Abstract
Coronary artery calcification (CAC) is a sex and age-dependent vascular pathology affecting normal coronary compliance and physiologic vasomotor response, as well as impairing adequate myocardial perfusion. CAC can be classified in two subtypes depending on the vascular layer affected: intimal or medial artery calcification. Denser deposits detected by imaging studies suggest the presence of advanced complicated lesions, which have shown to strongly correlate with atherosclerotic plaque burden. The diagnosis of coronary artery calcification is done by an electron-beam computed tomography scanner, and the degree of calcification is quantified using the Agatston score. Interventional treatment of calcified coronary arteries remains challenging. Focal coronary calcification is a well-known predictor of poor prognosis in patients undergoing percutaneous coronary intervention. The 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults recommended coronary artery bypass graft surgery (CABG) for patients with class III to IV CAC seen on intravascular ultrasound, presence of thrombotic or ulcer lesions, serious angle lesions >60 degrees, intimal tear lesions, diffuse lesion length >25mm, severe left ventricular dysfunction, and in patients where a coronary guidewire cannot pass the calcified lesion. The most commonly used grafts for coronary artery bypass are the left internal mammary artery and the greater saphenous vein. Graft choice for CABG depends on patient comorbidities and life expectancy, the location and number of coronary targets, and the availability of graft material. The preoperative assessment and operative steps for CABG are elucidated. Lastly, the evolution of coronary endarterectomy from a standalone intervention to an adjunct technique to CABG surgery is introduced.