Coronary Artery Bypass Grafting (CABG): bypass arteries on the heart that are blocked or narrowed down which cause decreased blood flow to the heart muscle. Blood carries oxygen and nutrients to the heart muscle and if impeded by blockages this can cause heart pain (angina) or if severe enough or if it abruptly blocks it can produce a myocardial infarction ("M.I." or "heart attack"). C.A.B.G. surgery will provide an alternate route for blood supply to the endangered heart muscle around the severe blockages.
This surgery Dr. Lico will routinely perform "off pump" or as an Off Pump Coronary Artery Bypass Grafting (OPCABG) procedure. This means that the heart/lung bypass machine will not be used to support the heart and lung functions during the surgical bypass procedure. However, the heart/lung machine can be utilized to support the patient if they were not a candidate for the less invasive OPCABG.
After the patient is placed to sleep by the anesthesiologist, who will support the patients breathing via a tube passed trough the mouth and throat and down into the trachea (windpipe), Dr. Lico begins the incisions. An incision is made down the middle of the breastbone so that the breastbone can be cut in half lengthwise. Dr. Lico then tuns his attention to harvesting the internal mammary artery (IMA, see below) while an assistant harvests SVG (see below) from the leg , if necessary.
Dr. Lico uses multiple possible conduit choices to supply blood past the blockages. It is important to let the surgeon or his assistants know if you have ever had surgical vein strippings for varicose veins in your legs or if you have ever been treated for clots in the veins in your legs (DVT) or had previous phlebitis in a leg (inflammation or infection of a vein).
The choices for conduit to supply blood flow past the blocked arteries on the heart include:
- Internal Mammary Artery (IMA): either the left or right IMA can be harvested from the inside of the chest wall, on the right side or the left side, adjacent to the sternum (breastbone). Once prepared the IMA makes an ideal bypass or conduit to carry blood past an arterial blockage on the heart.
- Greater Saphenous Vein: commonly referred to as reversed Saphenous Vein Graft (SVG): can be harvested from the right or left leg. This lays on the inner aspect of the thigh and on the inner aspect of the calf/lower leg. It extends from just above the ankle up to the groin. The preferred method of harvesting this vein is by the Endoscopic Vein Harvesting method (EVH). With this technique an approximately 2 cm. incision is made on the inner aspect of the leg just below or above the knee in order to locate the greater saphenous vein. Once the vein is located, a tunnel is created and a small telescope/dissector passed into the leg alongside the vein in order to free it from surrounding tissues and branches. Once freed up, the vein can be passed out of the leg and prepared for use as a conduit to carry blood past the arterial blockages on the heart.
- Radial Artery: the radial artery is one artery of the dual supply system in your right and left forearms that can sometimes be harvested from your arm if clinical exams and studies can document adequate continued blood flow to your hand from the remaining ulnar artery and palmar arch artery.
- Lesser Saphenous Vein: in rare instances, and if there is no other suitable tissue conduit to harvest, this vein can be harvested from the back of the left or right calf and be reversed and used as a bypass graft.
Once adequate conduit has been identified /harvested, Dr. Lico proceeds with the operation. A series of stabilizing tools are used to position the heart to allow Dr. Lico to visualize the coronary arteries that require bypass grafts to be placed (bypassed) onto them. The bypass grafts are anastamosed or sewn into position using very fine suture material.
Once the bypasses have been completed and Dr. Lico is satisfied that bleeding is under control, then the process of closing the chest incisions is performed. Previous to this, the leg and/or arm incisions will have been suture closed with absorbable suture material.
Chest drains are placed inside the pericardium (heart sack) and in the space around the lung, if the pleura (space around the lung) has been entered. These tubes help drain any excess blood or serum from the surgical area to an outside collecting chamber for the first several days after surgery.
Temporary pacemaker wires may be gently attached to the surface of the heart, which can be easily removed several days after surgery, if they are deemed necessary to support the heart rhythm and function.
At this time, the separated sternal bone edges are approximated (brought together) using stainless steel cables or wires. These cables help keep the bone edges together until they have adequate time to heal (typically over the next 8-12 weeks). The stainless steel cables or wires remain a permanent part of the sternal/chest wall closure (unless a problem related with the wires were to develop, which is very rare).
Then the soft tissue and skin over the sternum is closed with absorbable sutures and dry sterile dressings are placed over the incisions.
At this point the patient is transferred to a critical care bed by the team and transported to the Open Heart Unit.