• What is Coronary Artery Disease

    Overview of Coronary Artery Disease

    While there are many types of heart disease, “coronary disease” refers to the blockage(s) of the arteries feeding the heart itself. It is caused by the gradual accumulation of lipids (fats) in the blood vessels. This fatty obstruction prevents the normal amount of blood flow to the heart. The presence of coronary artery disease in westernized societies is widespread, affecting millions of people. It may be manifested as a heart attack, angina, or a general deterioration of heart function (i.e., congestive heart failure). Lahey's Lipid Clinic helps people with lipid problems.

    Treatment of Coronary Artery Disease

    The treatment of coronary artery disease has changed dramatically in recent years. Mild blockages can often be treated with medication and lifestyle change. More significant blockages may require treatment by revascularization, which can take two forms: percutaneous intervention (PCI) or coronary bypass surgery. Dr. David Martin and Lahey Residents

    PCI refers to any cardiac therapy performed through a slender tube called a catheter, usually inserted through the femoral artery in the upper part of the leg. Coronary artery blockages are identified by injecting a specialized dye into the heart's arteries. Should these obstructions require treatment, a number of techniques may be used. Most common is relieving the obstruction using a tiny angioplasty balloon, and ultimately, the insertion of a coronary stent. One or more stents may be inserted. This procedure has been 98 percent effective in relieving coronary artery obstructions. However, more extensive blockages may require bypass surgery.

    The most recent advance in using PCI to treat coronary artery disease has been the drug-coated stent, which delivers a small amount of specialized drug to the repaired area and reduces the likelihood of re-blockage at the treated site. Prior to the availability of drug-coated stents, the recurrence rate of coronary artery obstructions was 10 to 25 percent, but drug-coated stents have reduced this to less than 5 percent. Learn more about interventional cardiovascular procedures.

    Intravascular Ultrasound (IVUS)

    One of the recent advances in the assessment and treatment of coronary artery disease is the ability to visualize the inside of the artery using miniaturized ultrasonic probes in a process called intravascular ultrasound (IVUS). While not routinely required, its use sometimes enhances the diagnostic precision of coronary angioplasty.

    Surgery

    Illustration of coronary artery bypass graft (CABG) surgeryCoronary artery bypass graft (CABG) surgery is an operation in which blood is rerouted around one or more blocked coronary arteries by placing a new blood vessel graft around the blockage. These new grafts typically come from the arteries and veins located in the patient's chest, leg, or arm. The goals of the operation are to relieve the symptoms of coronary artery disease and to decrease the risk of future heart attack or heart failure.

    A minimally invasive coronary artery bypass graft procedure is also an option for some patients. Performed through smaller incisions and without dividing the breastbone, this less invasive procedure means less pain and a shorter recovery time. In some cases a heart-lung machine is not required. Ask your doctor to learn more.

    How is the operation performed?


    Profusionist monitoring functioning of the heart-lung machineThe operation is generally performed using one of two methods: “on pump” (traditional and most common) CABG surgery; and “off pump”, or beating heart, CABG surgery.

    “On Pump” CABG Surgery
    An incision is made in the skin overlying the breastbone. The breastbone is divided down its center with a fine surgical scroll saw, and the edges of the breastbone are separated to gain access to heart below. Connections are made to a heart-lung machine (the cardiopulmonary bypass pump). The “pump” then takes over for the patient's own heart and lung functions. The heart is stopped, and the surgeon proceeds to sew each new bypass to the heart. Once all bypasses are placed, the heart is restarted and resumes its normal function. The heart-lung machine is no longer needed and is disconnected. The breastbone and skin are sewn back together.

    “Off Pump”, or Beating Heart, CABG Surgery


    Typically, the incision in the skin and the division of the breastbone are created in the same way as with traditional CABG. In off pump CABG surgery, no connections are made to the heart-lung machine, and the bypasses are created while the heart is beating. Specialized equipment is used to gain access to, and hold relatively still, the portion of the heart being worked on. The heart continues to beat and supply blood to the body while the bypass grafts are sewn to the heart. Once all bypasses are placed, the breastbone and skin are closed in the same manner as with on pump CABG surgery.

    Where do the bypass grafts come from?

    The new grafts used in coronary bypass surgery most commonly come from:

    • The internal mammary artery (located in the chest wall)
    • Saphenous veins removed from the legs
    • The radial artery located in the forearm

    The internal mammary artery is the most commonly used arterial bypass graft, and is also associated with the best long-term results. Most patients require more than one bypass graft, and in such situations, a combination of internal mammary arteries and saphenous veins are typically used. The second most commonly used arterial graft is the radial artery, which is one of two arteries located in the forearm. Arterial bypass grafts generally last longer than saphenous vein bypass grafts.

    At Lahey clinic, the majority of patients who need saphenous vein bypass grafts can have these veins removed using a minimally invasive approach. Rather than making a long incision running the length of the leg, Lahey surgeons use specialized equipment to remove the vein through a small incision in the groin and one or two small incisions at the knee and in the calf. Smaller incisions are less painful, heal more quickly and are more aesthetically pleasing.

    On pump versus off pump: Which one is for me?

    The superiority of one technique over the other has not yet been established. Both “on pump” and “off pump” coronary artery surgeries are performed frequently and with excellent results at Lahey Clinic. Your surgeon will discuss the appropriate options, given your particular medical situation.
     

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