Before I start today’s article, I want to wish all my readers a very Happy Thanksgiving! You should enjoy your dinner because today is one of the few days when you need to give yourself permission to eat without guilt.
With that said, it’s time to talk about Heart Disease, specifically Coronary Artery Disease (CAD). Remember that there are 5 major risk factors for Atherosclerosis, and these include Hypertension, Type 2 Diabetes, Smoking, High Cholesterol, and Age. I want to give a little lesson about Heart Bypass Surgery.
First of all, I know most people get confused between having an angioplasty and a stent, NOT stint, and heart bypass surgery. Technically speaking, stent placement in a heart artery is a procedure and not an operation. It is done by a cardiologist in the cardiac cathetherization suite and the patient is just given sedation. Cardiologists do not open up the chest and “touch” the heart. They are not trained in surgery. I know the media always says that some famous person had heart surgery and had a stent placed. Now you know that is incorrect! I am only making this clarification because it is imperative that patients know and understand the difference between the two procedures. Both procedures are done to relieve an obstruction by giving the blood a new pathway to the heart.
Coronary Artery Bypass Surgery, know as a CABG, is done by a cardiac surgeon in the operating room under general anesthesia. During coronary artery bypass graft surgery, a blood vessel is removed or redirected from one area of the body and placed around the area or areas of narrowing to "bypass" the blockages and restore blood flow to the heart muscle. This vessel is called a graft. These substitute blood vessels can come from your chest, abdomen, legs, or arms. They're safe to use because there are other pathways that take blood to and from those tissues.
Which Blood Vessels Are Used for Grafts in Heart Bypass Surgery?
There are several types of bypass grafts used for heart bypass surgery. The surgeon decides which graft(s) to use, based on the location of the blockage, the amount of blockage, and the size of the patient's coronary arteries.
• Internal mammary arteries (also called internal thoracic arteries). The Left Internal Mammary Artery (LIMA) is the most common bypass graft used, as this has been shown to have the best long-term results (patency). In most cases, these arteries can be kept intact at their origin since they have their own oxygen-rich blood supply. During the procedure, the arteries are sewn to the coronary artery below the site of blockage. This artery is located in the chest on the underside of the sternum and can be accessed through the primary incision for the bypass surgery.
• Saphenous veins. These veins are removed from your leg, and then sewn from your aorta to the coronary artery below the site of blockage. Minimally invasive saphenous vein removal may be performed and results in less scarring and a faster recovery.
• Radial artery. There are two arteries in the lower part of the arm, the ulnar and radial arteries. Most people receive adequate blood flow to their arm from the ulnar artery alone and will not have any side effects if the radial artery is removed and used as a graft. Careful preoperative and intraoperative tests determine if the radial artery can be used. If you have certain conditions (such as Raynaud's, carpal tunnel syndrome, are a smoker, or painful fingers in cold air) you may not be a candidate for this type of bypass graft. The radial artery incision is in your forearm, about 2 inches from your elbow and ending about 1 inch from your wrist. Some people report numbness in the wrist after surgery. However, long-term sensory loss or numbness is uncommon.
• The gastroepiploic artery to the stomach and the inferior epigastric artery to the abdominal wall are less commonly used for grafting because these are actually in the abdomen. A patient needs to have both their chest and abdomen opened up. While cardiac surgeons don’t like to use this type of graft, infrequently we are left with no other choice.
It is common for three or four coronary arteries to be bypassed during surgery. I personally have done a CABG X 7, but this is extremely uncommon. A coronary artery bypass can be performed with traditional surgery or with a minimally invasive approach. Your surgeon will review your diagnostic tests prior to your surgery to see if you are a candidate for minimally invasive bypass surgery.
How Is Traditional Heart Bypass Surgery Performed?
During traditional heart bypass surgery, a surgeon makes an incision (about 6 to 8 inches) down the center of your sternum (breastbone) to get direct access to your heart. You are connected to a heart-lung bypass machine (called "on-pump" surgery), which allows for circulation of blood throughout your body during surgery. The heart is stopped and the surgeon then performs the bypass procedure described above. The heart is generally stopped for about 30-90 minutes of the 4-5 hour surgery. After surgery, the surgeon closes the breastbone with special sternal wires and the chest with special internal or traditional external stitches.
What Is Off-Pump Heart Bypass Surgery?
"Off-pump" or beating heart surgery allows surgeons to perform surgery while the heart is still beating. Not all patients are candidates for off-pump surgery. The heart-lung machine is not used. The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.
With present technology, all coronary arteries can be bypassed off-pump. The off-pump technique may be ideal for certain patients who have an increased risk of complications from being placed on the heart-lung machine, such as those who have vascular disease, heavy plaque buildup in the aorta (aortic calcification), carotid artery stenosis (narrowing or blockage in the arteries leading to the brain), prior stroke or transient ischemic attacks (TIAs), or breathing or kidney function problems.
What Is Minimally Invasive Heart Bypass Surgery?
During minimally invasive bypass surgery, the surgeon performs the surgery through a small incision (about 3 inches) or multiple small incisions in the chest. It may be an option for some patients who require a left internal mammary artery graft to the left anterior descending artery only.
Some patients are also candidates for surgery using robotic-assisted techniques, allowing surgeons to perform bypass surgery in a closed chest, beating-heart environment through even smaller keyhole incisions.
The benefits of minimally invasive bypass surgery include:
A smaller incision, thus a smaller scar.
A shorter hospital stay. In some cases, only 3 days are needed (instead of the average 5 to 6 days for traditional surgery).
Shorter recovery time.
Less bleeding.
Less potential for infection.
Less pain and trauma.
For further guidance or medical advocacy, please go to PaladinsMDs because “it’s like having a doctor in the family.”
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