Bilateral internal thoracic artery versus left internal thoracic artery and saphenous vein grafting in coronary artery bypass surgery

The study by Pevni et al. [1] elegantly illustrates the long-term clinical outcomes of 5301 patients who underwent coronary artery bypass grafting (CABG) surgery with bilateral internal thoracic artery grafting (BITA) and single internal thoracic artery grafting [1]. Despite improvement in long-term survival of patients who underwent BITA, a procedure recommended by the American Heart Association (AHA) guidelines and randomized controlled trials, the adoption of this technique is still slow even in developed countries [1, 2]. With the increasing prevalence of multiple morbidities associated with BITA, complications such as deep sternal wound infections tend to increase [2, 3]. In the 1980s, these occurrences were reported to be related to ischaemia of the sternal wall, an anatomophysiopathological aspect that could only be minimized by improving the internal thoracic artery (ITA) harvesting techniques [4]. A recent study reported a 5-fold increase in mortality, worsening of quality of life and elevated costs of hospitalization in patients with deep sternal wound infections [3], these results were different from the study by Pevni et al. [1] who found an increase in the incidence of deep sternal wound infections with BITA. Therefore, it would be important to define subgroups of patients in which BITA can be used without an increase in immediate morbimortality, by incorporating the favourable outcomes already established in the literature, and to define other subgroups, possibly with multiple morbidities, in which a single internal thoracic artery associated with a saphenous vein (SV) would be a more appropriate approach. Pevni et al. in their study reported that patients with low risk for infections were selected for BITA. This, in association with factors such as ITA skeletonization, and experience of the surgical team with the BITA technique, may be a major element for the positive results of their patients, corroborating the hypothesis that, even though more patients should receive BITA, not all of them are eligible for this approach, or for the systematic use of arterial grafts exclusively. It is crucial to look for alternatives such that the SV is no longer suboptimally used. Approaches such as arterio-venous composite grafts, no-touch technique, improved preservation of SV, and choice of valveless venous segments are technically feasible options with, in selected cases, results comparable to ITA grafts [5]. Thus, although there are considerable limitations with the SV in CABG, there is still a considerable technical margin to improve its medium and long-term outcomes.