QuestionSBA
QuestionChoice
Coronary stenting is often used in the management of acute coronary syndrome (ACS); however, for three-vessel coronary disease, outcomes are better with the use of CABG
32259
b
Insertion of drug-eluting coronary stents
QuestionChoice
This patient has significant three-vessel coronary artery disease. This is the most severe form of coronary atherosclerosis and management is usually with a CABG. This is a surgical procedure that aims to divert blood flow away from the areas of stenosis by using a graft from the chest, arm or leg
32258
a
Coronary artery bypass graft (CABG)
QuestionChoice
A heart transplant would be reserved for patients with severe heart failure or coronary artery disease that is refractory to all medical and surgical management options. A CABG would be considered first for a patient with triple-vessel disease
32261
d
Cardiac transplantation
QuestionChoice
Urgent revascularisation has a prognostic benefit in patients with ST-elevation myocardial infarction (STEMI). Therefore it would not be appropriate to manage this patient with medical management alone
32262
e
Medical management with dual antiplatelet therapy (DAPT)
QuestionChoice
Drug-coated balloons only (i.e. without stents) are used in certain centres for the treatment of certain cases of de novo coronary artery disease. They have the advantage that they avoid the risk of stent thrombosis and thereby reduce the length of dual antiplatelet treatment. However, for 3 vessel disease, CABG would be a better option
32260
c
Drug-coated balloon only angioplasty
QuestionComment
if there was only one or two vessels would stents be the best option? or would CABG still be preferred?
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Anon
QuestionComment
Why not a PCI?
26807
QuestionComment
AFAIK the choice to perform PCI vs CABG depends on many factors and may be influenced by the surgeon themselves as they may have a preference in terms of expertise. Generally in "multivessel" disease, CABG is the preferred option but there are instances where PCI could be used you are correct.

I believe the highest yield takeaway from the question is that the patient is diabetic. Diabetic patients have far more extensive and complex disease of their coronary arteries compared to non diabetic patients. If multi-vessel disease occurs in a diabetic then CABG is strongly preferred over PCI.
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;-;
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Loose Myopathy
QuestionComment
but would you attempt it in an acute setting though? i thought cabg would be done in a subacute setting
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BeethovenVirus-ed
QuestionComment
quesCardiologist
62013
QuestionComment
came looking for this comment
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Vaccine Complement
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Wilsons Chronic
Concept
Chapter
# Summary

A coronary artery bypass graft (CABG) is a revascularisation technique used to treat coronary artery disease. It uses harvested blood vessels from other parts of the body to bypass narrowed coronary arteries thus improving blood flow to the heart. It should be considered in those whose symptoms are not controlled by optimal medical management and in those who have complex 3 vessel disease. CABG has an excellent prognosis, with a 5-year survival estimated at 92%. 

# Definition 

A coronary artery bypass graft (CABG) is a revascularisation technique used to treat coronary artery disease. A surgeon uses a healthy blood vessel, usually veins taken from the leg or chest, and attaches it to the heart so blood can get round the narrowed coronary artery. 

# Indication 

Revascularisation with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) must be considered in patients with:  

* Symptoms which are not controlled by optimal medical management.
* Complex 3 vessel disease and/or significant left main stem on CTCA. 

PCI may be more cost-effective than CABG. However, CABG confers a mortality benefit in patients who are >65 years old, have diabetes, or who have complex 3 vessel disease (with or without left main stem stenosis). 

# Procedure

With the patient under general anaesthetic, a midline sternotomy incision is made and the chest is opened. The heart may be placed 'on-pump' or the surgery may be'off-pump'. Blood vessels are usually either harvested from the legs (long saphenous vein) or from the chest (internal mammary artery). These blood vessels are then attached to the heart to bypass narrowed coronary arteries. The procedure often takes between 3-6 hours. Most people make a full requires within 12 weeks. 

# Identifying CABG patients 

Common signs include: 

* Midline sternotomy scar
* Harvest scars - longitudinal graft scar on either leg. 
* No 'click' that you would expect with metallic valve replacement. 

# Complications

Common post-operative complications include post-operative bleeding, arrhythmias (most commonly atrial fibrillation), low output cardiac syndrome (requiring inotropes), and midline sternotomy wound infection. 

Long-term complications include narrowing of grafted vessels that require further treatment.

# Prognosis 

Overall survival at 5 years is estimated at 92%. 

# NICE Guidelines

[NICE Guidance for CABG](<https://www.nice.org.uk/guidance/IPG377>)

[NICE Guidance on Stable Angina](<https://www.nice.org.uk/guidance/cg126>)

# References

[2020 Article on the Role of Revascularisation in Stable Angina](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305572/)
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Coronary Artery Bypass
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Cardiology
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Coronary artery bypass grafting (CABG) is indicated for patients with significant three-vessel coronary artery disease to improve blood flow and reduce ischaemia.
A 61-year-old man with a background of type 1 diabetes and hypertension presents with a 30-minute history of chest pain radiating to the left jaw, which is unrelieved by rest or glyceryl trinitrate (GTN). He has anterolateral ST elevation on his ECG and is sent for urgent coronary angiography.

Coronary angiography shows significant stenosis of the left anterior descending, left circumflex and right coronary artery.

Which of the following is the best step in management?
a