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Updated: Dec 30, 2025
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Coronary Artery Target Selection and Survival After Bilateral Internal Thoracic Artery Grafting
Faisal G Bakaeen1, Kirthi Ravichandren1, Eugene H Blackstone2
1Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Insights
Bilateral internal thoracic artery (BITA) grafting improves survival when multiple important targets are bypassed. For patients with a nondominant left anterior descending (LAD) artery, selecting an important target for the second ITA reduces operative mortality.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Cardiac Surgery
Background:
- The significance of coronary arteries is linked to the myocardial mass they supply.
- Limited data exists on the impact of bypassed vessels on survival following bilateral internal thoracic artery (BITA) grafting.
Purpose of the Study:
- To investigate the influence of a dominant left anterior descending (LAD) artery and significant non-LAD targets on outcomes after BITA grafting.
- To evaluate the effect of target vessel importance on survival and operative mortality in BITA grafting procedures.
Main Methods:
- Analysis of 6,127 patients undergoing BITA grafting from 1972 to 2011.
- Categorization of non-LAD targets based on myocardial territory supplied (>75% vs. ≤75%).
- Multivariable analysis to identify risk factors for time-related mortality.
Main Results:
- Grafting the second internal thoracic artery (ITA) to multiple important targets was linked to improved long-term survival.
- In patients with a nondominant LAD, using a second ITA on a less important artery increased operative mortality risk.
- Saphenous vein grafts to important or less important targets did not impact long-term survival.
Conclusions:
- Maximizing myocardial supply through BITA grafting of multiple important targets enhances long-term survival.
- Selecting a critical target for the second ITA in patients with a nondominant LAD reduces operative mortality.
Background:
The importance of a coronary artery, based on the myocardial mass it perfuses, is well documented, but little is known about the importance of a vessel that has been bypassed and its effect on survival in the context of bilateral internal thoracic artery (BITA) grafting.
Objectives:
This study determined the effect of a dominant left anterior descending (LAD) artery and important non-LAD targets on outcomes after BITA grafting.
Methods:
From January 1972 to January 2011, of 6,127 patients who underwent BITA grafting, 2,551 received 1 ITA grafted to the LAD and had an evaluable coronary angiogram. A dominant LAD was defined as one that was wrapped around the left ventricular apex. Non-LAD targets were graded based on their terminal reach toward the apex: important: >75% (n = 1,698); and less important: ≤75% (n = 853). Mean follow-up was 14 ± 8.7 years. Multivariable analysis was performed to identify risk factors for time-related mortality.
Results:
A dominant LAD was present more frequently in patients with less important additional targets (51% vs. 35%; p < 0.0001). A total of 179 patients (7.0%) received a second ITA to multiple targets, 77 (43%) of which were to multiple important target vessels. Unadjusted late survival was similar regardless of degree of importance of the second ITA target-77% at 15 years (p = 0.70) for the important and less important targets, respectively. In the multivariable model, grafting the second ITA to multiple important targets was associated with better long-term survival (p = 0.005). In patients with a nondominant LAD, a second ITA grafted to a less important artery was associated with higher risk of operative mortality (2.4% vs. 0.51%; p = 0.007). A saphenous vein graft to an important or less important target did not influence long-term survival.
Conclusions:
In BITA grafting, bypassing multiple important targets to maximize myocardium supplied by ITAs improved long-term survival. In patients with a nondominant LAD, selecting an important target for the second ITA lowered operative mortality.
