Coronary Artery Bypass Grafting (CABG) Guidelines

Definition and Overview

The American College of Cardiology and European Heart Society recognize CABG as a standard treatment for patients with extensive coronary artery disease, with the procedure involving creating new pathways around significant coronary artery blockages using grafts, most commonly the left internal mammary artery (LIMA) and saphenous vein grafts 1
CABG was first introduced in the mid-1960s and evolved rapidly as the standard treatment for patients with extensive coronary artery disease 1

The American Heart Association recommends CABG for significant left main coronary artery stenosis (>50% diameter) 2, 3
The American College of Cardiology recommends CABG for left main equivalent disease: significant (≥70%) stenosis of both the proximal left anterior descending (LAD) and proximal left circumflex arteries 2, 4
CABG is indicated for three-vessel coronary disease (survival benefit is greater when left ventricular ejection fraction is <0.50) 2, 3
The American Heart Association recommends CABG for two-vessel disease with significant proximal LAD stenosis and either ejection fraction <0.50 or demonstrable ischemia on noninvasive testing 2, 5
CABG is indicated for unstable angina/non-ST-elevation MI with significant left main coronary artery stenosis or ongoing ischemia not responsive to maximal medical therapy 4, 3

Recent long-term results from the SYNTAX, ASCERT, and FREEDOM trials showed significantly better survival rates after CABG than after PCI 1
The European Heart Society prefers CABG over PCI for patients with complex 3-vessel coronary artery disease (SYNTAX score >22) 8
CABG is generally preferred over PCI for patients with multivessel disease with diabetes mellitus 8
The American College of Cardiology recommends CABG for significant left main coronary artery disease in suitable surgical candidates 8

The European Heart Society describes conventional on-pump CABG as a traditional approach using cardiopulmonary bypass (CPB) and cardioplegic arrest 1
Off-pump CABG is performed on a beating heart without cardiopulmonary bypass and may reduce morbidity related to CPB, particularly beneficial in high-risk patients 1
The European Heart Society notes that off-pump CABG currently accounts for approximately 20% of CABG procedures in Western countries and the majority in Asia 1
Off-pump CABG may reduce the incidence of renal failure, need for intra-aortic balloon pump, and reoperation for bleeding in emergency cases 9

The American College of Cardiology recommends that the left internal mammary artery (LIMA) should be given primary consideration for revascularization of the LAD artery in every patient undergoing CABG 5

The European Heart Society reports that CABG has demonstrated excellent long-term survival rates, with 5-year and 10-year survival of 88.3% and 76.6%, respectively, in minimally invasive procedures 10

The European Heart Society notes the increasing adoption of total arterial revascularization to improve long-term outcomes, and continued refinement of minimally invasive and hybrid approaches 10