CardioSurgeon.co.uk
Coronary artery bypass grafting (CABG) is a surgical procedure designed to improve blood flow to the heart muscle when the coronary arteries have become narrowed or blocked by fatty deposits. During the operation, healthy blood vessels (usually taken from the chest wall, arm, or leg) are used to “bypass” the blocked sections of the coronary arteries (vessels that supply blood directly to the heart muscle), creating new pathways for blood to reach the heart. By restoring a better blood supply, CABG can significantly relieve symptoms such as chest pain (angina), reduce shortness of breath (cardiac breathlessness), and improve overall exercise tolerance and quality of life. Importantly, in many patients, it also reduces the risk of future heart attacks and can improve long-term survival, particularly in those with more extensive coronary artery disease. The procedure is carefully tailored to each individual, with the aim of achieving the best possible outcome and long-lasting benefits.
Current evidence shows that coronary artery bypass grafting (CABG) is often the preferred method of revascularisation for patients with diabetes and disease affecting multiple coronary arteries, as it provides more durable results, better symptom relief, and improved long-term outcomes compared to alternative treatments in this group. This is particularly important in diabetes, where coronary disease tends to be more widespread and complex, patients with failed previous stents and for complex and critical left main stem disease (diseases main artery that supplies over 60% of the heart with blood). However, every patient is different, and when additional medical conditions are present (such as lung disease, kidney problems, or frailty) that may increase the risks of surgery, the decision becomes more nuanced. In these situations, the choice between CABG and other treatments, such as stenting, is best made through a multidisciplinary “heart team” with cardiologists, cardiac surgeons, and other specialists working together to carefully assess the individual risks and benefits, ensuring that the chosen treatment is tailored to the patient’s overall health, preferences, and long-term wellbeing.
During bypass surgery, a new disease free blood vessel is taken from your body and used to bypass the diseased heart vessel in order to supply blood to your heart muscle. This new blood vessel can be created from lengths of vein taken from your leg or from an artery in your arm, or by redirecting the ‘internal mammary artery’ from inside the chest wall to your heart. The removed vessel is called a graft.
Before your operation, a careful assessment is carried out to identify the best blood vessels (grafts) to use for your bypass surgery. These may include arteries from the chest wall (internal mammary arteries), the arm (radial artery), or veins from the leg (long saphenous vein). It is important to understand that removing these vessels does not harm the areas they come from, as the body has a rich, alternative blood supply that allows the arm, leg, and chest wall to function normally with fewer vessels. During the operation, these grafts are attached to the coronary arteries beyond the narrowed or blocked segments, creating new pathways for blood to reach the heart muscle and restore its blood supply. Most patients require more than one graft, depending on the number and location of blockages.
The use of bilateral internal mammary arteries (BIMA) should be considered in all patients with a reasonable life expectancy and a low risk of sternal wound complications. The radial artery constitutes an alternative as the second arterial graft in patients in whom BIMA grafting is not feasible, patients with a high risk of sternal wound complications, or as a third arterial graft. Bilateral IMA (BIMA) and radial artery have been shown to provide better patency rates than saphenous vein grafts (SVG), particularly for the left coronary artery system. We favour the use of skeletonised internal mammary arteries, which means the artery is carefully prepared to preserve surrounding tissues, improving blood flow and reducing the risk of complications such as wound problems. We also routinely use minimally invasive techniques such as endoscopic harvesting for the radial artery and long saphenous vein, which involve smaller incisions and less tissue disruption. These approaches are designed to maximise the long-term benefits of the operation while reducing pain, lowering the risk of infection, and supporting faster recovery, improved wellbeing, and earlier return to normal activities.
Ensuring graft patency during coronary artery bypass grafting (CABG) is critical to achieving the best possible surgical outcomes. The use of intraoperative flow assessment technology, such as Medistim TTFM & epi-arterial ultrasound imaging allow surgeons to verify graft function in real time, reducing the risk of technical errors and early graft failure. This approach is strongly supported by guidance from National Institute for Health and Care Excellence (NICE), which recognises the value of transit-time flow measurement (TTFM) in improving surgical quality assurance and patient safety. By identifying and correcting issues before the patient leaves the operating theatre, intraoperative patency assessment contributes to better long-term outcomes and reduced need for reintervention. We are committed to the highest standards of care and therefore we utilise this technology in 100% of our CABG procedures, ensuring every patient benefits from the most rigorous intraoperative quality control available.
It is important to understand that CABG does not cure the underlying process of coronary artery disease, which is a long-term condition related to factors such as ageing, cholesterol levels, diabetes, and lifestyle. Over time, further narrowing or blockages can develop, either in the bypass grafts themselves or in other coronary arteries that were not originally treated. For this reason, surgery is only one part of your overall treatment. Long-term success depends on careful risk factor management, including taking prescribed medications, maintaining a healthy diet, staying physically active, controlling blood pressure, cholesterol, and blood sugar levels, and avoiding smoking. With the right combination of surgery, medical therapy, and lifestyle optimisation, most patients achieve excellent long-term outcomes and a significant improvement in both quality and length of life.
The operation lasts approximately three to five hours and usually requires a hospital stay of 5-7 days. It is performed under general anaesthesia, which means you will be asleep during the procedure, and will feel no pain.
First the arteries or veins that are to be used for your grafts, will be removed and prepared. Your surgeon will then make a cut (traditionally about 25cm long, mini sternotomy about 10-12cm long) down the middle of your breastbone (sternum) and open the ribcage to reach the heart. Next, the movement (beat) of the heart is temporarily stopped using medication and the blood re-directed to a heart-lung (bypass) machine. This machine takes over the pumping action of the heart and lungs, adding oxygen to the blood and maintaining the blood circulation. With the heart now bloodless and not moving, the new grafts can be attached. Once completed, the blood is re-directed from the machine back to your heart, and the heart restarted.
The breastbone is re-joined using wires and the skin on your chest is sealed using dissolvable stitches. Tubes are put into small holes in your chest to drain blood and fluid that collects as part of the normal healing process.
Off-pump coronary artery bypass (OPCABG) surgery (also known as “beating heart” surgery) differs from traditional bypass surgery in that the heart-lung machine is not used and the heart is not stopped. Instead, modern technology and specialised stabilising devices allow the surgeon to gently steady small areas of the heart while it continues to beat, enabling precise and controlled placement of the bypass grafts while the rest of the heart continues to pump blood to the body. With current techniques, it is possible to bypass all major coronary arteries in this way.
This approach can be particularly beneficial for patients who may be at higher risk of complications from the heart-lung machine, such as those with significant aortic calcification, carotid artery disease, a history of stroke, or reduced lung or kidney function. Avoiding cardiopulmonary bypass may help reduce inflammation, bleeding, and certain neurological or organ-related complications in these higher-risk groups.
In our practice, off-pump CABG surgery is the preferred method of revascularisation in the majority of cases (approximately 90% of patients) reflecting our experience and the potential benefits of this technique. However, it is not suitable for every patient. The final decision on whether to perform surgery on-pump or off-pump is often made in the operating theatre, once the heart has been carefully assessed. Factors such as how well the heart tolerates positioning, the stability of the circulation, and other technical considerations all play an important role. Our priority is always to choose the safest and most effective approach tailored to each individual patient, ensuring the best possible outcome.
A hybrid approach to treating coronary artery disease combines the strengths of both surgical and minimally invasive techniques, using coronary artery bypass grafting (CABG) alongside stenting (percutaneous coronary intervention, or PCI) in a planned, sequential way. In this strategy, the most critical arteries (often the left anterior descending (LAD) and another left side of the heart artery) are treated with a durable surgical graft (preferably arterial), while other narrowed vessels (like the right coronary artery) are managed with stents.
Hybrid procedures for treating coronary artery disease allow patients to benefit from the long-term reliability of surgery where it matters most, while avoiding more extensive surgery for other areas. For many, this can mean a smaller operation, faster recovery, and a tailored treatment plan designed around their specific pattern of disease.
However, a hybrid approach is not suitable for everyone. It is typically reserved for a limited group of patients with particular anatomical patterns or medical conditions where combining treatments offers a clear advantage. It requires careful coordination between cardiac surgeons and interventional cardiologists, and in some cases may involve two separate procedures. While it can reduce recovery time and surgical impact, it may not provide the same comprehensive revascularisation as traditional CABG in more complex disease. For this reason, each case is assessed individually to ensure that this approach is only used when it offers the safest and most effective outcome for the patient.
