Bilateral skeletonized IMAs used as “in situ” grafts for different coronary territories: long-term propensity matching study

Abstract

Introduction

Bilateral internal mammary arteries (BIMAs) are the most advanced surgical option for coronary artery bypass grafting (CABG). This study compares outcomes between patients receiving skeletonized BIMAs as in situ grafts for different coronary territories and those undergoing CABG with a single internal mammary artery (SIMA).

Methods

Between 2013 and 2023, 7543 patients underwent CABG for multivessel coronary artery disease at our institution. BIMA grafting was performed in 1133 patients (15.02%), with in situ BIMA grafting in 283 patients (3.75%). The right internal mammary artery (RIMA) was used for the right coronary artery, and the left internal mammary artery (LIMA) for the left anterior descending artery. Propensity score matching yielded 280 patients in each group for comparison. Primary outcomes were 30-day and 10-year all-cause mortality. Secondary outcomes included length of hospital stay, incidence of postoperative major adverse cardiovascular and cerebrovascular events (MACCE), sternal wound infection, and the need for subsequent revascularization.

Results

There was no 30-day postoperative mortality, perioperative MACCE, or deep sternal wound infection in either group. Mean follow-up was 9.78 ± 0.62 years. The 10-year survival rate was significantly higher in the in situ BIMA group (86.07 ± 3.0%) compared to the SIMA group (78.6 ± 4.1%, p < 0.05).

Conclusion

Skeletonized BIMA grafting improves long-term survival compared to SIMA grafting, rendering traditionally accepted limitations for BIMA usage irrelevant. These findings support the broader adoption of BIMA grafting in CABG.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-025-01979-8.

Introduction

Coronary artery bypass grafting (CABG) is the standard treatment of multivessel coronary artery disease (CAD), improving quality of life and overall survival after surgery (Class I, Level of evidence B) [1–4]. Many different strategies for surgical treatment of CAD have been described in the literature [5, 6]. Over time, the widespread application of CABG and the development of technologies such as percutaneous transcatheter coronary angioplasty (PTCA), “off pump” CABG, and hybrid procedures have arisen questions regarding surgical operative technique and tactics, long-term patency rates, and overall safety [7–9].

The left internal mammary artery (LIMA) is widely accepted as a superior conduit over the saphenous vein (SV), radial artery (RA), and gastroepiploic artery (GEA), making it the standard for CABG surgery [10, 11]. Following LIMA’s success, the use of the right internal mammary artery (RIMA) has sparked debates about the risks and benefits of such a procedure among patients and medical practitioners. Over the last two decades, the combined use of left and right internal mammary arteries (LIMA and RIMA), known as bilateral IMAs (BIMAs), offers superior long-term outcomes compared to using a single internal mammary artery (SIMA), especially when used as in situ grafts for different coronary territories [2, 12]. However, conditions like diabetes, chronic obstructive pulmonary disease (COPD), and obesity have traditionally been viewed as limiting factors for the widespread BIMA use [10, 11, 13, 14].

The aim of this study is to compare immediate- and long-term outcomes in patients receiving skeletonized BIMAs used in situ for different coronary territories with those receiving a SIMA using propensity score matching (PSM).

Material and methods

This study was approved by The Institutional Review Board, and subjects provided informed consent. It included all patients who underwent elective, isolated primary CABG procedures with BIMA and additional venous grafts to address multi-vessel coronary artery disease at our institution from January 2013 to December 2023. Initially, 7543 patients were identified. The 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the surgical treatment of multivessel coronary artery disease were applied. Significant coronary artery disease is defined as stenosis of ≥ 50% in the left main coronary artery or ≥ 70% in the three main coronary arteries or their major epicardial branches, as demonstrated by conventional invasive coronary angiography (Class I, Level of Evidence C) [4].

In 7090 patients (94%), the skeletonized LIMA was used as an in situ graft mainly for left coronary artery targets. BIMA grafting was performed in 1133 patients (15.02%), with in situ BIMA grafting in 283 patients (3.75%). For these patients, the RIMA was used to revascularize the right coronary artery, while the LIMA was directed to the left anterior descending (LAD) artery territory. Exclusion criteria included patients undergoing emergency surgery, those operated without cardiopulmonary bypass, previous cardiac surgery, and concomitant valve procedures. Patients with RIMA extended by additional grafts or LIMA used as a free graft or composite graft with the radial artery were also excluded [15].

BIMA patients (n = 283 unmatched; n = 280 matched) were compared with SIMA patients (n = 6507 unmatched; n = 280 matched) in propensity score matching analysis (Tables 1 and 2). Patients in the in situ BIMA group were further stratified into two subgroups: those who received only in situ BIMA grafts and those who received additional saphenous vein grafts (SVGs). Postoperative outcomes, including mortality, were analyzed between these subgroups.

Table 1.

Clinical characteristics of the unmatched population

Parameter	In situ BIMA (n = 283)	SIMA (n = 7090)	p
Gender
Male	188(66.43%)	5105(72.0%)	< 0.05
Mean age	62.1 ± 0.7	59.2 ± 0.3	0.81
Previous MI	136(48.05%)	4679(65.99%)	< 0.05
EF mean	51.1 ± 2.1%	40.9 ± 3.0%	< 0.05
EF < 30%	24(8.57%)	850(11.98%)	< 0.05
EF > 30%	256(91.43%)	6240(88.02%)	< 0.05
COPD	70(24.73%)	2234(31.5%)	< 0.05
Diabetes	39(13.78%)	1346(18.98%)	< 0.05
NIDDM	29(10.24%)	1006(14.19%)	< 0.05
IDDM	10(3.53%)	340(4.79%)	< 0.05
BMI	27.7 ± 2.3	29.2 ± 4.3	0.76
Syntax score II
0–22	84(29.68%)	1510(21.29%)	< 0.05
23–32	94(33.21%)	2230(31.45%)	< 0.05
> 32	105(37.1%)	3350(47.26%)	< 0.05
Average	27.5 ± 8.9	29.6 ± 7.0	< 0.05
CCS
II	178(62.89%)	4093(57.73%)	< 0.05
III	105(37.11%)	2997(42.27%)	< 0.05
Logistic Euro SCORE II	2.24	3.15	< 0.05

MI myocardial infarction, COPD chronic obstructive pulmonary disease, BMI body mass index, NIDDM non-insulin-dependent diabetes mellitus, IDDM insulin-dependent diabetes mellitus, CCS Canadian Cardiovascular Society grading score

Table 2.

Clinical characteristics of the matched population

Parameter	In situ BIMA (n = 280)	SIMA (n = 280)	p
Gender
Male	186(66.42%)	186(66.42%)	1.0
Mean age	62.1 ± 0.7	62.0 ± 0.8	0.92
Previous MI	135(48.21%)	135(48.21%)	1.00
EF mean	52.1 ± 2.3%	52.7 ± 2.2%	0.95
EF < 30%	24(8.57%)	24(8.57%)	1.0
EF > 30%	256(91.42%)	256(91.42%)	1.0
COPD	69(24.64%)	68(24.28%)	0.91
Diabetes	39(13.92%)	39(13.92%)	1.0
NIDDM	29(10.35%)	29(10.35%)	1.0
IDDM	10(3.57%)	10(3.57%)	1.0
BMI	27.8 ± 1.3	28.9 ± 1.6	0.61
Syntax score II
0–22	83(29.64%)	85(30.35%)	0.81
23–32	92(36.5%)	95(33.92%)	0.88
> 32	105(37.5%)	100(35.71%)	0.82
average	27.5 ± 8.2	28.3 ± 9.8	0.92
CCS
II	177(63.21%)	175(62.5%)	0.91
III	103(36.78%)	105(37.5%)	0.88
Logistic Euro SCORE II	2.24	2.43	0.86

MI myocardial infarction, COPD chronic obstructive pulmonary disease, BMI body mass index NIDDM non-insulin-dependent diabetes mellitus, IDDM insulin-dependent diabetes mellitus CCS Canadian Cardiovascular Society grading score

Perioperative risk was calculated according to the Logistic European System for Cardiac Operative Risk Evaluation II (EuroSCORE) and Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery Score II (SYNTAX score II) [1, 4, 16–19]. The mean average baseline SYNTAX score II were 27.5 ± 8.2 in the BIMA group and 28.3 ± 9.8 in the SIMA group (p = ns).

Operative technique

All patients underwent conventional median sternotomy. Internal mammary arteries (IMAs) were harvested using a skeletonized “no-touch” technique, as previously described [14, 20].

Standard cardiopulmonary bypass (CPB) with mild systemic hypothermia (32–34 °C), aortic cross-clamping, and cardioplegic arrest was used in all cases. In the BIMA group, RIMA was used for revascularization of the right coronary artery or its branches (mainly posterior descending artery), and LIMA was used for revascularization of the LAD artery. Other targets were revascularized with SV grafts. In the SIMA group, LIMA was used for the LAD, while other targets were revascularized with SV grafts.

LIMA and RIMA anastomosis were created by 8–0 continuous, running polypropylene suture. Single antiplatelet medications after CABG surgery were recommended indefinitely (EACTS 2007/AHA 2011 guidelines, Level of evidence 1a) [21].

The definition of periprocedural myocardial infarction (MI) suggested by arbitrary convention was used in this study. The following parameters should be considered as diagnostic of a CABG-related MI (called type 5 MI): (i) biomarker values more than five times the 99 th percentile of the upper reference limit following CABG when associated with the appearance of new pathological Q waves or new left bundle branch block; (ii) angiographically documented new graft or native coronary artery occlusion; or (iii) imaging evidence of new loss of viable myocardium [22].

Data collection and follow-up

Demographic data, intraoperative details, and postoperative outcomes were collected from patient records. Follow-up data were obtained through outpatient clinic visits and phone interviews. The primary endpoint was all-cause mortality at 30 days and 5 years, and 10 years after surgery. Secondary endpoints included length of hospital stay, incidence of postoperative major adverse cardiovascular and cerebrovascular events (MACCE), sternal wound infection, and the need for subsequent percutaneous coronary interventions (PCI). Symptom measures by Canadian Cardiovascular Society (CCS) angina pectoris grading score were also recorded.

Statistical analysis

To reduce selection bias, PSM was employed. A logistic regression model was used to calculate propensity scores based on variables such as age, sex, comorbidities (including diabetes, COPD, and obesity), EuroSCORE II, and SYNTAX score II. Patients were matched 1:1 using the nearest-neighbor method with a caliper of 0.2. After matching, the baseline characteristics between the BIMA and SIMA groups were compared to ensure balance (Tables 1 and 2).

Continuous variables were expressed as mean ± standard deviation and number (%). Normally distributed scale data were analyzed using an unpaired t-test. Categorical variables were analyzed using Fisher’s test. Survival curves were drawn on an actuarial basis using the Kaplan–Meier technique (Sigma Stat, Inpixon HQ, Palo Alto, CA, USA). The log-rank test was used to assess differences in survival distributions between the two groups. A p value less than 0.05 was considered significant for all comparisons. All statistical analyses were performed using SPSS version 26.0 (IBM Corp, Armonk, NY).

Results

Immediate postoperative results

The average CPB time was slightly longer in the in situ BIMA group (126.4 ± 15.2 min) compared to the SIMA group (121.8 ± 14.9 min), but this difference was not statistically significant (p = 0.12). The mean numbers of grafts per patient were 3.2 ± 0.8 in the BIMA group and 3.1 ± 0.7 in the SIMA group (p = 0.34). No significant differences were observed between the isolated in situ BIMA and in situ BIMA + SVG subgroups.

The length of hospital stay was comparable between the BIMA and SIMA groups (7.8 ± 1.5 days vs. 8.2 ± 1.4 days, respectively; p = 0.22) (Table 3). The incidence of postoperative MACCE within 30 days was comparable between the groups (2.5% in the in situ BIMA group vs. 3.0% in the SIMA group; p = 0.03). No cases of deep sternal wound infection were reported in the BIMA group, while two cases (0.7%) were noted in the SIMA group (p = 0.24). For all patients, future medical treatment was aligned with long-term guideline-directed medical therapy (GDMT) [3, 4].

Table 3.

Perioperative data (30 days) in BIMA vs. SIMA in matched patients

Parameter	In situ BIMA (n = 280)	SIMA (n = 280)	p
MACCE
Death, stroke or MI	7(2.5%)	8(2.85%)	ns
Stroke	2(0.71%)	3(1.07%)	ns
MI	4(1.42%)	3(1.07%)	ns
Total mortality	1(0.35%)	2(0.71%)	ns
Repeat revascularization	1(0.35%)	0(0.0%)	ns
CPB time (min)	126.4 ± 15.2%	121.8 ± 14.9%	ns
Number of grafts	3.2 ± 0.8	3.1 ± 0.7	ns
Average length of stay	7.8 ± 1.5 days	8.2 ± 1.4 days	ns

BIMA bilateral internal mammary artery bypass grafting, SIMA single internal mammary artery bypass grafting, MACCE major adverse cardiovascular and cerebrovascular events, MI myocardial infarction, CPB cardiopulmonary bypass

Follow-up study

The follow-up study was achieved at a rate of 100% (280 in situ BIMA + 280 SIMA pts). The average time of follow-up was 105 months (85–120). All patients reported significant clinical improvements measured by improved CCS class and freedom from angina. The mean CCS class in both groups before surgery was 2.38, and this changed to 1.12 during the mean follow-up period. Mean left ventricle ejection fraction (EF) was EFbima = 50.1 ± 5.1% vs. EFsima = 52.4 ± 6.1% (p = ns) and remained stable 5 years after surgery. However, 10 years after surgery, a significant reduction in EF was recorded in the SIMA group (EFbima = 46.5 ± 4.4%, EFpci = 40.1 ± 6.7%) (p < 0.05). The need for subsequent PCI within 5 years was significantly lower in the in situ BIMA group (8.6%) compared to the SIMA group (14.3%; p = 0.03). Survival rates at 5 and 10 years after surgery were 95.35 ± 4.0% vs. 94.65 ± 4.0% (p = ns), and 86.07 ± 3.0% vs.78.6 ± 4.0% (p < 0.05), respectively (Fig. 1). The major causes of late mortality were cardiac failure, rhythm disturbances, and cerebrovascular accidents (Table 4).

Fig. 1.

Ten-year survival rate follow-up in patients with BIMA compared to SIMA. N, number of patients at risk at each time point

Table 4.

Causes of late mortality in BIMA vs. SIMA matched patients

Causes of death	In situ BIMA (n = 280)	SIMA (n = 280)	p
Cardiac causes
Cardiac failure	15(5.35%)	29(10.35%)
Myocardial infarction	6(2.14%)	11(3.92%)
Ventricular arrhythmia	3(1.07%)	5(1.78%)
Total	24(8.57%)	45(16.07%)	< 0.05
Other causes
Cerebrovascular accident	6(2.14%)	7(2.5%)
Malignancy	5(1.78%)	4(1.42%)
Sudden death	4(1.42%)	4(1.42%)
Total	15(5.35%)	15(5.35%)	ns
Overall mortality rate	39(13.93%)	60(21.43%)	< 0.05

BIMA bilateral internal mammary artery bypass grafting, SIMA single internal mammary artery bypass grafting

Discussion

The number of patients with coronary artery disease remains high, and is still increasing [23]. CABG surgery remains the preferred mode of revascularization in patients with multi-vessel coronary artery disease. The LIMA is commonly used for left coronary territories, and SV is used for other targets. Such a policy was traditionally accepted for decades and was considered to be the gold standard by most surgeons [16, 17]. The findings of this study emphasize the significant advantages of utilizing in situ BIMAs over a SIMA in CABG surgery. This is particularly relevant as cardiovascular diseases continue to be a leading cause of morbidity and mortality globally [23, 24]. Although the survival advantages of BIMA grafting are well documented, its use is frequently limited by concerns regarding perioperative complexities.

Reports about the application of BIMA for myocardial revascularization can be followed back to the 1960 s when Rene Favaloro described the utilization of BIMA implants into the myocardial syncytium [25]. The use of BIMA grafts for conventional direct coronary anastomoses was first reported in 1973, and soon after, BIMA usage in CABG surgery was promoted in the cardiac surgical community as a superior way of surgical treatment to achieve greater territorial coronary artery revascularization with arterial grafting [26]. During the last two decades, we have seen different developmental histories in the evolution of the CABG approach. Many questions have been raised related to graft selection and design, from on-pump to off-pump CABG procedures, harvesting, and hybrid techniques [27, 28]. Basic sciences recently confirmed biological support for BIMA long-term benefits in respect to atherosclerosis, inflammation, thrombosis, and cell signaling pathways [12]. Given that the RIMA is biologically identical to the LIMA, it is logical to advocate for in situ BIMA superiority compared to LIMA-SV grafting [17].

Our study demonstrated that the survival advantage of in situ BIMA grafting became evident approximately 5 years postoperatively and remained consistent over a decade-long follow-up, with an exceptional 100% follow-up achievement. These findings align with earlier research indicating better long-term patency rates and reduced need for repeat revascularization procedures compared to venous grafts or SIMA [12, 29]. For instance, the Arterial Revascularisation Therapies (ART) trial, one of the largest randomized trials comparing SIMA and BIMA, demonstrated a trend towards improved outcomes with BIMA, although it did not achieve statistical significance, likely due to methodological factors such as crossovers and the inclusion of less experienced centers. However, diabetes, COPD, and obesity have been accepted as limitations for extensive use of BIMA [10, 11, 13, 14]. Unlike the ART trial, our study showed a significant advantage with in situ BIMA, suggesting that when the IMA harvesting is performed by a hand of experienced surgeons, the potential benefit of in situ BIMA grafting may be fully realized. BIMA harvesting with the skeletonized technique, especially with harmonic technology, provides better IMA length, detailed graft visualization, and minimal trauma to the chest wall. Thus, the skeletonized technique used in this series makes traditionally accepted limitations for the usage of BIMA irrelevant [14, 20]. Another important issue is a patient selection and the need to individualize the treatment plan. The role of contemporary risk stratification tools like the EuroScore II and SYNTAX score II cannot be underestimated. These tools, in addition to patient anatomy, could be helpful in identifying patients who may benefit most from a more aggressive revascularization strategy with BIMA. In our study, the use of PSM ensured that patients in the BIMA and SIMA groups were well balanced to give further credibility to the observed outcome.

The superiority of the BIMAs with regard to patency rate and long-term outcomes seems to provide enough evidence in the recently published literature to convince more surgeons about the advantages of BIMA grafting [5, 11, 12, 16, 29]. BIMA grafts demonstrated a survival advantage as early as 5 years post-surgery, leading up to an 18% survival benefit at 15 years follow-up [12, 16, 17]. In addition to that, BIMA used during CABG is associated with a reduced incidence of repeated revascularization when compared with other ways of revascularization (PCI or SV grafting), especially in multivessel coronary artery disease. Thus, these data strongly recommend the use of BIMAs as the preferred conduits in CABG [12, 16, 17].

A lack of strategic planning in graft configuration can be a significant concern when relying exclusively on arterial grafts for complete myocardial revascularization. In our study, 57 patients in the in situ BIMA group received exclusively in situ BIMA grafts without the use of SVGs. A comparative analysis between this subgroup and the overall in situ BIMA group did not reveal any significant differences in mortality or other major outcomes. This suggests that the addition of SVGs in selected cases did not adversely impact survival, supporting the safety and feasibility of in situ BIMA grafting as an independent revascularization strategy. However, further studies with larger sample sizes may be needed to validate these findings.

While LIMA, including sequential and composite grafting techniques, has demonstrated its superiority in the left coronary artery territory, there are many controversies regarding RIMA attached to the right coronary artery (RCA) territory. The long-term patency of arterial grafts to the RCA has been well documented to correlate strongly with the severity of native coronary stenosis [30–32]. Long-term patency rates could be compromised due to the incidence of competitive flow, which in the RCA territory has an incidence of about 10%. Thus, when grafting to the RCA with RIMA, it is strongly recommended to avoid competitive flow and early graft occlusion by using RIMA on severe stenosis by angiography of ≥ 90% [3, 31]. Unfortunately, there is a relatively small number of published papers to support such statistics in detail.

Regardless of these proven results, most surgeons are reluctant to use both IMAs, especially for different coronary territories, due to its technical demands, prolonged duration of the procedure, and slightly increased sternal wound infection rates. Even in the pivotal SYNTAX trial, less than a third of patients in the three-vessel disease subgroup received BIMAs [33]. The incidence of BIMAs utilization in routine clinical practice is around 20% in Europe and less than 5% in most respective cardiac surgery centers in the United States of America (USA) [12, 17]. Over the last 5 years, there was no growth in BIMA use among Medicare beneficiaries in the USA, and the frequency of BIMA use during CABG remains low [34]. According to the latest reports, regular use of BIMA for coronary revascularization was currently adopted only by a few centers, and the absolute USA national rate of BIMA use declined from 0.318 per 1000 beneficiaries in 2009 to 0.204 in 2014 (p < 0.0001) [35, 36]. However, there was significant variation in BIMA use worldwide, which demonstrates an opportunity for continued growth of BIMA grafting globally.

Most of the arguments for being unenthusiastic to use BIMAs in CABG surgery are still present in our division as well. Variations in individual surgical skill within the team often raise important questions about the balance between safety and efficiency: What defines an acceptable level of safety? How can optimal surgical speed be achieved without compromising outcomes? Thus, the personal learning curve should have a major influence in deliberately selecting the team for such a procedure. Nevertheless, our study confirms that BIMAs used for CABG are safe with respect to immediate and long-term postoperative outcomes.

Comparative advantages of different coronary territories

BIMA grafting offers distinct advantages when used to revascularize specific coronary territories. We previously reported that systematic utilization of skeletonized LIMA could be successfully applied in patients with CAD [37]. Furthermore, we also published that skeletonized LIMA is a better option for myocardial revascularization compared to PCI and stenting even in a single vessel LAD disease [12, 29]. Such an approach has been associated with improved survival, reduced rates of recurrent angina, and lower incidence of myocardial infarction [12, 14, 29]. In contrast, the RIMA can be used to graft other coronary arteries, such as RCA or circumflex arteries, providing a durable and reliable conduit. The use of BIMA, with each artery dedicated to different coronary territories, maximizes the use of arterial grafts, which are less prone to atherosclerosis and other degenerative changes compared to venous grafts. This strategic use of BIMA can be particularly advantageous in patients with multi-vessel coronary artery disease, where different ischemic zones require revascularization [38].

Beyond the well-established benefits of arterial grafting, this study also underscores the strategic advantage of in situ RIMA for young surgeons seeking to optimize long-term outcomes without introducing additional complexity. Unlike composite Y- or T-grafts, which require additional anastomoses and introduce potential flow competition or technical complexity, the in situ RIMA configuration provides a simpler, more reproducible, and hemodynamically efficient alternative. This technique preserves native arterial flow dynamics, avoids the challenges associated with free graft manipulation, and minimizes concerns about competitive flow or conduit spasm [12]. Furthermore, from a practical standpoint, this approach is particularly beneficial for young surgeons who are in the early phases of adopting BIMA grafting. By integrating the in situ RIMA-to-RCA strategy into routine practice, they can achieve the well-documented benefits of bilateral arterial grafting without the added complexity of LIMA-RIMA Y-grafts or sequential anastomoses. This method allows for greater procedural consistency while maintaining the flexibility to adapt intraoperatively based on patient anatomy [12, 16].

Limitations of the study

Although our results demonstrated low postoperative mortality and favorable long-term outcomes, this study has important limitations. The first one is patient selection in this cohort. The decision-making process for BIMA’s patient selection was strongly based on intraoperative findings, such as local RCA anatomy, the length of the RIMA graft, and the distance between the RIMA and the targeted spot for coronary anastomosis. Thus, it is difficult to perform complete randomization before the heart exposure. Another limitation is the single-center design and, consequently, the small sample size. Although the study achieved 100% follow-up, the overall sample size remains relatively small compared to larger multicenter randomized controlled trials. This limits the generalizability of our findings to a broader patient population. Furthermore, although we observed significant benefits with skeletonized BIMA grafting in experienced hands, the results may not necessarily translate to institutions or surgeons with less experience in this technique. Finally, there is a lack of long-term assessments. While survival and event-free rates were analyzed, additional assessments, such as patency rates, myocardial perfusion imaging, or functional stress tests, could have provided further insights into graft patency and efficacy, especially when performed on targets with less than 90% stenosis. Future research should focus on addressing these limitations through larger, multicenter, randomized controlled trials with extended follow-up periods to validate and refine the optimal approach for CABG surgery with BIMA grafting.

Conclusion

In conclusion, this study demonstrates that BIMAs, as in situ grafting in CABG surgery used for different coronary territories, offer superior long-term outcomes compared to SIMA grafting. Patients who received BIMA grafts exhibited a lower incidence of repeat PCI, better long-term left ventricular function preservation, and improved 10-year survival rates. These findings support the increased adoption of BIMA grafting, particularly for younger patients with fewer comorbidities, where the long-term survival benefit is likely to be most pronounced. Our data confirm unparalleled benefits of BIMA grafting for different coronary territories. Our conclusion is independent of traditionally accepted risk factors incorporated in the EuroSCORE II and Syntax score II and is exclusively method related.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

All authors contributed equally in conceptualising, writing and reviewing the manuscript.

Funding

None.

Data Availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request. Due to ethical restrictions and patient confidentiality agreements, individual-level data are not publicly accessible.

Declarations

Ethics approval

The present study was approved by the institutional ethics committee and approved by The Institutional Review Board.

Informed consent statement

Obtained from the patient.

Conflict of interest

The authors declare that there is no conflict of interest.

The authors have no relevant financial or non-financial interests to disclose.

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

The authors have no financial or proprietary interests in any material discussed in this article.

Statement of human and animal rights

This manuscript reports a study on human subjects. The procedures were followed in accordance with the 1964 Helsinki Declaration and its later amendments, or comparable ethical standards.