MICS CABG (Multivessel) Part I

MICS CABG (Multivessel) Part I

How many bypasses can be done by the MICS CABG technique?

This is a question that’s frequently asked by patients. Why does this question arise so frequently?

The vast majority of patients who are referred for bypass surgery (CABG) require two or more bypass grafts. The medical community is still not fully aware of the technique of MICS CABG and its wrongly believed that only a single graft can be done by MICS CABG. This is because most surgeons are still learning the technique and are capable of performing a single bypass. When these surgeons or physicians are consulted they incorrectly advise patients against undergoing an MICS CABG. This article was particularly written to educate and to simply to dispel this myth.

Are these patients given wrong information? In a way yes although it may be more from ignorance rather than on purpose. Many senior physicians are actually unaware and spend little time in updating themselves about current techniques. Less often we find that although the physicians knew, they actually discouraged patients from undergoing a less invasive procedure that was actually beneficial. The reasons for this are manifold. First incomplete knowledge breeds fear. Older physicians may be in touch with older surgeons who are unable to adapt to evolving techniques and therefore may condemn them from the fear of loosing clientele. Some may find it uncomfortable to call a younger colleague to enquire about a technique they are unaware of. Irrespective of the cause, it’s the patient who ends up suffering.

In part II of this article I will highlight our experience with MICS multi vessel bypass with actual patient details and scientific evidence towards the same.

Please leave a comment. If you or a member of your family has undergone a multi vessel MICS CABG, do write your story.

Part II of this post will carry a true patient experience. Its a must read!

Multi vessel MICS CABG is possible and performed on a daily basis


Patients receiving 2 or more bypass grafts by MICS

Endoscopic Vein Harvesting

Endoscopic Vein Harvesting

Endoscopic Vein Harvesting

Coronary artery bypass graft surgery, or CABG is an established and life saving procedure often performed to bypass a blocked vessel in the heart and thus restores healthy blood flow to the heart. This involves two primary steps

  1. Healthy blood vessels are removed or harvested from the chest, leg, or arm to be used in creating the vessel to be used as bypass or bypasses.
  2. The usual sites where the blood vessel is removed are
  • Internal mammary artery in the Chest
  • Long or Short Saphenous vein in the leg
  • Radial Artery in the Forearm

The bypass basically creates an alternative pathway for the blood to flow from the aorta to the Heart.

The vessels can be removed or harvested from the leg and forearm either using the Traditional Open Harvesting technique or the more advanced Endoscopic harvest (EVH) technique.


Patients recieving EVH in USA


Pateints receiving EVH in Apollo, Bangalore

Bypass grafts

How do we know which of these is the better technique?

Endoscopic Vein Harvesting (EVH)

With EVH, the surgeon is able to remove the long saphenous vein or the radial artery from a very small incision (Approximately 2 cms). He uses a specialized instrument called the endoscope to isolate and remove the vessel under high definition videoscopic guidance. This has been a very safe and reliable technique.

EVH is particularly recommended in those with diabetes, peripheral vascular disease, smokers, those with skin infection and in the obese. In general practically all patients in all age groups benefit from EVH. EVH does add a small additional cost to the operation on account of the disposable device used.

Open Vein Harvesting (Traditional Technique)

In this method the surgeon makes a long incision on your leg extending from the groin to the ankle for saphenous vein harvesting or arm  (extending from the wrist to the elbow for Radial Artery harvesting). This method has been in practice since the beginning of heart surgery. While being a safe and established technique it is primitive, crude and morbid.

  • This technique is also used as a back up when EVH fails in patients with very fatty legs or when the vein is diseased.

Stents or Coronary Bypass Surgery (CABG): What every patient must know!

There is no one treatment guaranteed to be effective for all cases of coronary artery disease. But because there are different treatment options, it is important for every patient to have the information and resources necessary, after talking with a variety of healthcare professionals, to make informed decisions.

To determine the recommended form of treatment, physicians must first consider the extent of the problem. For those who have multivessel or left main coronary artery disease, surgery, not percutaneous intervention (PCI or Angioplasty) or stents, offers the best long-range outcome, according to David Taggart, MD, Professor of Cardiovascular Surgery at England’s University of Oxford.

Dr. Taggart, who has criticized the increasing trend to treat all patients with PCI or angioplasty without offering a surgical option, showed flaws in 15 trials of angioplasty versus surgery. Dr. Taggert believes that for the studies, low risk patients were used, whose outcomes would be excellent with any treatment.


“For these studies, 176,250 people were screened to find the ideal patients, and 95 percent of those screened were excluded,” Taggart said. “None of the patients in the trial had left main disease. Patients do want less invasive treatment, assuming the results are the same. But that is definitely not the case here.”

Dr. Taggart believes that part of the problem involves those who are responsible for decision making with patients. He said that when patients are informed of possible heart problems, their research should extend beyond a visit to a cardiologist.

“Failure to discuss CABG (coronary artery bypass grafting) means that the patient is often denied the best treatment option,” Taggert said. “Consent for PCI is often obtained inappropriately. Doctors are obligated to explain alternate options if they are more effective. Usually, the cardiologist is the gatekeeper, and there is a conflict of self-interest there, it is a self-referral. All patients with multivessel disease should be treated by a multidisciplinary team, including a surgeon.”


Heart with bypass grafts

Heart with bypass grafts



Taggert said that CABG is a remarkably safe and effective procedure, and has a good, long range prognosis.

Studies have also shed light on the merits of CABG over PCI under appropriate conditions. For example, a study published 2005 in the New England Journal of Medicine concluded that for patients with two or more diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than stenting. That study showed that patients with three blocked arties who received stents were 56 percent more likely to die within three years as those who had bypass surgery. That study was addressed in a Wall Street Journal article which said that stenting, the popular, minimally invasive angioplasty procedure, carries a higher risk of death long term than does open heart bypass surgery as a treatment for blocked arteries. The Journal reported that more than a third of patients who received stents needed either surgery or additional angioplasties with stents within three years.