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Updated: Feb 19, 2026
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Does Use of Bilateral Internal Mammary Artery Grafting Reduce Long-Term Risk of Repeat Coronary Revascularization? A
Alexander Iribarne1, Joseph D Schmoker2, David J Malenka2
1From Department of Surgery, Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (A.I., D.J.M., J.N.M., J.P.D., E.M.O., A.W.D.); Department of Medicine, Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (D.J.M.); Department of Surgery, Section of Cardiac Surgery, University of Vermont Medical Center, Burlington (J.D.S., B.J.L.); Department of Surgery, Section of Cardiac Surgery, Central Maine Medical Center, Lewiston (P.W.W.); Department of Surgery, Section of Cardiac Surgery, Catholic Medical Center, Manchester, NH (B.M.W.); Department of Surgery, Section of Cardiac Surgery, Maine Medical Center, Portland (R.D.Q., R.S.K.); Department of Surgery, Section of Cardiac Surgery, Eastern Maine Medical Center, Bangor (J.D.K.); and Department of Surgery, Section of Cardiac Surgery, Concord Hospital, NH (G.L.S.). alexander.iribarne@hitchcock.org.
Insights
Bilateral internal mammary artery (BIMA) grafting reduces the need for repeat coronary revascularization compared to single internal mammary artery (SIMA) grafting. This improved long-term survival and reduced revascularization risk suggests BIMA should be more frequently considered in coronary artery bypass grafting.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Coronary artery bypass grafting (CABG) is a critical procedure for managing coronary artery disease.
- Bilateral internal mammary artery (BIMA) conduits have shown superior long-term survival compared to single internal mammary artery (SIMA) conduits.
- Data regarding repeat revascularization rates after BIMA versus SIMA grafting are less established.
Purpose of the Study:
- To compare the frequency, timing, and type of repeat coronary revascularization between patients undergoing CABG with BIMA versus SIMA.
- To evaluate the long-term outcomes associated with BIMA versus SIMA grafting in terms of revascularization and survival.
Main Methods:
- A multicenter, retrospective analysis of 47,984 CABG surgeries from 1992-2014.
- Propensity-matched analysis comparing 1,297 patients receiving BIMA to 1,297 patients receiving SIMA.
- Primary endpoint: freedom from repeat coronary revascularization.
Main Results:
- BIMA grafting was associated with a significantly higher freedom from repeat revascularization (HR, 0.78; P=0.009).
- Repeat revascularization occurred in 15.1% of BIMA patients versus 19.4% of SIMA patients (P=0.004).
- BIMA grafting also demonstrated a reduction in all-cause mortality at 12 years (HR, 0.79; P=0.001) without increased in-hospital morbidity.
Conclusions:
- Bilateral internal mammary artery grafting is associated with a reduced risk of repeat revascularization.
- BIMA grafting improves long-term survival following coronary artery bypass grafting.
- Consideration of BIMA conduits should be increased during CABG procedures.
Background:
Although previous studies have demonstrated that patients receiving bilateral internal mammary artery (BIMA) conduits during coronary artery bypass grafting have better long-term survival than those receiving a single internal mammary artery (SIMA), data on risk of repeat revascularization are more limited. In this analysis, we compare the timing, frequency, and type of repeat coronary revascularization among patients receiving BIMA and SIMA.
Methods:
We conducted a multicenter, retrospective analysis of 47 984 consecutive coronary artery bypass grafting surgeries performed from 1992 to 2014 among 7 medical centers reporting to a prospectively maintained clinical registry. Among the study population, 1482 coronary artery bypass grafting surgeries with BIMA were identified, and 1297 patients receiving BIMA were propensity-matched to 1297 patients receiving SIMA. The primary end point was freedom from repeat coronary revascularization.
Results:
The median duration of follow-up was 13.2 (IQR, 7.4-17.7) years. Patients were well matched by age, body mass index, major comorbidities, and cardiac function. There was a higher freedom from repeat revascularization among patients receiving BIMA than among patients receiving SIMA (hazard ratio [HR], 0.78 [95% CI, 0.65-0.94]; P=0.009). Among the matched cohort, 19.4% (n=252) of patients receiving SIMA underwent repeat revascularization, whereas this frequency was 15.1% (n=196) among patients receiving BIMA (P=0.004). The majority of repeat revascularization procedures were percutaneous coronary interventions (94.2%), and this did not differ between groups (P=0.274). Groups also did not differ in the ratio of native versus graft vessel percutaneous coronary intervention (P=0.899), or regarding percutaneous coronary intervention target vessels; the most common targets in both groups were the right coronary (P=0.133) and circumflex arteries (P=0.093). In comparison with SIMA, BIMA grafting was associated with a reduction in all-cause mortality at 12 years of follow-up (HR, 0.79 [95% CI, 0.69-0.91]; P=0.001), and there was no difference in in-hospital morbidity.
Conclusions:
BIMA grafting was associated with a reduced risk of repeat revascularization and an improvement in long-term survival and should be considered more frequently during coronary artery bypass grafting.
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