Bilateral versus single internal-thoracic-artery grafts at 10 years

David P. Taggart, Umberto Benedetto, Stephen Gerry, Douglas G. Altman, Alastair M. Gray, Belinda Lees, Mario Gaudino, Vipin Zamvar, Andrzej Bochenek, Brian Buxton, Cliff Choong, Stephen Clark, Marek Deja, Jatin Desai, Ragheb Hasan, Marek Jasinski, Peter O'Keefe, Fernando Moraes, John Pepper, Siven SeevanayagamCatherine Sudarshan, Uday Trivedi, Stanislaw Wos, John Puskas, Marcus Flather, Arterial Revascularization Trial investigators

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BACKGROUND: Multiple arterial grafts may result in longer survival than single arterial grafts after coronary-artery bypass grafting (CABG) surgery. We evaluated the use of bilateral internal-thoracic-artery grafts for CABG.

METHODS: We randomly assigned patients scheduled for CABG to undergo bilateral or single internal-thoracic-artery grafting. Additional arterial or vein grafts were used as indicated. The primary outcome was death from any cause at 10 years. The composite of death from any cause, myocardial infarction, or stroke was a secondary outcome.

RESULTS: A total of 1548 patients were randomly assigned to undergo bilateral internal-thoracic-artery grafting (the bilateral-graft group) and 1554 to undergo single internal-thoracic-artery grafting (the single-graft group). In the bilateral-graft group, 13.9% of the patients received only a single internal-thoracic-artery graft, and in the single-graft group, 21.8% of the patients also received a radial-artery graft. Vital status was not known for 2.3% of the patients at 10 years. In the intention-to-treat analysis at 10 years, there were 315 deaths (20.3% of the patients) in the bilateral-graft group and 329 deaths (21.2%) in the single-graft group (hazard ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.12; P=0.62). Regarding the composite outcome of death, myocardial infarction, or stroke, there were 385 patients (24.9%) with an event in the bilateral-graft group and 425 patients (27.3%) with an event in the single-graft group (hazard ratio, 0.90; 95% CI, 0.79 to 1.03).

CONCLUSIONS: Among patients who were scheduled for CABG and had been randomly assigned to undergo bilateral or single internal-thoracic-artery grafting, there was no significant between-group difference in the rate of death from any cause at 10 years in the intention-to-treat analysis. Further studies are needed to determine whether multiple arterial grafts provide better outcomes than a single internal-thoracic-artery graft. 

Original languageEnglish
Pages (from-to)437-446
Number of pages10
JournalNew England Journal of Medicine
Issue number5
Publication statusPublished - 31 Jan 2019


  • Aged
  • Cause of Death
  • Coronary Artery Bypass/methods
  • Coronary Artery Disease/mortality
  • Female
  • Follow-Up Studies
  • Humans
  • Intention to Treat Analysis
  • Male
  • Mammary Arteries/transplantation
  • Middle Aged
  • Myocardial Infarction/epidemiology
  • Stroke/epidemiology
  • Survival Analysis

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