When Is CABG Indicated?
The decision between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI - angioplasty and stenting) is one of the most important in cardiovascular medicine, made jointly by cardiac surgeons, interventional cardiologists, and the patient.
CABG is preferred over PCI in:
- Left main coronary artery stenosis (>50%) - CABG provides more durable protection of the left ventricle
- Three-vessel coronary artery disease (triple vessel disease) - especially in patients with diabetes where CABG shows survival benefit vs. stenting long-term
- Complex multi-vessel disease with low SYNTAX score for PCI and high surgical risk score (anatomy favouring surgical revascularisation)
- Previous PCI failure or re-stenosis in multiple vessels
- Combined coronary disease with valvular heart disease requiring simultaneous repair
CABG vs. PCI outcomes (major trials):
- SYNTAX Trial: CABG superior to PCI for triple-vessel and left main disease at 5 years
- FREEDOM Trial (diabetics): CABG significantly better 5-year survival than PCI in multi-vessel diabetics
- Left main: EXCEL Trial - similar outcomes at 3 years; CABG benefit emerges at 5+ years
Graft types:
- Left Internal Mammary Artery (LIMA): Gold standard; longest-lasting graft (90% patent at 10 years); used to bypass the left anterior descending artery (LAD - the most critical coronary vessel)
- Radial artery: Second arterial graft for additional targets; 80-85% patent at 10 years
- Saphenous vein graft (SVG): Harvested from leg; widely used for additional bypasses; 60-70% open at 10 years (less durable than arterial grafts)
- Total arterial revascularisation (bilateral LIMA + radial) provides best long-term results in younger patients
Off-pump CABG (Beating Heart Surgery): In standard CABG, the heart-lung machine (cardiopulmonary bypass) maintains circulation while the heart is stopped. Off-pump CABG is performed on the beating heart using a mechanical stabiliser to hold the local area still during anastomosis. Potential advantages: avoids pump-related neurological complications; suitable for patients with calcified aorta or poor cardiopulmonary reserve. Technical demands are higher - available at our partner hospitals with experienced off-pump surgeons.
The CABG Procedure and Hospital Course
Pre-operative assessment:
- Coronary angiogram (catheterisation): essential for surgical planning - defines vessel anatomy and target bypass sites
- Echocardiogram: left ventricular function, valve status
- Carotid duplex ultrasound (assess for carotid disease - relevant to cerebral perfusion on bypass)
- Pulmonary function tests, creatinine, HbA1c, INR (anticoagulation review)
- Share all cardiac investigations with BB Global Health before travel
Surgery:
- General anaesthesia; median sternotomy (sternal bone is divided vertically)
- Graft vessels harvested simultaneously by second surgeon (LIMA + vein or + radial)
- Cardiopulmonary bypass established (on-pump) or stabiliser placed (off-pump)
- Distal anastomoses (connections to coronary arteries beyond the blocks): performed first
- Proximal anastomoses: grafts attached to the aorta
- Number of bypasses: typically 2-4 (double, triple, or quadruple bypass)
- Chest closed over sternal wires; drain placed
Cardiac ICU (Day 0-1):
- Patient wakes in cardiac ICU; ventilator removed within 4-8 hours usually
- Arterial line, central venous line, chest drains, urinary catheter, cardiac monitoring
- IV antibiotic prophylaxis; anticoagulation commenced
Hospital ward (Day 2-7):
- Physiotherapy from Day 2: sitting, standing, walking progressively
- Chest drains removed Day 2-3; pacing wires removed Day 3-5
- Sternal wound care; breathing exercises (incentive spirometry)
- Discharge Day 7-10 for uncomplicated cases
Post-discharge (in Turkey - hotel stay):
- 10-14 days hotel recovery before flying home is strongly recommended (sternal stability, wound healing, altitude considerations)
- Total flight restriction: minimum 10-14 days for medium-distance flights; 4-6 weeks for long-haul
Recovery and Long-Term Outcomes
Recovery milestones:
- Week 1-2: Rest; light household activity; no driving; incision care
- Week 4: Most patients can drive; light walking programme
- Week 6: Sternal stability usually complete; restrictions on heavy lifting lift
- Week 8-12: Return to work (desk jobs); structured cardiac rehabilitation begins
- Month 3-6: Full physical activity resumed; exercise stress testing
Cardiac rehabilitation: Structured exercise, dietary, psychological, and medication optimisation programme significantly improves outcomes. BB Global Health advises on cardiac rehabilitation resources in home country post-discharge from Turkey.
Long-term outcomes (CABG):
- Symptom relief: >90% of patients are angina-free at 1 year
- Survival: in appropriate indications (left main, triple vessel, diabetes), CABG provides survival benefit vs. medical therapy and stenting at 5-10 years
- LIMA graft patency 10 years: 90-95%
- SVG patency 10 years: 60-70%
- Repeat revascularisation rate: 5-10% at 10 years
Medications after CABG:
- Aspirin (for life) - maintains graft patency
- Statin (for life) - slows progression of coronary disease
- Beta-blocker (typically 6-12 months minimum; often long-term for LV dysfunction)
- ACE inhibitor (for LV dysfunction or diabetes)
- Blood glucose management (diabetic patients - tight control crucial for graft longevity)
Cost overview: All-inclusive CABG in Turkey: -15,000-25,000 (depending on number of bypasses, off-pump vs. on-pump, ICU duration). UK private sector equivalent: -40,000-80,000.