Multiple and total arterial coronary artery bypass grafting

There is still a discouraging discrepancy between evidence and “real world” surgical practice when it comes to the use of more than 1 arterial graft in coronary artery bypass grafting. Abundant data from observational studies have confirmed the superiority of multiple and total arterial revascularization approaches in terms of long-term survival. However, it is claimed that allocation treatment bias and unmeasured bias might have contributed to these results. On the other hand, the largest trial (ART) comparing single internal thoracic artery plus saphenous vein grafts versus bilateral internal thoracic arteries did not prove significant survival benefit in the intention-to-treat analysis. The high crossover rate between the 2 arms of the trial and the frequent use of radial artery in the single internal thoracic artery arm might have further narrowed the potential difference between the 2 grafting strategies. However sufficient and consistent support for the use of more than 1 arterial graft exists. The main features to consider when selecting the type of coronary revascularization are life expectancy, patient’s comorbidities, and surgeon’s skills and experience.