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Bilateral internal thoracic artery use in coronary bypass surgery: is there a benefit?



Over the past three decades, there have been a plethora of retrospective observational data and meta-analyses which support the hypothesis of improved clinical outcomes using bilateral internal thoracic arteries (BITA) when compared to saphenous vein grafts (SVGs). However, recently published results have brought this thinking into doubt. We discuss the existing literature on the subject and attempt to clarify the appropriate use of BITA in coronary artery bypass surgery (CABG).


A review of all existing meta-analyses on BITA was conducted to better understand the utility of BITA in CABG. A review of the largest randomized controlled trials on the subject was then compared to the observational data.


In all existing meta-analyses, BITA shows a significant advantage over the use of a single internal thoracic artery (SITA) with SVGs. The two largest randomized controlled trials evaluating BITA failed to show a survival advantage and brought into question the complications associated with BITA.


At present, the use of multiple arterial grafts remains a reasonable choice, particularly in young patients, provided that their use does not increase the operative risk. Further evidence currently being collected may lend a definitive answer in the near future.

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  1. 1.

    Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med. 1986;314:1–6.

    Article  CAS  PubMed  Google Scholar 

  2. 2.

    Benedetto U, Caputo M, Gaudino M, et al. Right internal thoracic artery or radial artery? A propensity-matched comparison on the second-best arterial conduit. J Thorac Cardiovasc Surg. 2017;153:79–88.

    Article  PubMed  Google Scholar 

  3. 3.

    Locker C, Schaff HV, Dearani JA, et al. Multiple arterial grafts improve late survival of patients undergoing coronary artery bypass graft surgery : analysis of 8622 patients with multivessel disease. Circulation. 2012;126:1023–30.

    Article  PubMed  Google Scholar 

  4. 4.

    Lytle BW, Blackstone EH, Loop FD, et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg. 1999;117:855–72.

    Article  CAS  PubMed  Google Scholar 

  5. 5.

    Leonard JR, Abouarab AA, Tam DY, Girardi LN, Gaudino MFL, Fremes SE. The radial artery: Results and technical considerations. J Card Surg. 2018;33:213–8.

    Article  PubMed  Google Scholar 

  6. 6.

    Benedetto U, Altman DG, Gerry S, et al. Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: Insights from the Arterial Revascularization Trial. J Thorac Cardiovasc Surg. 2016;152:270–6.

    Article  PubMed  Google Scholar 

  7. 7.

    Buttar SN, Yan TD, Taggart DP, Tian DH. Long-term and short-term outcomes of using bilateral internal mammary artery grafting versus left internal mammary artery grafting: a meta-analysis. Heart. 2017;103:1419–26.

    Article  PubMed  Google Scholar 

  8. 8.

    Gaudino M, Di Franco A, Rahouma M, et al. Unmeasured confounders in observational studies comparing bilateral versus single internal thoracic artery for coronary artery bypass grafting: a meta-analysis. J Am Heart Assoc. 2018;7:e008010.

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Rizzoli G, Schiavon L, Bellini P. Does the use of bilateral internal mammary artery (IMA) grafts provide incremental benefit relative to the use of a single IMA graft? A meta-analysis approach. Eur J Cardiothorac Surg. 2002;22:781–6.

    Article  PubMed  Google Scholar 

  10. 10.

    Taggart DP, D’Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet. 2001;358:870–5.

    Article  CAS  PubMed  Google Scholar 

  11. 11.

    Takagi H, Goto S, Watanabe T, Mizuno Y, Kawai N, Umemoto T. A meta-analysis of adjusted hazard ratios from 20 observational studies of bilateral versus single internal thoracic artery coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2014;148:1282–90.

    Article  PubMed  Google Scholar 

  12. 12.

    Weiss AJ, Zhao S, Tian DH, Taggart DP, Yan TD. A meta-analysis comparing bilateral internal mammary artery with left internal mammary artery for coronary artery bypass grafting. Ann Cardiothorac Surg. 2013;2:390–400.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Yi G, Shine B, Rehman SM, Altman DG, Taggart DP. Effect of bilateral internal mammary artery grafts on long-term survival: a meta-analysis approach. Circulation. 2014;130:539–45.

    Article  PubMed  Google Scholar 

  14. 14.

    Taggart DP, Altman DG, Gray AM, et al. Randomized trial of bilateral versus single internal-thoracic-artery grafts. N Engl J Med. 2016;375:2540–9.

    Article  PubMed  Google Scholar 

  15. 15.

    Gansera B, Gillrath G, Lieber M, Angelis I, Schmidtler F, Kemkes BM. Are men treated better than women? outcome of male versus female patients after CABG using bilateral internal thoracic arteries. Thorac Cardiovasc Surg. 2004;52:261–7.

    Article  CAS  PubMed  Google Scholar 

  16. 16.

    Kinoshita T, Asai T, Suzuki T. Off-pump bilateral skeletonized internal thoracic artery grafting in patients with chronic kidney disease. J Thorac Cardiovasc Surg. 2015;150:315–21.

    Article  PubMed  Google Scholar 

  17. 17.

    Raza S, Sabik JF, Masabni K, Ainkaran P, Lytle BW, Blackstone EH. Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus. J Thorac Cardiovasc Surg. 2014;148:1257–1266.e9.

    Article  PubMed  Google Scholar 

  18. 18.

    Nasso G, Coppola R, Bonifazi R, Piancone F, Bozzetti G, Speziale G. Arterial revascularization in primary coronary artery bypass grafting: Direct comparison of 4 strategies—Results of the Stand-in-Y Mammary Study. J Thorac Cardiovasc Surg. 2009;137:1093–100.

    Article  PubMed  Google Scholar 

  19. 19.

    Gaudino M, Crea F, Cammertoni F, Massetti M. The radial artery: a forgotten conduit. Ann Thorac Surg. 2015;99:1479–85.

    Article  PubMed  Google Scholar 

  20. 20.

    Benedetto U, Raja SG, Albanese A, Amrani M, Biondi-Zoccai G, Frati G. Searching for the second best graft for coronary artery bypass surgery: a network meta-analysis of randomized controlled trials. Eur J Cardiothorac Surg. 2015;47:59–65.

    Article  PubMed  Google Scholar 

  21. 21.

    Gaudino MFL, Ruel M, Taggart DP. Blaise Pascal and the evidence on the use of multiple arterial grafts for coronary artery bypass surgery after the interim analysis of the Arterial Revascularization Trial. Curr Opin Cardiol. 2018;33:245–8.

    Article  PubMed  Google Scholar 

  22. 22.

    Gaudino M, Alexander JH, Bakaeen FG, et al. Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial—rationale and study protocol. Eur J Cardiothorac Surg. 2017;52:1031–40.

    Article  PubMed  Google Scholar 

  23. 23.

    Dimitrova KR, Hoffman DM, Geller CM, Dincheva G, Ko W, Tranbaugh RF. Arterial grafts protect the native coronary vessels from atherosclerotic disease progression. Ann Thorac Surg. 2012;94:475–81.

    Article  PubMed  Google Scholar 

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Corresponding author

Correspondence to Jeremy R. Leonard.

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Ethical approval, Statement of Human and Animal Rights, Informed consent – Being a Review article, these are not required.

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The authors declare that they have no conflict of interest.

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Leonard, J.R., Abouarab, A.A., Taggart, D.P. et al. Bilateral internal thoracic artery use in coronary bypass surgery: is there a benefit?. Indian J Thorac Cardiovasc Surg 34, 230–233 (2018).

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  • BITA
  • Coronary artery bypass surgery
  • Multiple arterial grafts