Coronary Artery Target Selection and Survival After Bilateral Internal Thoracic Artery Grafting

Faisal G. Bakaeen*, Kirthi Ravichandren, Eugene H. Blackstone, Penny L. Houghtaling, Edward G. Soltesz, Douglas R. Johnston, Stephanie L. Mick, José L. Navia, Michael Zhen Yu Tong, Kenneth R. McCurry, Rami Akhrass, Mouin Abdallah, Gösta B. Pettersson, Nicholas M. Smedira, Eric E. Roselli, A. Marc Gillinov, Lars G. Svensson

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

36 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)258-268
Number of pages11
JournalJournal of the American College of Cardiology
Issue number3
StatePublished - Jan 28 2020


  • cardiac surgery
  • coronary artery bypass grafting
  • ischemic heart disease
  • survival

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


Dive into the research topics of 'Coronary Artery Target Selection and Survival After Bilateral Internal Thoracic Artery Grafting'. Together they form a unique fingerprint.

Cite this