Bilateral Internal Thoracic Artery Grafting in Coronary Surgery: A Three-Tier Decision Framework
- 1Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, Cattedra di Cardiochirurgia, Università “G. d’Annunzio”, 66100 Chieti, Italy
- 2Dipartimento di Malattie Cardiovascolari, Cattedra di Cardiochirurgia, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
Abstract
The left internal mammary artery grafted to the left anterior descending artery (LAD) is the main determinant of survival in coronary artery bypass grafting, but the choice of the second graft remains controversial. The use of both mammary arteries offers a greater long-term survival benefit compared with a single mammary artery graft; however, this advantage is delayed and diminished when compared with a single mammary artery graft plus a radial artery graft. Furthermore, this approach is associated with a higher risk of sternal complications and, via mechanisms of competitive flow and steal phenomenon, of perioperative coronary malperfusion. This article proposes organising the clinical decision-making process according to three hierarchical levels: (1) absolute contraindications based on the patient’s medical history that preclude the use of a particular graft (thoracic irradiation, subclavian artery disease, acute aortic dissection); (2) the haemodynamic adequacy of the graft for the target coronary territory; (3) the assessment of the risk of delayed sternal healing in the individual patient, where skeletonization has reduced the historical significance of diabetes. Overlaying these is a transversal variable represented by the harvesting technique (pedicled mammary artery vs. skeletonized mammary artery, together with the surgeon’s learning curve), which re-interprets apparently unfavourable results and distinguishes the risk associated with the graft itself from that of the surgical procedure. The model aims to rationalise patient selection and reduce the persistent underutilisation of bilateral mammary artery grafting. It should be noted at the outset that this survival advantage rests largely on observational and propensity-matched evidence and has not been confirmed on an intention-to-treat basis by the only adequately powered randomised trial, so that the model proposed here is offered as a framework for selection rather than as a claim of established superiority.
Related
- Two-stage surgical resection of a massive primary posterior mediastinal dedifferentiated liposarcoma with bilateral thoracic extension: a case report
- Minimally Invasive Coronary Artery Bypass Grafting (MICS-CABG) Versus Conventional Off-Pump Coronary Artery Bypass Grafting (OPCAB): A Single-Center Analysis of Early Outcomes and Institutional Experience
- Age-Normalized Baseline Renal Function: A Simple Risk Marker in Coronary Artery Bypass Grafting
- Novel cardiac computed tomography-based preoperative indicator associated with intraoperative graft flow in coronary artery bypass grafting
- Minimally Invasive Coronary Artery Bypass Grafting in Patients With Prior Myocardial Infarction: A Propensity Score-Matched Retrospective Study
BibTeX
@article{giammarco2026bilateral,
title = {{Bilateral Internal Thoracic Artery Grafting in Coronary Surgery: A Three-Tier Decision Framework}},
author = {Gabriele Di Giammarco and Massimo Massetti},
journal = {Journal of Clinical Medicine},
year = {2026},
month = oct,
doi = {10.3390/jcm15207932},
url = {https://www.mdpi.com/2077-0383/15/20/7932},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Bilateral Internal Thoracic Artery Grafting in Coronary Surgery: A Three-Tier Decision Framework
AU - Gabriele Di Giammarco
AU - Massimo Massetti
PY - 2026
DA - 2026/10/01
JO - Journal of Clinical Medicine
DO - 10.3390/jcm15207932
UR - https://www.mdpi.com/2077-0383/15/20/7932
AB - The left internal mammary artery grafted to the left anterior descending artery (LAD) is the main determinant of survival in coronary artery bypass grafting, but the choice of the second graft remains controversial. The use of both mammary arteries offers a greater long-term survival benefit compared with a single mammary artery graft; however, this advantage is delayed and diminished when compared with a single mammary artery graft plus a radial artery graft. Furthermore, this approach is associated with a higher risk of sternal complications and, via mechanisms of competitive flow and steal phenomenon, of perioperative coronary malperfusion. This article proposes organising the clinical decision-making process according to three hierarchical levels: (1) absolute contraindications based on the patient’s medical history that preclude the use of a particular graft (thoracic irradiation, subclavian artery disease, acute aortic dissection); (2) the haemodynamic adequacy of the graft for the target coronary territory; (3) the assessment of the risk of delayed sternal healing in the individual patient, where skeletonization has reduced the historical significance of diabetes. Overlaying these is a transversal variable represented by the harvesting technique (pedicled mammary artery vs. skeletonized mammary artery, together with the surgeon’s learning curve), which re-interprets apparently unfavourable results and distinguishes the risk associated with the graft itself from that of the surgical procedure. The model aims to rationalise patient selection and reduce the persistent underutilisation of bilateral mammary artery grafting. It should be noted at the outset that this survival advantage rests largely on observational and propensity-matched evidence and has not been confirmed on an intention-to-treat basis by the only adequately powered randomised trial, so that the model proposed here is offered as a framework for selection rather than as a claim of established superiority.
SN - 2077-0383
ER -