Coronary Artery Disease

At Saint Luke’s Mid America Heart Institute, we offer a full-range of treatment options for patients with coronary artery disease in order to achieve the best possible outcomes. Treatment of CAD varies greatly between hospitals, and Saint Luke’s treats the most complex patient cases, and even offers advanced training to centers around the world. For arteries with chronic total occlusions (CTOs), Saint Luke’s performs 150-180 CTO PCI procedures with a success rate of more than 85 percent.

Understanding Coronary Artery Disease

Understanding Coronary Artery Disease (CAD)

Front view of heart showing coronary arteries.

To understand coronary artery disease (CAD), you need to know how your heart works. Your heart is a muscle that pumps blood throughout your body. To work right, your heart needs a steady supply of oxygen. It gets this oxygen from blood supplied by the coronary arteries.

Cross section of healthy artery.

Healthy artery. When a coronary artery is healthy and has no blockages, blood flows through easily. Healthy arteries can easily supply the oxygen-rich blood your heart needs.

Cross section of artery with damaged inner lining.

 

Damaged artery. Coronary artery disease begins when damage to the artery lining leads to the buildup of fat-like substances and cholesterol along the artery wall. This is called plaque. This damage could be caused by things like high blood pressure or smoking. This plaque buildup begins to narrow the arteries carrying blood to the heart. This is called atherosclerosis.

Cross section of artery with plaque buildup.

Narrowed artery. As more plaque builds up, your artery has trouble supplying blood to your heart muscle when it needs it most, such as during exercise. You may not feel any symptoms when this happens. Or you may feel angina—pressure, tightness, achiness, or pain in your chest, jaw, neck, back, or arm.

Cross section of artery with plaque buildup and blood clot.

 

Blocked artery. A piece of plaque may break off and completely block the artery. Or a blood clot may plug the narrowed artery. When this happens, blood flow is blocked from reaching the heart. Without oxygen-rich blood, part of the heart muscle becomes damaged and stops working. You may feel crushing pressure or pain in or around your chest. This is a heart attack (acute myocardial infarction, or AMI) and is a medical emergency.

What is coronary bypass graft surgery?

Coronary artery bypass graft surgery (CABG) is a procedure used to treat coronary artery disease. Coronary artery disease (CAD) is the narrowing of the coronary arteries – the blood vessels that supply oxygen and nutrients to the heart muscle. CAD is caused by a build-up of fatty material within the walls of the arteries. This build-up narrows the inside of the arteries, limiting the supply of oxygen-rich blood to the heart muscle.

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One way to treat the blocked or narrowed arteries is to bypass the blocked portion of the coronary artery with a piece of a healthy blood vessel from elsewhere in your body. Blood vessels, or grafts, used for the bypass procedure may be pieces of a vein from your leg or an artery in your chest. An artery from your wrist may also be used. Your doctor attaches one end of the graft above the blockage and the other end below the blockage. Blood bypasses the blockage by going through the new graft to reach the heart muscle. This is called coronary artery bypass surgery.

Traditionally, to bypass the blocked coronary artery, your doctor makes a large incision in the chest and temporarily stops the heart. To open the chest, your doctor cuts the breastbone (sternum) in half lengthwise and spreads it apart. Once the heart is exposed, your doctor inserts tubes into the heart so that the blood can be pumped through the body by a heart-lung bypass machine. The bypass machine is necessary to pump blood while the heart is stopped. 

While the traditional "open heart" procedure is still commonly done and often preferred in many situations, less invasive techniques have been developed to bypass blocked coronary arteries. "Off-pump" procedures, in which the heart does not have to be stopped, were developed in the 1990's. Other minimally invasive procedures, such as keyhole surgery (done through very small incisions) and robotic procedures (done with the aid of a moving mechanical device), may be used.

Why might I need coronary artery bypass surgery?

Your doctor uses coronary artery bypass graft surgery (CABG) to treat a blockage or narrowing of one or more of the coronary arteries to restore the blood supply to your heart muscle.

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Symptoms of coronary artery disease may include:

  • Chest pain
  • Fatigue (severe tiredness)
  • Palpitations
  • Abnormal heart rhythms
  • Shortness of breath
  • Swelling in the hands and feet
  • Indigestion

Unfortunately, you may not have any symptoms in early coronary artery disease, yet the disease will continue to progress until there’s enough artery blockage to cause symptoms and problems. If the blood supply to your heart muscle continues to decrease as a result of increasing blockage of a coronary artery, you may have a heart attack. If the blood flow can’t be restored to the particular area of the heart muscle affected, the tissue dies.

There may be other reasons for your doctor to recommend CABG surgery.

What are the risks of coronary artery bypass surgery?

Possible risks of coronary artery bypass graft surgery (CABG) include:

  • Bleeding during or after the surgery
  • Blood clots that can cause heart attack, stroke, or lung problems
  • Infection at the incision site
  • Pneumonia
  • Breathing problems
  • Pancreatitis
  • Kidney failure
  • Abnormal heart rhythms
  • Failure of the graft
  • Death

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor before the procedure.

How do I get ready for coronary artery bypass surgery?

 

  • Your doctor will explain the procedure and you can ask questions.
  • You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if anything is unclear.
  • Along with a review of your health history, your doctor may do a complete physical exam to make sure you are in otherwise good health before having the procedure. You may need blood tests or other diagnostic tests.
  • You will be asked to not eat or drink for 8 hours before the procedure, generally after midnight.
  • You may be asked to shower with a soap or special cleanser the night before and the morning of surgery.
  • Tell your doctor if you are pregnant or think you could be.
  • Tell your doctor if you are sensitive to or are allergic to any medicines, iodine, latex, tape, or anesthetic medicines (local and general).
  • Tell your doctor about all medicines (prescription and over-the-counter), vitamins, herbs, and supplements that you are taking.
  • Tell your doctor if you have a history of bleeding disorders or if you are taking any blood-thinning medicines, aspirin, or other medicines that affect blood clotting. You may be told to stop some of these medicines before the procedure.
  • Your doctor may do blood tests before the procedure to find out how long it takes your blood to clot.
  • Tell your doctor if you have a pacemaker or any other implanted cardiac device.
  • If you smoke, stop smoking as soon as possible. This may improve your chances for a successful recovery from surgery and benefit your overall health.
  • Based on your medical condition, your doctor may ask you to do other things to get ready.

 

What happens during coronary artery bypass?

Coronary artery bypass graft surgery (CABG) requires a stay in a hospital. Procedure may vary depending on your condition and your doctor's practices.

Generally, CABG follows this process:

  1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.
  2. You will change into a hospital gown and empty your bladder.
  3. A healthcare professional will insert an intravenous (IV) line in your arm or hand. Other catheters will be put in your neck and wrist to monitor your heart and blood pressure, as well as to take blood samples. 
  4. You will lie on your back on an operating table.
  5. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated (put into a deep sleep), a breathing tube will be put into your throat and you will be connected to a ventilator, which will breathe for you during the surgery.
  6. A catheter will be put into your bladder to drain urine.
  7. The skin over the surgical site will be cleaned with an antiseptic solution.
  8. Once all the tubes and monitors are in place, your doctor will make incisions (cuts) in one or both of your legs or one of your wrists to access the blood vessel(s) to be used for the grafts. He or she will remove the vessel(s) and close those incision(s).
  9. The doctor will make an incision (cut) down the center of your chest from just below the Adam's apple to just above the navel.
  10. The doctor will cut the sternum (breastbone) in half lengthwise. He or she will separate the halves of the breastbone and spread them apart to expose your heart.

Coronary artery bypass graft surgery--on-pump procedure

  1. To sew the grafts onto the very small coronary arteries, your doctor will need to stop your heart temporarily. Tubes will be put into the heart so that your blood can be pumped through your body by a heart-lung bypass machine.
  2. Once the blood has been diverted into the bypass machine for pumping, your doctor will stop the heart by injecting it with a cold solution.
  3. When the heart has been stopped, the doctor will do the bypass graft procedure by sewing one end of a section of vein over a tiny opening made in the aorta, and the other end over a tiny opening made in the coronary artery just below the blockage. If your doctor uses the internal mammary artery inside your chest as a bypass graft, the lower end of the artery will be cut from inside the chest and sewn over an opening made in the coronary artery below the blockage.
  4. You may need more than one bypass graft done, depending on how many blockages you have and where they are located. After all the grafts have been completed, the doctor will closely check them as blood runs through them to make sure they are working.
  5. Once the bypass grafts have been checked, the doctor will let the blood circulating through the bypass machine back into your heart and he or she will remove the tubes to the machine. Your heart may restart on its own, or a mild electric shock may be used to restart it.
  6. Your doctor may put temporary wires for pacing into your heart. These wires can be attached to a pacemaker and your heart can be paced, if needed, during the initial recovery period.

Coronary artery bypass surgery--off-pump procedure

  1. Once your doctor has opened the chest, he or she will stabilize the area around the artery to be bypassed with a special instrument.
  2. The rest of the heart will continue to function and pump blood through the body.
  3. The heart-lung bypass machine and the person who runs it may be kept on stand-by just in case the procedure need to be completed on bypass.
  4. The doctor will do the bypass graft procedure by sewing one end of a section of vein over a tiny opening made in the aorta, and the other end over a tiny opening made in the coronary artery just below the blockage.
  5. You may have more than one bypass graft done, depending on how many blockages you have and where they are located.
  6. Before the chest is closed, the doctor will closely examine the grafts to make sure they are working.

Procedure completion, both methods

  1. Your doctor will sew the sternum together with small wires (like those sometimes used to repair a broken bone).
  2. He or she will insert tubes into your chest to drain blood and other fluids from around the heart. 
  3. Your doctor will sew the skin over the sternum back together.
  4. Your doctor will put a tube through your mouth or nose into your stomach to drain stomach fluids.
  5. He or she will then apply a sterile bandage or dressing.

What happens after coronary artery bypass surgery?

In the hospital

After the surgery, you may be taken to the recovery room and then the intensive care unit (ICU) to be closely monitored. Machines will constantly display your electrocardiogram (ECG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. Coronary artery bypass surgery (CABG) requires an in-hospital stay of at least several days.

You will most likely have a tube in your throat to help with breathing through a ventilator (breathing machine) until you are stable enough to breathe on your own. As you continue to wake up from the anesthesia and start to breathe on your own, your doctor can adjust the breathing machine to allow you to take over more of the breathing. When you are awake enough to breathe completely on your own and you are able to cough, your doctor will remove the breathing tube. In most cases, the breathing tube is removed soon after the operation, usually the same day or by early the next morning. Your doctor will also remove the stomach tube at this time.

After the breathing tube is out, a nurse will help you cough and take deep breaths every couple of hours. This will be uncomfortable due to soreness, but it is very important that you do this to keep mucus from collecting in your lungs and possibly causing pneumonia. Your nurse will show you how to hug a pillow tightly against your chest while coughing to help ease the discomfort.

The surgical incision may be tender or sore for several days after a CABG procedure. Take a pain reliever for soreness as recommended by your doctor. Aspirin or certain other pain medicines may increase the chance of bleeding. Be sure to take only recommended medicines.

Your doctor may delivery medicines through the IV to help your blood pressure and your heart, and to control any problems with bleeding. As your condition stabilizes, he or she will gradually decrease and then stop these medicines.

Once your doctor removes the breathing and stomach tubes and you are stable, you may start to drink liquids. You can gradually include more solid foods as you can handle them. 

When your doctor determines that you are ready, you will be moved from the ICU to a post-surgical nursing unit. Your recovery will continue there. You can gradually increase your activity as you get out of bed and walk around for longer periods. You can eat solid foods as soon as you can tolerate them.

A member of your care team will arrange for you to go home and schedule a follow-up visit with your doctor.

At home

Once you are home, it will be important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. Your doctor will remove the sutures or surgical staples during a follow-up office visit, if they were not removed before leaving the hospital.

Do not drive until your doctor tells you it's OK. You may have other activity restrictions.

Tell your doctor if you have any of the following:

  • Fever of 100.4°F (38°C) or higher, or  chills
  • Redness, swelling, or bleeding or other drainage from any of the incision sites
  • Increase in pain around any of the incision sites
  • Trouble breathing
  • Rapid or irregular pulse
  • Swelling in the legs
  • Numbness in the arms and legs
  • Persistent nausea or vomiting

Your doctor may give you other instructions after the procedure, depending on your situation.



Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would  happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure

Coronary Artery Bypass Surgery

Coronary Artery Bypass Surgery

Front view of heart with three bypass grafts.

Your coronary arteries are the vessels that carry blood to your heart muscle. If one or more of these arteries are blocked, blood can’t flow to the heart muscle. In this case, the heart muscle may die (heart attack) or become weakened and damaged and cause chest pain (angina). You may have shortness of breath, increasing tiredness (fatigue), leg swelling, or a run-down feeling. Coronary artery bypass surgery makes a path for blood to flow around a blockage. It helps reduce the risk for further damage to your heart caused by the lack of blood. It may also ease your symptoms of angina or shortness of breath. 

Getting ready for surgery

Prepare for the procedure as you have been instructed. In addition:

  • Be sure to tell your healthcare provider about all medicines you take. This includes over-the-counter medicines. It also includes herbs and other supplements. You may need to stop taking some or all of them before surgery as directed by your healthcare provider.

  • Follow any directions you are given for not eating or drinking before surgery.

Preparing the bypass graft

First, a healthy blood vessel (graft) is taken from another part of your body. Taking this graft usually doesn't affect blood flow in that body part. Often more than one blockage occurs. If you have more than one blockage, you may need more than one graft. Sometimes the doctors will do special ultrasound tests to look at the possible grafts before surgery. One or more of these blood vessels will be used for the graft:

  • The saphenous vein, which is located in the leg.

  • The radial artery, which is located by the wrist.

  • The internal thoracic (mammary) arteries, which are located in the chest wall. There are two internal thoracic arteries, one on each side of the chest. Typically, the left one is used, but sometimes both are used.

Reaching the heart

While one member of the bypass team is harvesting the graft or grafts, another member works to reach your heart. The provider makes an incision in your chest. Then he or she opens the breastbone (sternum) down the middle and pulls it apart. The breastbone is held open throughout surgery. This puts pressure on the nerves of the chest. This is why you may have soreness and muscle spasms in your chest, shoulders, and back during recovery.

Attaching the graft

A small opening is made in the coronary artery, past the blockage:

  • If a saphenous vein or radial artery is used, one end of the graft is sewn onto this opening. The other end is typically sewn on to the aorta. Neither the diseased artery nor the blockage is removed. If a stent is present, it is not removed either. This is because the stent will already have become a permanent part of the artery.

  • If the internal thoracic (mammary) artery is used, one end of the graft is sewn onto this opening. The other end is already attached to a branch of the aorta.

Finishing up

Once the graft has been attached, blood will start flowing through this new pathway to bypass the blockage. If you have multiple blockages, more than one bypass may be done. Then your breastbone is rejoined with wires. These wires will stay in your chest permanently. They rarely cause a problem. They are safe around microwaves and airport metal detectors. The incision is closed, and you are taken to the intensive care unit to begin your recovery.

Using a heart-lung machine

Coronary artery bypass surgery can be done with the heart still beating (off pump) or with the heart still (on pump.) Your surgery team can tell you more about which type of surgery you will have:

  • On-pump surgery. A machine does the work of your heart and lungs during surgery. Blood is circulated through a heart-lung machine. The machine supplies the blood with oxygen and pumps it back through the body. In these cases, the heart may be stopped temporarily before the graft is attached. Your own heart and lungs start working again after the bypass is completed.

  • Off-pump surgery. The heart-lung machine is not used and the heart is not stopped. This is sometimes called a "beating heart" procedure.

There are advantages and disadvantages to each technique. If you have a question about why your doctor is using one technique instead of the other, don't be afraid to ask.

 

Risks and complications

You and your surgeon can discuss the risks and possible complications of coronary artery bypass surgery. They may include:

  • Excessive bleeding. You may need a blood transfusion or a trip back to the operating room.

  • Infection of the incision sites

  • Lung infection (pneumonia)

  • Fast or irregular heartbeat. This is almost always temporary.

  • Nerve injury or muscle spasms

  • Breathing problems

  • Memory problems or confusion

  • Heart attack, stroke, or death

  • Damage to other parts or organs of your body because of problems with blood circulation

What is anomalous coronary artery intervention?

Anomalous coronary artery intervention is a procedure to correct a problem with the coronary artery. An anomalous coronary artery may have an irregularity with its starting point, course, shape, or branching. The specific problem may cause the artery to be blocked. During the procedure, the blocked part of the artery is opened up.

The heart pumps blood to the body and lungs. But it also needs its own supply of blood to keep it alive. The coronary arteries supply blood to the heart muscle. These arteries arise from the aortic sinuses. The aortic sinuses are in the aorta. The aorta is the large blood vessel that sends blood from the heart out to the whole body.

There are 2 coronary arteries that normally arise from these sinuses. The right coronary artery arises from the right aortic sinus. The left coronary artery arises from the left aortic sinus. These 2 arteries branch off into other coronary arteries. In some people, the branching of the coronary arteries is abnormal. This occurs before birth. No one knows what causes it. It may cause no problems. But in some cases, significant complications or even sudden death may occur.

Fatty deposits may form inside the arteries. This is known as atherosclerosis. The deposits can block the flow of blood through the arteries. The arteries may also become compressed due to the abnormal paths they take.

To treat this condition, your doctor can use angioplasty and a stent to fix the artery. The procedure is done with a thin, flexible tube (catheter) that has a tiny balloon at its tip. The catheter is put into a blood vessel in the groin or wrist. It’s then gently advanced to the coronary artery. The balloon is inflated. This pushes aside the fatty deposits and makes space in the artery. Or, it opens up a compressed area. A small mesh tube called a stent is then put in the area. It’s left in place to keep the area open. The catheter is then removed.

Why might I need an anomalous coronary artery intervention?

Treatment is often advised for people with this condition who have symptoms. An anomalous coronary artery may not cause any symptoms. Or it may cause symptoms such as chest pain or fainting with exercise, or abnormal heart rhythms. This may mean that the heart muscle is not getting enough blood.

Getting treatment for a blocked anomalous coronary artery can prevent serious problems. These include lack of blood to the heart muscle (ischemia), irregular heart rhythms, and sudden cardiac death.

Some people with an anomalous coronary artery can be treated with medicines and lifestyle changes. In other cases, a person may need the intervention procedure. Or your doctor may advise a different type of surgery. Talk with your doctor about the risks and benefits of each procedure for you.

What are the risks of anomalous coronary artery intervention?

All procedures have risks. The risks of this procedure include:

  • Excess bleeding
  • Blood vessel damage from the catheters
  • Infection
  • Blood clot that can lead to stroke or blockage of the stent
  • Abnormal heart rhythm, which can cause death in rare cases
  • Allergic reaction to the dye
  • Heart attack
  • Need for coronary artery bypass grafting, if the artery doesn’t open with the procedure

Your risks may vary based on your overall health, the severity of your condition, and other factors. Ask your doctor about which risks apply most to you.

How do I prepare for an anomalous coronary artery intervention?

Talk with your healthcare provider how to prepare for your procedure. Tell your healthcare provider about all the medicines you take. This includes over-the-counter medicines such as aspirin. You may need to stop taking some medicines ahead of time, such as blood thinners. If you smoke, you’ll need to stop before your procedure. Talk with your healthcare provider if you need help to stop smoking.

You may need some tests before the procedure, such as:

  • Chest X-ray
  • Electrocardiogram, to check the heart rhythm
  • Blood tests, to assess your general health
  • Echocardiogram, to view heart and the blood flow through the heart
  • Multidetector computed tomography scan (MDCT) or cardiac magnetic resonance (MR), if more information about the blood vessels is needed

Do not eat or drink after midnight the night before your procedure. Tell your healthcare provider about any recent changes in your health, such as a fever.

What happens during an anomalous coronary artery intervention?

Talk with your healthcare provider about what to expect during your procedure. The procedure often takes place in a cardiac catheterization lab. A cardiologist and a team of specialized nurses and technicians work together. A typical procedure may go like this:

  • An IV will be put in your arm or hand before the procedure starts. You’ll be given sedation through the IV line. This will make you relaxed and sleepy during procedure.
  • Hair in the area of your procedure may be removed. The area may be numbed with a local anesthesia.
  • The healthcare provider will make a small incision in a blood vessel in your groin or wrist. He or she will then insert a long, thin wire into this cut. The wire acts as a guide for during the procedure.
  • The healthcare provider will then insert a thin, flexible tube (catheter) over the wire. It has a tiny deflated balloon on the end. The catheter will be threaded through the blood vessel all the way into the coronary artery. Continuous X-ray images may be used to show exactly where the catheter is.
  • The balloon will be inflated inside the narrow part of the artery. This will stretch the area open.
  • A mesh tube called a stent may be left in place in the area. This will help keep the area open.
  • The balloon will be deflated, and the catheter will be removed.
  • The incision site in the groin or wrist will be closed and bandaged.

What happens after an anomalous coronary artery intervention?

After the procedure, you will spend several hours in a recovery room. You may be sleepy and confused when you wake up. Your healthcare team will watch your vital signs, such as your heart rate and breathing. You’ll be given pain medicine if you need it.

You may need to lie flat without bending your legs for several hours after the procedure. This is to help prevent bleeding from the incision site. You will need to stay in the hospital overnight. Your healthcare provider will tell you more about what to expect.

After you go home, you may need to take medicines to help prevent blood clots. You may need to take them for a short time, or take them for a longer time. You may also need to take antibiotics. Your healthcare provider will let you know about any other changes in your medicines. You can take pain medicine at home if you need it. Ask your healthcare provider which to take.

You can resume your normal activities when you get home. But do not do strenuous activities or heavy lifting for several days. Your doctor may give you more instructions.

Make sure to keep all of your follow-up appointments. This will help your healthcare provider keep track of your progress. Your doctor may order follow-up tests. These may include an electrocardiogram or an echocardiogram.

Call your healthcare provider right away if you have any of the following:

  • Swelling or pain that gets worse
  • Fluid or blood leaking from the incision site
  • Fever
  • Chest pain

Follow all of your healthcare provider’s instructions. This includes any advice about medicines, exercise, and wound care.

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would  happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure
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Saint Luke's Cardiovascular Consultants

A leader in cardiac care, Saint Luke’s Cardiovascular Consultants treats patients throughout the Kansas City area and surrounding communities. Our medical team consists of both board-certified clinical cardiologists as well as physicians certified in specialty areas of cardiology including interventional cardiology, echocardiography, nuclear cardiology, preventive cardiology, and electrophysiology.