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Ann Thorac Surg 1997;64:599-605
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Single Versus Bilateral Internal Mammary Artery Grafts: 10-Year Outcome Analysis

Section of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

Background. The superior long-term patency of the internal mammary artery (IMA) confers important short-term and late survival advantages when grafted to the left anterior descending coronary artery. However, it remains uncertain whether patients derive additional survival benefit when both IMAs are used in coronary revascularization.

Methods. Between June 1983 and May 1986, 160 patients (mean age 60 years) received bilateral IMA grafts for coronary artery bypass procedures, and in 93% of patients, the right IMA was used to bypass the left coronary system. During a similar interval, a group of 161 patients matched for symptomatic status and extent of disease (mean age, 62 years) received a single left IMA and saphenous vein grafts.

Results. The two groups were similar with respect to gender, preoperative angina class, priority status, extent of coronary artery disease, left ventricular function, and number of distal anastomoses. Diabetes was more prevalent in the patient group receiving a single IMA graft (27% versus 17.5%; p = 0.05). Early outcome was similar in the two groups; operative mortality was 0.6% for the patient group receiving single IMA grafts and 0% for those with bilateral IMA grafts. The mean follow-up of 320 hospital survivors was 10 years. Univariate analysis revealed significantly fewer overall deaths in the patients receiving bilateral IMA grafts (n = 30; p = 0.05), and less late cardiac mortality (n = 12; p = 0.016). Ten-year actuarial survival for patients dismissed from the hospital was 76% for those receiving single IMA graft versus 85% for those receiving bilateral IMA grafts. Multivariate analysis revealed diabetes (risk ratio = 1.73), advancing age (risk ratio = 1.08), and lower ejection fraction (risk ratio = 1.01) to be the only significant predictors of late cardiac death. Use of a single IMA graft was not significant (p = 0.138) despite a risk ratio of 1.78. Use of only a single IMA graft correlated with an increased risk of angina recurrence (p < 0.001), late myocardial infarction (p = 0.019), and risk of any cardiac event (p < 0.001).

Conclusions. Independent risk factors for late death were diabetes mellitus, older age, and reduced ejection fraction. Patients receiving bilateral IMA grafts had better long-term survival than those with a single IMA graft, but this was not independent of diabetes. Multivariate analysis, however, did confirm that compared with single arterial grafts, bilateral IMA grafting was an independent predictor of lower rates of angina recurrence, late myocardial infarction, and the composite end point of any cardiac event.

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				A. Kramer, M. Mastsa, Y. Paz, C. Locker, D. Pevni, J. Gurevitch, I. Shapira, O. Lev-Ran, and R. Mohr Bilateral skeletonized internal thoracic artery grafting in 303 patients seventy years and older J. Thorac. Cardiovasc. Surg., August 1, 2000; 120(2): 290 - 297. [Abstract] [Full Text] [PDF]

				G. Speziale, G. Ruvolo, R. Coppola, and B. Marino Intraoperative flow measurement in composite Y arterial grafts Eur. J. Cardiothorac. Surg., May 1, 2000; 17(5): 505 - 508. [Abstract] [Full Text] [PDF]

				J.-A. Barra, E. Bezon, P. Mondine, A. Resk, M. Gilard, J. Mansourati, and J. Boshat Surgical angioplasty with exclusion of atheromatous plaques in case of diffuse disease of the left anterior descending artery: 2 years' follow-up Eur. J. Cardiothorac. Surg., May 1, 2000; 17(5): 509 - 514. [Abstract] [Full Text] [PDF]

				R. Dion, D. Glineur, D. Derouck, R. Verhelst, P. Noirhomme, G. El Khoury, E. Degrave, and C. Hanet Long-term clinical and angiographic follow-up of sequential internal thoracic artery grafting Eur. J. Cardiothorac. Surg., April 1, 2000; 17(4): 407 - 414. [Abstract] [Full Text] [PDF]

				J. Gurevitch, A. Kramer, C. Locker, I. Shapira, Y. Paz, M. Matsa, and R. Mohr Technical aspects of double-skeletonized internal mammary artery grafting Ann. Thorac. Surg., March 1, 2000; 69(3): 841 - 846. [Abstract] [Full Text] [PDF]

				J. Tatoulis, B. F. Buxton, J. A. Fuller, and A. G. Royse Total arterial coronary revascularization: techniques and results in 3,220 patients Ann. Thorac. Surg., December 1, 1999; 68(6): 2093 - 2099. [Abstract] [Full Text] [PDF]

				O. Wendler, B. Hennen, T. Markwirth, J. Konig, D. Tscholl, Q. Huang, E. Shahangi, H.-J. Schafers, and S. H. G. Borst T GRAFTS WITH THE RIGHT INTERNAL THORACIC ARTERY TO LEFT INTERNAL THORACIC ARTERY VERSUS THE LEFT INTERNAL THORACIC ARTERY AND RADIAL ARTERY: FLOW DYNAMICS IN THE INTERNAL THORACIC ARTERY MAIN STEM J. Thorac. Cardiovasc. Surg., November 1, 1999; 118(5): 841 - 848. [Abstract] [Full Text] [PDF]

				A. G. Royse, C. F. Royse, and J. S. Raman Exclusive Y graft operation for multivessel coronary revascularization Ann. Thorac. Surg., November 1, 1999; 68(5): 1612 - 1618. [Abstract] [Full Text] [PDF]

				O. Jegaden, L. Bontemps, G. de Gevigney, A. Eker, P. Montagna, C. Chatel, R. Itti, and P. Mikaeloff Does the extended used of arterial grafts compromise the myocardial recovery after coronary artery bypass grafting in left ventricular dysfunction? Eur. J. Cardiothorac. Surg., October 1, 1999; 14(4): 353 - 359. [Abstract] [Full Text] [PDF]

				K. A. Eagle, R. A. Guyton, R. Davidoff, G. A. Ewy, J. Fonger, T. J. Gardner, J. P. Gott, H. C. Herrmann, R. A. Marlow, W. C. Nugent, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/ American Heart Association task force on Practice Guidelines (Committee to revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery) J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1262 - 1347. [Full Text] [PDF]

				T. M. Sundt III, H. B. Barner, C. J. Camillo, and W. A. Gay Jr Total arterial revascularization with an internal thoracic artery and radial artery T graft Ann. Thorac. Surg., August 1, 1999; 68(2): 399 - 404. [Abstract] [Full Text] [PDF]

				A. M. Calafiore, G. Vitolla, A. L. Iaco, C. Fino, G. Di Giammarco, F. Marchesani, G. Teodori, G. D'Addario, and V. Mazzei Bilateral internal mammary artery grafting: midterm results of pedicled versus skeletonized conduits Ann. Thorac. Surg., June 1, 1999; 67(6): 1637 - 1642. [Abstract] [Full Text] [PDF]

				J.-M. Farinas, M. Carrier, Y. Hebert, R. Cartier, M. Pellerin, L. P. Perrault, and L. C. Pelletier Comparison of long-term clinical results of double versus single internal mammary artery bypass grafting Ann. Thorac. Surg., February 1, 1999; 67(2): 466 - 470. [Abstract] [Full Text] [PDF]

				A. G. Royse, C. F. Royse, P. Shah, A. Williams, S. Kaushik, and J. Tatoulis Radial artery harvest technique, use and functional outcome Eur. J. Cardiothorac. Surg., February 1, 1999; 15(2): 186 - 193. [Abstract] [Full Text] [PDF]

				S. Noda and H. B. Barner Arterial conduits Ann. Thorac. Surg., January 1, 1999; 67(1): 285 - 286. [Full Text] [PDF]

				F. D. Loop Coronary artery surgery: the end of the beginning Eur. J. Cardiothorac. Surg., December 1, 1998; 14(6): 554 - 571. [Abstract] [Full Text] [PDF]

				M. Sousa Uva, E. Braunberger, M. Fisher, Y. Fromes, P. H. Deleuze, J. A. Celestin, and O. M. Bical Does bilateral internal thoracic artery grafting increase surgical risk in diabetic patients? Ann. Thorac. Surg., December 1, 1998; 66(6): 2051 - 2055. [Abstract] [Full Text] [PDF]

				H. B. Barner Arterial grafting: techniques and conduits Ann. Thorac. Surg., November 1, 1998; 66(90050): S2 - 5. [Abstract] [Full Text] [PDF]

				J. Tatoulis, B. F. Buxton, and J. A. Fuller Bilateral radial artery grafts in coronary reconstruction: technique and early results in 261 patients Ann. Thorac. Surg., September 1, 1998; 66(3): 714 - 720. [Abstract] [Full Text] [PDF]

				H. Oster, J. Graff, W. Knake, and R. Widera Minimally invasive coronary revascularization in elderly patients Ann. Thorac. Surg., September 1, 1998; 66(3): 1073 - 1075. [Abstract] [Full Text] [PDF]

				D. A. Cooley Coronary Bypass Grafting With Bilateral Internal Thoracic Arteries and the Right Gastroepiploic Artery Circulation, June 23, 1998; 97(24): 2384 - 2385. [Full Text] [PDF]

				T. M. Bergsma, J. G. Grandjean, A. A. Voors, P. W. Boonstra, P. den Heyer, and T. Ebels Low Recurrence of Angina Pectoris After Coronary Artery Bypass Graft Surgery With Bilateral Internal Thoracic and Right Gastroepiploic Arteries Circulation, June 23, 1998; 97(24): 2402 - 2405. [Abstract] [Full Text] [PDF]

				M. Cassese, G. Speziali, G. L. Martinelli, and M. Diena Reduced complication rate in bilateral mammary artery-to-coronary artery bypass grafting. Ann. Thorac. Surg., June 1, 1998; 65(6): 1841 - 1842. [Full Text] [PDF]