CABG, my first 60 years

CABG, my first 60 years

Posted by Salvatore Tribastone on 13 June 2019

Coronary artery bypass grafting, also known as CABG, is currently considered one of the most commonly performed procedures when it comes to open heart surgery. While Adam Hammer did describe coronary artery disease for the first time in 1876, it wasn’t until 1910 when the first description of this particular procedure was made.

An approximate two decades after Alexis Carrel described the procedure of coronary artery bypass grafting, Dr. John Gibbon developed the very first heart-lung machine, which provided a way for a cardiopulmonary bypass, leading the way toward making CABG a real possibility within the medical industry.

Several advancements were made in the area of surgical procedures to assist in the treatment of cardiovascular diseases. In 1950, Arthur Vineberg made the first internal mammary artery implant in the myocardium. The procedure was considered successful when visualizing the implant by arteriography and verifying the communication between the mammary artery and the coronary artery. However, the Vineberg technique had a high incidence of postoperative thrombosis and mortality. Three years later, the first reported procedure where arterial grafts were implanted in the coronary circulation of a patient. Another important advancement was made when an open coronary artery endarterectomy was performed for the first time without the use of cardiopulmonary bypass. Probably, the aortocoronary bypass could not have been done without the previous development of endarterectomy to remove atheromatous plaques in the coronary arteries, successfully performed for the first time in 1955 and which continued to be perfected until, in 1961, Senning performed a coronary endarterectomy with grafting of a saphenous vein segment. In 1964, Donald Effler used pericardial grafts for the first time at endarterectomy sites instead of mammary artery or saphenous vein.

Dr. René G. Favaloro was responsible for standardizing and systematizing the technique of the coronary artery bypass grafting in the 1960s. Shortly afterward, this surgery would become one of the most practiced in the world, since it provided the possibility of prolonging and improving the lives of thousands of patients with severe coronary disease (atherosclerosis). The great innovation of Favaloro was to connect the saphenous vein (extracted from the leg) with the coronary artery, to generate a shortcut or derivation for the irrigation of the heart. From its revolutionary direct revascularization technique, millions of lives were saved around the world.

It wasn’t until 1961, however, that the first coronary artery bypass was successfully conducted on a human patient. Prior to this achievement, previous experiments were only conducted on animal models. This was also when many advancements started to become present in the field of coronary artery surgical procedures. Researchers started to invest more time and money into scientific studies, as well as technological advancements, in order to produce better results and, of course, to make the process of coronary artery bypass grafting a safer procedure for the patient in the end.

The use of coronary artery bypass grafting procedures increased significantly during the 1980s. During this time, the procedure was also heavily researched and made safer than it was before. This led to a large improvement in the success of the procedures performed in the general population, among patients with existing cardiovascular complications.

Since these times, we have seen quite a significant number of advancements in recent years. While coronary artery bypass grafting is still an option utilized by surgeons to assist in the treatment of certain cardiovascular conditions today, there are now less invasive procedures that can also be utilized in some cases. Technology has also allowed for the development of certain robotic-assisted surgeries that greatly enhances the overall success of the procedure, allows for a significant reduction in the procedure’s invasiveness, and also ultimately leads to a safer option for the patient.

Surgery Off-pump coronary artery bypass (OPCABG) allows diminishing the myocardial suffering and the development of a systemic inflammatory response in the patient. Therefore, the subsequent appearance of complications associated with it is reduced. This method was very controversial at the beginning, however, the excellent results derived from this technique led to the fact that it is currently one of the most widely used revascularization method worldwide.

In the year 2,000, there were an estimated 519,000 coronary artery bypass grafting procedures conducted throughout the world. This year the procedures reached a peak – this marked the most CABG procedures ever conducted in a single year.

Due to the improvements in technology that now allows for minimally invasive procedures to be an initial option for patients, we have observed a decline in the number of CABG procedures performed worldwide. In 2012, for example, there were approximate 300,000 CABG procedures conducted throughout the entire world, a 219,000 decline from the year 2000.

The bypass was twentieth-century surgery since it transformed coronary atherosclerosis from a fatal disease to a treatable chronic disease. With the passage of time, this surgery was modified, previously it was necessary to perform this surgery with an extracorporeal circulation pump, however at present it is no longer necessary to use this device.

Currently, recent guidelines on myocardial revascularization (2018, ESC – EACTS), despite the great progress of percutaneous revascularization (PCI), highlight the role of CABG in patients with diabetes, EF <35%, contraindications to DAPT, recurrent intrastent stenosis, multivessel disease with SYNTAX score> 22, predictable incomplete revascularization with PCI, need for other Cardiac interventions, ascending aorta pathologies with surgical indication.

CABG is 60 years old and still alive.

@salvotribastone

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