Overview

A coronary artery bypass graft (CABG) is a surgical procedure used to treat coronary heart disease.

It diverts blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply to the heart.

Why it's carried out

Like all organs in the body, the heart needs a constant supply of blood.

This is supplied by 2 large blood vessels called the left and right coronary arteries.

Over time, these arteries can become narrowed and hardened by the build-up of fatty deposits called plaques.

This process is known as atherosclerosis.

People with atherosclerosis of the coronary arteries are said to have coronary heart disease.

Your chances of developing coronary heart disease increase with age.

You're also much more likely to be affected if:

• you smoke
• you're overweight or obese
• you have a high-fat diet

Coronary heart disease can cause angina, which is chest pain that occurs when the supply of oxygen-rich blood to the heart becomes restricted.

While angina can often be treated with medicine, severe angina may require a coronary artery bypass graft to improve the blood supply to the heart.

Another risk associated with coronary heart disease is the possibility of one of the plaques in the coronary artery rupturing (splitting), creating a blood clot.

If the blood clot blocks the blood supply to the heart, it can trigger a heart attack.

A coronary artery bypass graft may be recommended to reduce your chances of having a heart attack.

The procedure

A coronary artery bypass graft involves taking a blood vessel from another part of the body (usually the chest, leg or arm) and attaching it to the coronary artery above and below the narrowed area or blockage.

This new blood vessel is known as a graft. The number of grafts needed will depend on how severe your coronary heart disease is and how many of the coronary blood vessels are narrowed.

A coronary artery bypass graft is carried out under general anaesthetic, which means you'll be unconscious during the operation. It usually takes between 3 and 6 hours.

Recovery

Most people will need to stay in hospital for at least 7 days after having a coronary artery bypass graft.

You should have a follow-up appointment, typically about 6 to 8 weeks after your operation.

Recovering takes time and everyone recovers at slightly different speeds.

Generally, you should be able to sit in a chair after 1 day, walk after 3 days, and walk up and down stairs after 5 or 6 days.

When you go home, you'll need to take things easy for a few weeks.

You should be able to return to most of your normal activities after about 6 weeks, including working, driving and having sex. If you have a heavy manual job, you may need to stay off work longer.

Most people make a full recovery within 12 weeks.

Risks of surgery

As with all types of surgery, a coronary artery bypass graft carries a risk of complications.

These are usually relatively minor and treatable, such as an irregular heartbeat or a wound infection, but there's also a risk of serious complications, such as a stroke or heart attack.

After surgery

After having a coronary artery bypass graft, most people will experience a significant improvement in symptoms such as breathlessness and chest pain, and their heart attack risk will be lowered.

But a coronary artery bypass graft isn't a cure for coronary heart disease.

If you don't make lifestyle changes, such as eating a healthy diet and exercising regularly, your grafted arteries will also eventually become hardened and narrowed.

In some cases, a coronary artery bypass graft may need to be repeated or you may need a procedure to widen your arteries using a small balloon and a tube called a stent (coronary angioplasty).

Alternatives

A coronary angioplasty is the main alternative to a coronary artery bypass graft.

It's a less invasive operation where a long, flexible, hollow plastic tube called a catheter is inserted into a blood vessel in your arm or groin.

The tip of the catheter is guided under X-ray to the arteries that supply your heart, to the point where the narrowing of the artery has occurred.

A balloon attached to the catheter is then inflated to widen the artery and a small metal tube called a stent is often used to help keep the artery open.

It usually takes less time to recover from a coronary angioplasty than from a coronary artery bypass graft, but there's a higher chance that the procedure will need to be repeated.

Also, a coronary angioplasty may not be recommended if multiple coronary arteries have become blocked and narrowed or the structure of the blood vessels near your heart is abnormal.

How long will I have to wait for surgery?

The length of time you'll have to wait to have a coronary artery bypass graft will vary from area to area.

Your GP or cardiac surgeon should be able to tell you what the waiting lists are like in your area or at the hospital you have chosen.

Ideally, you should be treated within 3 months of the decision to operate.

Why it's done

How is it performed?

Before your coronary artery bypass graft (CABG), your surgeon will discuss every aspect of the procedure with you.

This will give you the opportunity to ask any questions to make sure you understand the procedure fully.

As the procedure is carried out using a general anaesthetic (where you're asleep during the operation), you mustn't eat or drink for at least 6 hours before the operation.

You may be able to drink clear fluids like water, squash, black tea or black coffee until about 2 hours before the operation. Your care team will be able to advise you further about this.

During the operation

Coronary artery bypass graft surgery usually lasts 3 to 6 hours. But it may take longer depending on how many blood vessels are being attached.

Blood vessels can be taken from your leg (saphenous vein), inside your chest (internal mammary artery), or your arm (radial artery).

Other blood vessels in these areas are able to compensate for the loss of these blood vessels after the operation.

The number of blood vessels used will depend on how severe your coronary heart disease is and how many of the coronary blood vessels have become narrowed.

If you need 2, 3 or 4 grafts, you may hear your operation referred to as a double, triple or quadruple bypass.

One of the graft vessels is usually taken from your chest (internal mammary artery).

Surgeons prefer to use this vessel because it doesn't narrow over time, unlike the blood vessels taken from your leg or arm.

Once all the graft vessels have been removed, your surgeon will make a cut down the middle of your chest so they can divide your breastbone (sternum) and access your heart.

During the procedure, your blood may be rerouted to a heart-lung bypass machine. This takes over from your heart and lungs, pumping blood and oxygen through your body.

Your heart will be temporarily stopped using medication while your surgeon attaches the new grafts to divert the blood supply around the blocked artery.

After the grafts have been attached, your heart will be started again using controlled electrical shocks.

Your breastbone will then be fixed together using permanent metal wires and the skin on your chest sewn up using dissolvable stitches.

Newer surgical techniques

Off-pump coronary artery bypass surgery (OPCAB)

More surgeons are now performing off-pump coronary artery bypass surgery (OPCAB), which is a variation of the conventional procedure.

A coronary artery bypass graft is often described as on-pump surgery because it involves using a heart-lung bypass machine to pump blood and oxygen around your body during the procedure, while the heart is temporarily stopped.

During OPCAB, your heart is still beating while the new blood vessel grafts are attached and a heart-lung bypass machine isn't used.

According to the National Institute for Health and Care Excellence (NICE), the procedure works as well as a coronary artery bypass using a pump.

The benefits of OPCAB are:

• it often takes less time to perform than the conventional procedure 
• it can reduce your chance of bleeding during the surgery
• you may be less likely to develop certain serious complications after surgery, such as a stroke
• your stay in hospital will usually be shorter

The main disadvantage is that OPCAB is more technically demanding because the grafted vessels have to be delicately connected while the heart is beating.

This means the procedure may be too difficult to perform if a large number of blood vessels need to be grafted.

For the same reason, if emergency surgery is required, there may not be ready access to a surgeon with the training required to perform an OPCAB.

Read the NICE guidelines about off-pump coronary artery bypass grafting.

Endoscopic saphenous vein harvesting (ESVH)

Endoscopic saphenous vein harvesting (ESVH) is a less invasive method of removing the veins from your legs.

Rather than making a large cut in your leg, the surgeon makes a number of small ones near your knee. This is known as keyhole surgery.

A special device called an endoscope will be inserted into the cut.

An endoscope is a thin, long flexible tube with a light source and video camera at one end, so that images of the inside of your body can be relayed to an external television monitor.

The endoscope allows the surgeon to locate your saphenous vein. Surgical instruments can also be passed along the endoscope to remove a section of the vein. Nearby tissue is then sterilised with antibiotic fluid and the cut is healed.

The main advantages of this technique are that there's likely to be a:

• shorter hospital stay
• lower risk of leg wound infections
• quicker recovery from CABG

Read the NICE guidelines about endoscopic saphenous vein harvest for coronary artery bypass grafting.

Totally endoscopic robotically assisted coronary artery bypass (TECAB) grafting

Totally endoscopic robotically assisted coronary artery bypass (TECAB) grafting is a newer technique in heart surgery.

It's a minimally invasive (keyhole) method of performing a heart bypass.

During a TECAB grafting procedure, the surgeon deflates your lungs and makes a number of small cuts between your ribs.

Robotic arms, controlled by the surgeon, are used to carry out the surgery.

An endoscope is attached to the robotic arms so the surgeon can see inside your body and view the results of the surgery on a screen.

TECAB grafting can be carried out using a heart-lung bypass machine, or it can be done off-pump.

There are lower rates of wound infection with this type of surgery, plus minimal scarring and a faster recovery time.

But as this is a new technique that's only been carried out on a small number of people, it's difficult to assess how effective and safe it is in the short and long term, and how the outcomes compare with other types of surgery.

If you're considering having TECAB, it's important you understand there are still uncertainties about how safe the procedure is and how well it works.

Read the NICE guidelines about totally endoscopic robotically assisted coronary artery bypass grafting.

Recovery

You'll usually need to stay in hospital for around 7 days after having a coronary artery bypass graft (CABG) so medical staff can closely monitor your recovery.

During this time, you may be attached to various tubes, drips and drains that provide you with fluids, and allow blood and urine to drain away. These will be removed as you get better.

It's likely you'll feel some discomfort and grogginess after the procedure, but you'll be given painkillers to help relieve any pain.

Tell your doctor or nurse if the pain increases or you notice any excessive bleeding.

Recovering from a coronary artery bypass graft procedure takes time and everyone recovers at slightly different speeds.

Generally, you should be able to sit in a chair after 1 day, walk after 3 days, and walk up and down stairs after 5 or 6 days.

Most people make a full recovery within 12 weeks of the operation.

But if you experience complications during or after surgery, your recovery time is likely to be longer.

You should have a follow-up appointment, typically about 6 to 8 weeks after your operation.

At home

To ease any soreness where the cuts were made, you may need to continue taking painkillers at home for a few weeks. 

Wearing loose, comfortable clothing that doesn't rub on your wounds can also help.

For the first 3 to 6 weeks, you'll probably feel tired a lot of the time. This is because your body is using a lot of energy to heal itself.

By 6 weeks, you should be able to do most of your normal activities and by 3 months you're likely to be fully recovered.

Caring for your wound

The metal wires holding your breastbone (sternum) together are permanent.

But the stitches closing your skin will gradually dissolve over the weeks following surgery as your skin heals.

While you're recovering in hospital, you'll be told about how to care for your wounds at home.

It's important to keep the wounds clean and protect them from the sun while they're healing.

You'll have a scar where the surgeon cut down your chest, as well as where the grafted blood vessel (or vessels) was taken from.

These will be red at first, but will gradually fade over time.

Activities

The team caring for you in hospital will also usually be able to advise you about any activities you need to avoid as you recover.

Generally, in the first few days after you return home from hospital you can do light activities, such as:

• walking short distances
• cooking
• playing card and board games
• lifting light objects

After about 6 weeks, you may be well enough to do slightly more strenuous activities, such as:

• driving
• carrying children
• carrying heavier objects (but not very heavy objects, such as bags of compost or cement)
• vacuuming
• mowing the lawn
• having sex

The length of time you need off work varies from person to person.

If you're recovering well and your job isn't physically strenuous, you can usually go back to work in about 6 to 8 weeks.

But you'll normally need more time off if you experience any complications or your job involves a lot of standing and lifting.

While recovering, it's best to try to build up your activities gradually over time and make sure you take regular rests when you feel tired.

Side effects of surgery

After you have been discharged from hospital, you may experience some side effects as a result of the operation.

These can include:

• loss of appetite
• constipation
• swelling or pins and needles where the blood vessel graft was removed
• muscle pain or back pain
• tiredness and difficulty sleeping
• feeling upset and having mood swings

It's natural to feel a bit low after having bypass surgery. You'll experience good and bad days. Your recovery will take weeks, rather than days.

Side effects tend to disappear within 4 to 6 weeks of the operation.

A full recovery may take about 3 months or longer, depending on your fitness, age and the severity of your condition.

If you'd like some extra support and advice while you recover, speak with your GP or contact the British Heart Foundation, who can provide you with details of local heart support groups.

When to seek medical advice

Call 999 if you:

• have chest pain
• have extreme shortness of breath
• have palpitations that make you feel dizzy or faint
• feel extremely unwell

Follow any advice that you have been given on discharge from hospital.

See a GP if you have:

• worsening pain in or around the wound
• redness and swelling around the wound
• pus or blood coming from the wound
• a very high temperature or you feel hot and shivery

Call 111 Wales if you're unable to contact your GP.

Cardiac rehabilitation

Many hospitals offer a cardiac rehabilitation programme for people who have had heart surgery.

The programme, which usually lasts at least 6 weeks, aims to help you recover from the procedure and get back to everyday life as quickly as possible.

A member of the cardiac rehabilitation team may speak to you about this when you go into hospital to have your operation.

You may be invited to join a cardiac rehabilitation programme starting a few weeks after you leave hospital.

Cardiac rehabilitation programmes vary widely throughout the country, but most will cover areas such as exercise, education, relaxation and emotional support.

The British Heart Foundation has more information about cardiac rehabilitation.

Life after a coronary artery bypass graft

When you have fully recovered from your operation, it's important to adopt a healthy lifestyle to reduce your risk of developing further heart problems in the future.

For example, you should:

• stop smoking if you smoke
• eat a healthy, balanced diet
• lose weight if you're overweight or obese
• moderate your alcohol intake
• exercise regularly 

You should also continue to take any medications you have been prescribed.

Complications

Possible complications of a coronary artery bypass graft

Complications can happen during or after a coronary artery bypass graft. Some complications can be serious or life-threatening.

Your doctor will explain the risks to you before the operation. They'll only recommend a coronary artery bypass graft if the risks are lower than the risks of not treating your heart problem.

Wound infection

There's a small chance that the wound in your chest or the wounds where blood vessels were removed could get infected after the operation. This can be treated with antibiotics.

Bleeding

If you have bleeding after the operation you may need more surgery. Some people may need a blood transfusion.

Problems with your heart rhythm

Some people get an irregular heartbeat (arrhythmia) after having a coronary artery bypass graft. This usually gets better after a few days.

Kidney problems

A coronary artery bypass graft can affect how well your kidneys work. This usually gets better after a few days. It's more likely to happen if you already had kidney problems before the operation.

If it does not get better it can lead to kidney failure, which may need to be treated with dialysis.

Memory problems

It's common for people to find they have problems with their memory after the operation. This usually gets better without treatment after a few months.

Heart attack or stroke

It's possible to have a heart attack or a stroke during or soon after the operation. If this happens you'll need emergency treatment.

Call your care team if:

You've recently had a coronary artery bypass graft and you have:

• pain or redness around your wound that's getting worse or not getting better (redness may be less obvious on brown or black skin)
• bleeding or pus from your wound
• a high temperature, or you feel hot, cold or shivery
• heart palpitations, where your heartbeat becomes more noticeable

These could be signs of an infection or problems with your heart rhythm.

If you cannot call your care team then ask for an urgent GP appointment, call 111 or get help from 111 online.

Call 999 if:

• you get sudden pain or discomfort in your chest that does not go away – the pain can feel like squeezing or pressure inside your chest, burning or indigestion
• you get pain that spreads to your left or right arm, or your neck, jaw, stomach or back
• you have chest pain and you feel sweaty, sick, light headed or short of breath
• you have difficulty speaking or moving your arm or leg, or your face has dropped on one side

You could be having a heart attack or stroke. Call 999 straight away as you need immediate treatment in hospital.

Do not drive yourself to A&E.

The person you speak to at 999 will give you advice about what to do.