Coronary artery bypass graft (CABG)

Expert reviewer, Mr Mark Yeatman, Cardiothoracic Surgeon
Next review due November 2020

A coronary artery bypass graft is a procedure to improve the blood flow to your heart. It’s used to treat coronary heart disease, which is usually caused by a build-up of fatty deposit in your arteries known as plaques.

Coronary artery bypass graft surgery is also known as CABG, which you may well hear pronounced as ‘cabbage’.

About CABG

Your heart is supplied with oxygen and nutrients by blood vessels called your coronary arteries. If you have coronary heart disease, these arteries are narrowed or blocked. This can starve your heart of oxygen, which causes angina (a feeling of chest pain, chest tightness and breathlessness) or sometimes a heart attack.

Having a CABG procedure can relieve your angina symptoms, and may reduce the risk of a heart attack. It can improve your quality of life and help you keep active.

During the CABG procedure:

• your surgeon takes a blood vessel (called a graft) from your chest, leg or arm
• they use the graft to bypass the narrowed or blocked coronary artery (which is left in place)
• blood then flows safely through the bypass to reach your heart muscle

It’s common to have more than one graft at a time. If you have two, three or four grafts, it’s known as a double, triple or quadruple bypass.

You’ll usually need to stay in hospital for five to seven days. It’s done under general anaesthetic, which means that you’ll be asleep during the operation.

Your doctor may suggest CABG if your angina hasn’t responded to medicines or other treatment (see Alternatives). It can be very effective, but it’s not suitable for everyone – including older people who can be at greater risk of complications. CABG can also have fewer benefits if you smoke, are overweight or have other conditions such as diabetes as well as angina.

And CABG won't cure coronary heart disease, so it's possible that you might get more blockages in future. Making some healthy lifestyle changes will help reduce the chance of this happening.

Preparing for CABG

Your surgeon will discuss with you what will happen before, during and after your coronary artery bypass graft (CABG) operation. They’ll explain the risks, any pain you might have, how long it may take to recover and what medicines you may be prescribed. This is your opportunity to ask questions so that you fully understand. You don’t have to go ahead with the procedure if you decide you don’t want it. Once you understand the procedure, and if you agree to have it, you’ll be asked to sign a consent form.

Your doctor may want to do some tests to check your current health before you’re admitted to hospital for the operation. These may include:

• a chest X-ray to look at the size, shape and condition of your heart and lungs
• an electrocardiogram (ECG) to check your heart’s electrical activity
• an echocardiogram to see how well your heart is working
• blood tests to check your liver function
• taking ‘swab’ samples to rule out any infections like MRSA

Very occasionally you may need another operation before the CABG procedure if an ultrasound shows the carotid arteries that take blood to your brain are blocked. This increases the risk of stroke during the bypass. Your doctor can do a ‘carotid endarterectomy’ under local anaesthetic. They’ll cut into an artery in your neck and remove the fatty deposit blocking it.

Your surgeon and anaesthetist will both talk to you about preparing for your CABG. You should fast before an operation under general anaesthetic and they’ll advise you when you should last have anything to eat or drink. If you smoke, you’ll be asked to stop. Smoking increases the risk of complications from the surgery. Your doctor may ask you to temporarily stop any medicines you normally take. Or they may prescribe something else beforehand, like calcium channel blockers to stop spasms in arteries taken from your arm.

Before you go into the operating theatre, hair may be removed from your chest, arms and legs so it’s easier for the surgeon to do the procedure. Don’t shave yourself at home before your procedure as this can increase your risk of infection.

Alternatives to CABG

There are several alternative treatments for angina that your doctor may consider before, or instead of, coronary artery bypass grafting. These include the following.

• Medicines, including calcium channel blockers and/or beta-blockers, may improve your symptoms or prevent your condition from getting worse.
• A coronary angioplasty (also called a percutaneous coronary intervention) opens your coronary artery from inside, using a special balloon. The balloon is inserted in a plastic tube called a catheter, into a blood vessel in your groin or wrist, up into your coronary artery. Often a stent (a small metal tube) is used to help keep the artery open. When the coronary artery is opened up like this, the blood can flow more easily to your heart muscle.

The treatment you’re offered will depend on how severe your symptoms are, the condition of your coronary arteries and how healthy you are generally. Your surgeon will discuss with you which treatment is best for you, and the different risks and benefits. For instance, coronary artery bypass graft can offer better long-term relief of angina symptoms but take longer to recover from than a coronary angioplasty.

The CABG procedure

Your procedure will probably take between three and six hours. You’ll have a general anaesthetic, which means you’ll be asleep during your operation.

Your surgeon will take an artery or vein from your leg, arm or chest to use as a graft. If your surgeon needs to bypass more than one coronary artery, they’ll probably use both an artery and a vein. They will also consider your general health, previous treatment and other conditions, like diabetes, in choosing the best vein or artery for a bypass. Removing these blood vessels doesn’t affect circulation in the parts they’re taken from, though you may get some short-term weakness. For more information, see our FAQ: Will taking the graft have any adverse effects?

To reach your heart, your surgeon will make a cut down the middle of your breastbone (sternum) and will open your chest. They’ll then attach the grafts in the correct places to bypass the narrowed parts of your coronary arteries.

Your surgeon may temporarily stop your heart and divert your blood to a machine that pumps it outside your body while they attach the new grafts. This helps to maintain oxygen levels in your blood during the operation. Or your surgeon may attach the new grafts while your heart is still beating. This type of surgery is called off-pump or beating heart CABG. Your doctor will explain it to you beforehand. See our FAQ: What is an off-pump CABG? for more information.

After attaching the grafts, your surgeon will restart your heart (if it was stopped in the operation). They’ll then rejoin your breastbone using stainless steel wires that will stay inside your body permanently. Your surgeon will close the skin on your chest with staples or stitches.

Keyhole surgery

CABG can sometimes be done using keyhole surgery. This is minimally invasive surgery – also called mini heart bypass surgery. The main difference between keyhole surgery and the traditional CABG procedure is that your breastbone doesn’t need to be cut.

There are several different kinds of keyhole surgery for coronary artery bypass grafting. Your surgeon will make two or three small cuts in your chest and will pass special instruments through the cuts to do the operation. They may use remote-controlled surgical instruments (known as robot-assisted surgery).

Keyhole surgery for CABG is becoming more widely used. Recent evidence suggests that although the procedure may take longer than traditional surgery it can mean you recover more quickly, with less pain. It isn’t suitable for everybody – it can depend on which artery is blocked and if you need more than a single bypass. Your surgeon will explain if it's appropriate for you.

If you do have keyhole surgery, there's a chance your surgeon may need to convert to open surgery if they can’t complete the operation safely.

Aftercare for CABG

Intensive care

After your CABG procedure, you’ll be taken to the hospital’s intensive care unit (ICU). Here you’ll be closely monitored until you wake up and your condition is stable. This could take six to 24 hours. Then you’ll usually be moved to a ward that provides specialist care for patients after heart operations. Altogether, you’ll probably be in hospital for about five to seven days.

While in hospital, you’ll be connected to machines that record the activity of your heart, lungs and other body systems. These might include a ventilator machine to help you breathe.

You’ll be offered pain relief to help with any discomfort as the anaesthetic wears off.

You’ll probably have an intravenous (IV) tube placed into your vein to give you fluids and medicines. You may have a catheter to drain urine from your bladder into a collection bag. You may also have tubes running out from the chest wound. These drain fluid into another bag and are usually removed after a day or two.

You may be wearing compression stockings on your legs to help maintain circulation. You’ll be encouraged to get out of bed and move around as this will help prevent chest infections and blood clots developing in your legs.

Physiotherapy and rehabilitation

While you’re in hospital, you’ll usually be visited by a physiotherapist (a health professional who specialises in maintaining and improving movement and mobility). They’ll guide you through exercises designed to help your recovery, including breathing. The physiotherapist will support you to walk independently as soon as possible. Being mobile reduces the risk of chest infections and helps your lungs work properly. You may be given advice on how to sit to encourage normal blood flow.

You may also meet a nurse or physiotherapist who particularly specialises in cardiac rehabilitation. Cardiac rehabilitation is a tailored programme of exercise and support to help you regain physical strength and self-confidence and improve your overall health. Starting a programme in hospital or soon after you go home can reduce the risk of complications after your operation. See Recovery for more information on what’s involved.

Going home

When you're ready to go home, you’ll need to arrange for someone to drive you. Try to have a friend or relative stay with you for the first week or so.

Your nurse will give you some advice about caring for your healing wounds before you go home. You’ll need to keep them clean and avoid using scented products or exposing them to direct sunlight. Some discharge from the wounds is normal for a few days. You’ll be shown how to change your dressings or a district nurse may visit you at home to do this.

For more information, see our page: Caring for your surgical wounds.

You’ll probably be prescribed painkillers to take during the first couple of weeks after you leave hospital. You may be shown how to support your chest wound so it hurts less when you cough, sneeze, laugh or move around. You may be given support stockings to wear at home that will help prevent blood clots forming in your legs.

You may be given a date for a follow-up appointment, usually six weeks after your operation.

Your doctor may want to review the medicines you have been taking to help your heart condition and may prescribe new ones for long-term use. It’s important that you manage conditions like diabetes, high cholesterol and high blood pressure. Your cardiac rehabilitation programme will help you make changes to live more healthily, like stopping smoking.

It can take two months or more for your breastbone to join together again. You might notice an occasional clicking sound in the meantime.

The length of time the dissolvable stitches in your skin take to disappear depends on what type you have. But they’ll usually dissolve in about six to eight weeks. If your stitches are not dissolvable, they can be removed after eight to 10 days. Your GP can do this for you.

Recovering from CABG

The time it takes to make a full recovery from a CABG procedure varies between individuals. Any discomfort in your chest will usually be gone after six months. You may notice pain that’s worse when you first wake up and when you move your arms, shoulders and legs.

If you need pain relief, you can take over-the-counter painkillers such as paracetamol. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice.

Cardiac rehabilitation

Your cardiac rehabilitation programme will probably go on for at least six weeks. It starts with an assessment soon after your operation. This identifies activities and support that suit your individual interests and needs, including your general health and other conditions. It will help you set realistic, personal goals and tackle any worries you have.

The programme can include group or individual sessions, at home or in a community setting. It may involve regular contact to motivate you to stop smoking, keep active or eat more healthily. It will help you access the right support if you’re depressed or anxious after your surgery. See our FAQs for more information on how you may feel after CABG.

An important part of cardiac rehabilitation is an exercise programme and advice on increasing your daily activity as you recover. Good posture can help avoid related neck and back problems. You’ll get advice on exercising safely and activities to avoid while your breastbone heals, which could take up to three months. You shouldn’t lift heavy objects for a while, or do anything that puts strain on your chest. The programme will encourage you to build up your stamina gradually, especially through regular walks.

Driving and flying

Follow your surgeon's advice about when it’s safe to drive or ride a motorbike. You shouldn’t drive if you’re taking strong painkillers that make you drowsy.

Unless you drive for a living, you don’t need to tell the Driver and Vehicle Licensing Agency (DVLA) about your operation but you mustn’t drive for at least a month afterwards.

If you have any concerns about driving again, speak to your surgeon and always follow their advice. You should be comfortable in a driving position and be able to safely control the car, including making an emergency stop. Sudden movements may be painful. It can help to put a cushion between your chest and seat belt. You might want to practise in a safe place first, without starting the engine, and to avoid long journeys for a while.

If you drive a lorry or a bus, you must notify the DVLA about your operation. You won’t be allowed to drive a lorry or bus for three months. It’s best to contact your motor insurer too so that you’re aware of their recommendations.

It’s normally safe to fly around eight weeks after your operation, but inform your travel insurance company and speak to your doctor about any concerns.

Returning to work

It could be about three months before you can go back to work, but it depends on how strenuous your job is. Your cardiac rehabilitation programme can help you get back to work sooner. Your employer may be able to help by offering you lighter duties at first.

Dr Jenny Lesser, consultant occupational physician shares her advice and expertise around How to get back to work after sick leave.

Side-effects of CABG

These are the unwanted but mostly temporary effects you may get after having the procedure. They’ll usually clear up on their own, and cardiac rehabilitation can help. Side-effects of CABG include:

• discomfort and perhaps itching from your healing wounds
• some swelling and bruising around the area where your graft was taken from, for example your leg
• tingling and weakness in your arm if a graft was taken from there
• tiredness, and mood swings – feeling upset and emotional
• loss of appetite and nausea
• muscle pains in your shoulders or upper back, and possibly also pain in your neck and bottom from sitting or lying in one position
• constipation
• scarring – you’ll have permanent scars, which will be pink and noticeable at first, but usually fade over time
• a change in your sleeping patterns
• shortness of breath due to a build-up of fluid in your lungs

Complications of CABG

Complications are when problems occur during or after the procedure. Possible complications of any operation include infection, nerve damage, breathing problems, excessive bleeding or developing a blood clot, usually in the leg (deep vein thrombosis, DVT). Specific complications of CABG can include:

• memory loss, and problems thinking clearly – this is usually only temporary
• irregular heartbeat (arrhythmia)
• heart attack
• stroke
• kidney failure
• infection of your wound
• problems with your vision

Tell your GP if you get sudden or severe pain in your chest or calf, and if a wound gets red, inflamed or discharges pus.

Most people who have CABG won’t get these complications. Your risk tends to be greater if you have the surgery as an emergency or if you have other diseases or conditions, like diabetes. There’s also more risk of complications if you’re older, a smoker or obese.

The potential complications of CABG can be serious. But it’s important to remember that you’d also be at risk of some of these complications, like heart attack, if you didn’t have the procedure. Your doctor can help you weigh up the benefits and risks before you decide whether or not to have the procedure.