative treatment, may have a higher risk
If you have keyhole surgery, there’s a chance your surgeon may need to convert your keyhole procedure to open surgery. This means making a bigger cut on your chest. This is only done if it’s impossible to complete the operation safely using the keyhole technique.

The exact risks are specific to you and differ for every person, so we have not included statistics here. Ask your surgeon to explain how these risks apply to you

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