Coronary Artery Bypass Graft (CABG)

Coronary artery bypass grafting is a major cardiac surgical procedure performed under general anaesthesia, typically lasting three to six hours depending on the number of bypasses required. In conventional on-pump surgery, the heart is arrested and cardiopulmonary bypass (the heart-lung machine) maintains systemic circulation while the surgeon constructs each bypass conduit. The left internal mammary (thoracic) artery is the preferred conduit for the left anterior descending artery bypass due to its superior long-term patency; the great saphenous vein from the leg and the radial artery from the forearm are used as supplementary conduits. In off-pump (beating-heart) surgery, bypasses are constructed on the still-beating heart using mechanical stabilisers, avoiding cardiopulmonary bypass.

Patient selection is based on coronary angiography demonstrating significant stenosis in multiple vessels or in critical locations (left main disease, proximal three-vessel disease) where complete revascularisation by percutaneous coronary intervention is not appropriate. Left ventricular function, the presence of diabetes, and the extent of disease influence the decision between surgical and percutaneous approaches. Pre-operative optimisation of cardiac medications, renal function, and glycaemic control is important for reducing peri-operative risk.

Post-operatively, patients are nursed in the intensive care unit for twenty-four to forty-eight hours before transfer to a high-dependency ward. Hospital stay is typically five to eight days. Sternal healing requires approximately six to eight weeks during which upper extremity loading is restricted. Patients should not drive for four to six weeks. Full functional recovery and return to normal activity typically takes two to three months. Cardiac rehabilitation — a structured exercise and education programme — is an evidence-based component of post-CABG care that significantly reduces re-admission rates and improves long-term outcomes.

CABG represents the highest cost bracket among elective surgical procedures in this guide. Quoted package prices from centres in lower-cost countries typically include the surgical procedure, ICU stay, full inpatient hospital stay (usually seven to ten days), cardiac surgical team fees, anaesthesia, and standard post-operative medications. However, the overall cost is highly sensitive to case complexity: a double bypass in an otherwise healthy elective patient differs enormously in resource use from a triple bypass in a patient with diabetes and impaired renal function.

Costs that may be excluded from package prices include pre-operative cardiac catheterisation and angiography if not already performed, echocardiography, blood products used during surgery, extended ICU stay due to complications, and cardiac rehabilitation. Post-operative medications — including antiplatelet agents, statins, beta-blockers, and ACE inhibitors — represent ongoing costs after discharge. Patients should also clarify whether the package includes medical management of peri-operative complications such as atrial fibrillation (a common post-CABG occurrence requiring rate-control or anticoagulation) or wound infections.

Following surgery, patients spend one to two days in the cardiac surgical intensive care unit, during which ventilatory support is weaned and haemodynamic stability is confirmed. Transfer to a high-dependency or general cardiac ward follows, and the total hospital stay is typically five to seven days. The sternotomy — the vertical incision through the breastbone — is the dominant constraint on early recovery. Sternal precautions, which prohibit pushing or pulling with the arms, lifting anything heavier than approximately one kilogram, and any activity that causes sternal click or pain, are maintained for eight to twelve weeks to allow full bony union.

Cardiac rehabilitation, a supervised programme of gradually progressive exercise combined with education on risk factor modification, typically begins four to eight weeks after discharge and runs for six to twelve weeks. Patients generally return to light daily activities within two to four weeks, though driving is not permitted for four to six weeks. Return to sedentary work may be possible at six to eight weeks; physically demanding work may require three months or longer. Full recovery — characterised by resumed exercise tolerance, complete sternal healing, and stable cardiac medications — is typically achieved by three months, with ongoing functional improvement evident over the following year.

CABG carries the most stringent post-operative travel restrictions of any procedure in this guide. Patients are typically unfit for long-haul air travel for six to eight weeks following surgery due to sternal instability, the risk of in-flight haemodynamic instability, and the greatly elevated risk of deep vein thrombosis and pulmonary embolism. Any patient considering CABG abroad must plan for a stay of at least six to eight weeks near the hospital or must arrange ground or medically supervised repatriation if complications require transfer. Short-haul flights within this period may be feasible in selected patients after individual cardiothoracic assessment.

The availability and quality of intensive care facilities is a primary consideration when selecting a centre abroad. Patients and family members should verify that the hospital has a cardiac surgical ICU with mechanical circulatory support capability (intra-aortic balloon pump at minimum) and that experienced perfusionists are present for on-pump cases. Operative records, graft configuration diagrams, and discharge medication lists must be obtained before leaving the hospital; these are essential for any cardiologist or cardiac surgeon managing the patient subsequently in the home country. Cardiac rehabilitation must be pre-arranged with a facility in the home country before departure, as early enrolment after discharge is associated with significantly better outcomes.