Coronary artery disease (angina pectoris and chest pain)

The surgical treatment of coronary artery disease (CAD), according to the last European Guidelines for myocardial revascularization, is the gold standard treatment and should be preferred than PCI in case of two-vessel disease involving proximal left anterior descending (LAD) stenosis or three-vessel disease in patients with diabetes mellitus. CABG should be performed rather than PCI even in case of left main or three-vessel disease without diabetes mellitus in patients with high or intermediate SYNTAX score (a measure of anatomical complexity of CAD). The principal objective of CABG is to obtain complete revascularization by bypassing all severe stenoses (at least 50% diameter reduction) in all coronary arterial trunks and branches having a diameter of about 1 mm or more. The surgical revascularization by coronary artery bypass grafting (CABG) is performed with a median sternotomy approach, using arterial or venous conduits as bypass grafts. As vein graft the right or left greater saphenous vein is used, harvested from the leg with open or endoscopic technique. As arterial graft a single (mostly the left), or a double internal thoracic artery (ITA) is used; alternative arterial grafts are the non-dominant arm radial artery or the right gastroepiploic artery. Because three or more individual conduits cannot be conveniently used in most patients, at least some of the grafts, especially venous, may require sequential (side-to-side) anastomoses. Surgery can be performed either "on-pump", cross-clamping the aorta with cardioplegic arrest of the heart or "off-pump" with beating heart. CABG offers complete myocardial revascularization and better long-term outcome in patients with multivessel or left main CAD, especially with intermediate or high anatomical complexity.