Coronary Artery Disease: Global Impact

Coronary artery disease (CAD) is one of the major health problems in the developing countries. Every year, nearly 2 million deaths from this CAD in the European Union, amongst man are 16% and women 15% deaths due to this CAD(WEBBER et al 2012). In 2015 nearly 20 thousand coronary artery bypass surgery, 115 thousand revascularisation performed in the United Kingdom (Abu-Omar and Taggart 2018). The development of coronary artery disease (CAD) takes place when the major blood vessels supplying oxygen, blood, and nutrients (coronary arteries) to the human heart gets diseased or damaged. The deposits that contain Cholesterol in the form of plaque in the human arteries and inflammation are generally blamed for the CAD. After building up of the plaque, the coronary arteries are narrowed, and blood flows are decreased to the heart. Eventually, there can be shortness of breath, chest pain (angina) or other CAD symptoms or signs caused by the decreased blood flow. If the blockage is complete, it can cause a heart attack (MENEES and BATES 2010).

As the development of CAD can be over decades, a problem may not be noticed until a heart attack or a significant blockage (LIBBY 2004). However, many things can be done for prevention and treatment of CAD. A big impact can be made with a healthy lifestyle.

Coronary Artery Bypass Surgery:

Coronary Artery Bypass Surgery (CAGB) is one of the most common surgical procedures performed on the heart, with roughly 1 million procedures performed every year worldwide. It is one of the gold standard operations for the CAD.CABG is an highly effective in reliving symptoms of ischaemic heart disease, as well as improving life expectancy is better and improved quality of life after this procedure. CABG is one the safe procedure by the help of enhanced medical, surgical management and anaesthetic to advance the mortality in recent years (BODEN et al 2007). A study like prospective, randomised, open-label, non-inferiority NOBLE trial is a development trial in 36 hospitals in nine northern European countries. People with left main disease required revascularisation by percutaneous coronary intervention (PCI) or CABG. The trial concluded with saying that mortality was similar after the both procedure but patient treated with PCI had higher rates of non-procedural myocardial infarction and need repeat revascularisation (Holm et al 2019).

The standard of CABG is to bypass the diseased sections of the coronary circulation by using venous and arterial conduits. The common conduits used is long saphenous vein from both legs and internal mammary artery from either side of the chest and also from either left or right hand once they done the Alan test(physical examination of the arterial blood flow to the hands (STONE et al. 2016). CABG is used for treating a blockage or narrowing of coronary arteries so that the supply of blood to the heart muscle is restored. The coronary artery disease’s symptoms includes: (a) Indigestion; (b) Swelling of feet and hands; (c) Shortness of breath; (d) Abnormal heart rhythms; (e) Palpitations; (f) Fatigue; and (g) Chest pain.

However, the patient, in the early CAD, may not have any symptoms, although the progression of the disease will continue until there is blockage in the artery that causes problems and symptoms (TAGGART 2005). If there is continual degree of blood supply to the heart muscle resulting from the coronary arteries’ increased blockage, one may have a heart attack. If the restoration of the blood flow to the affected heart muscle’s particular area is not possible, there is death of the tissues. ). The benefits of arterial grafts is more superior patency compare to the vein grafts and it is more popular graft for left anterior descending artery. The long saphenous vein graft is a popular and common conduit for bypass surgery. And the vein can be harvested by open technique, bridging technique and the latest keyhole surgery (JEON et al. 2010). When comparing the open and keyhole surgery for conduit harvest, the keyhole surgery allows the patient for early mobilisation, reduced morbidity and also shortening hospital stay. To do efficiently the keyhole surgery (endoscopic vein harvesting), we need to make sure the conduit is good, whether it is superficial or deep, any varicosity and the size of the conduit.by doing the vein mapping with the help of ultrasonography machines (Hussain 2018). (Frank Manetta et al 2017) concluded that bedside ultrasonography vein mapping helps the conduit harvester and perfect non-invasive method for preoperative assessment for the suitability of conduit for CABG surgery.

Currently,Since the long saphenous vein mapping is done by the vascular department ,it is not always very accurate and helpful to do the keyhole method to harvest a conduit from leg.so we have do again in the anaesthetic room once the patient is sleep to find out the accurate and mark the place with marker pen. Long saphenous vein has been the commonest conduit used for the revascularization of the surgical coronary. The vein assessment assisted by the ultrasound is superior to the traditionally done long saphenous vein’s clinical examination to discern suitability and path for the usage as conduit. The long saphenous vein’s preoperative ultrasound mapping is rapidly and easily accomplished that allows the selection of the optimal surgical site and avoids potential wound complications and surgical dissection unnecessarily. The ultrasound mapping technique of the long saphenous vein can be described for the conduit harvest in CABG surgery. At the same time we are doing this procedure at least 2 times for the same patient and also spending money unnecessary and also wasting time for the patient. According to the National institute for health and care excellence (NICE) guidelines recommends to do the vein mapping by the harvester.it is very important to the vein mapping by yourself to get an good ideal and the confident by doing this ultrasonography by yourself.

reference

ABU-OMAR, Y. & TAGGART, D.P. 2018, "Coronary artery bypass surgery", Medicine, vol. 46, no. 9, pp. 555-559.

HOLM, N.R., MÄKIKALLIO, T., LINDSAY, M.M., SPENCE, M.S., ERGLIS, A., MENOWN, I.B.A., TROVIK, T., KELLERTH, T., KALINAUSKAS, G., MOGENSEN, L.J.H., NIELSEN, P.H., NIEMELÄ, M., LASSEN, J.F., OLDROYD, K., BERG, G., STRADINS, P., WALSH, S.J., GRAHAM, A.N.J., ENDRESEN, P.C., FRÖBERT, O., TRIVEDI, U., ANTTILA, V., HILDICK-SMITH, D., THUESEN, L., CHRISTIANSEN, E.H., Örebro universitet & Institutionen för medicinska vetenskaper 2019, "Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non-inferiority NOBLE trial", The Lancet, .

HUSSAIN, S.M.A. 2018, "The Role of Tomographic Ultrasonography in Conduit Mapping before Coronary Artery Bypass Grafting", Radiology research and practice, vol. 2018, pp. 2097305-7.

MANETTA, F., YU, P., MATTIA, A., KARAPTIS, J.C. & HARTMAN, A.R. 2017, "Bedside Vein Mapping for Conduit Size in Coronary Artery Bypass Surgery", JSLS : Journal of the Society of Laparoendoscopic Surgeons, vol. 21, no. 2, pp. e2016.00083.

MENEES, D. S. and BATES, E. R., 2010. Evaluation of patients with suspected coronary artery disease. Coron Artery Dis. 21(7), pp.386-90.

LIBBY, P., 2004. Mechanisms of acute coronary syndromes and their implications for therapy. The New England Journal of Medicine. 368( 21), pp. 2004–2013.

TAGGART, D. P., 2005. Surgery is the best intervention for severe coronary artery disease. BMJ. 330, pp.785–6.

WEBBER, B. J., Seguin, P. G., Burnett, D, G., et al.. 2012. Prevalence of and risk factors for autopsy-determined atherosclerosis among US service members, 2001-2011. JAMA. 308, pp.2577-83.

BODEN, W. E., O'ROURKE, R. A., TEO, K. K., et al., 2007. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 356, pp.1503.

STONE, G. W., SABIK, J. F., SERRUYS, P. W., et al., 2016. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med. 375, pp. 2223-2235.

JEON, C., CANDIA, S. C., WANG, J. C., et al., 2010. Relative spatial distributions of coronary artery bypass graft insertion and acute thrombosis: a model for protection from acute myocardial infarction. Am Heart J. 160, pp.195-201.