Dr Mokadam discloses a financial relationship with Abbott, Medtronic, and SynCardia.Coronary artery bypass graft surgery (CABG) premiered as an effective therapy for angina, but after several decades of intense evaluation, the primary indication for CABG is a well-demonstrated survival advantage [1Mohr F.W. Morice M.C. Kappetein A.P. et al.Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary artery disease: 5-year follow-up of the randomized clinical SYNTAX trial.Lancet. 2013; 381: 629-638Abstract Full Text Full Text PDF PubMed Scopus (1249) Google Scholar, 2Hillis L.D. Smith P.K. Anderson J.L. et al.2011 ACCF/AHA guidelines for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines.J Am Coll Cardiol. 2011; 58: e123-e210Crossref PubMed Scopus (601) Google Scholar], largely attributable to arterial conduit utilization. Indeed, the surgical literature is replete with evidence of arterial grafting benefits of CABG, including prolonged graft patency, reduced cardiovascular events, and improved survival, particularly when more than one arterial graft is utilized [3Yi G. Shine B. Rehman S.M. Altman D.G. Taggart D.P. Effect of bilateral internal mammary artery grafts on long-term survival.Circulation. 2014; 130: 539-545Crossref PubMed Scopus (216) Google Scholar]. Nevertheless, practical enthusiasm for multiple-arterial CABG has consistently lagged behind objective benefits and may be decreasing even as scrutiny of CABG and other cardiovascular interventions grows ever intense [4Aldea G.S. Bakaeen F.G. Pal J. et al.Guidelines on arterial conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar]. Dr Mokadam discloses a financial relationship with Abbott, Medtronic, and SynCardia. Addressing the subjective claim that perioperative complications are increased with multiple-arterial CABG, in this issue of The Annals of Thoracic Surgery, Schwann and colleagues [5Schwann T.A. Habib R.H. Wallace A. et al.Operative outcomes of multiple-arterial versus single-arterial coronary bypass grafting.Ann Thorac Surg. 2018; 105: 1109-1120Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar] examined recent practices of CABG conduit selection using The Society of Thoracic Surgeons Adult Cardiac Database (2004 to 2015). Primary findings were of marginally increased, risk-adjusted operative mortality and increased sternal wound infection when bilateral internal thoracic arteries (BITA) were used compared with the single internal thoracic artery cohort. Operative mortality and sternal infection were similar among the left internal thoracic artery–radial artery cohort and single internal thoracic artery cohort. Instinctual response to these results may be to view multiple-arterial grafting with increased skepticism, and finally to acknowledge dogma that multiple-arterial CABG is harmful. The authors carefully and rightfully reiterate that these isolated results should not detract from the well-demonstrated, long-term advantages of multiple-arterial CABG. These data, while powerfully representing nearly every US patient undergoing isolated CABG between 2004 and 2015, are also subject to selection bias and other serious confounding conditions. Any experience with BITA may be accompanied by increased rates of sternal infection compared with unrandomized “controls” owing to relative degree of perioperative sternal ischemia. Although threefold mortality was shown in the present study, mortality from deep sternal wound infection is dramatically reduced by modern methods of treating sternal infection, and recent data suggest that long-term advantages of CABG are not influenced by the development of sternal infection. In contrast, the ART randomized study of more than 3,100 patients clearly shows no difference in operative mortality or 5-year survival among BITA versus single internal thoracic artery CABG [6Taggart D.P. Altman D.G. Gray A.M. et al.Randomized trial of bilateral versus single internal-thoracic-artery grafts.N Engl J Med. 2016; 375: 2540-2549Crossref PubMed Scopus (278) Google Scholar]. Perhaps most importantly, this work by Schwann and colleagues provides a fascinating analysis of surgical decision making and the prism with which we view literature and its applicability to clinical practice. During the period when the Schwann data were compiled, convincing evidence mounted for the advantages of multiple-arterial CABG [4Aldea G.S. Bakaeen F.G. Pal J. et al.Guidelines on arterial conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar, 6Taggart D.P. Altman D.G. Gray A.M. et al.Randomized trial of bilateral versus single internal-thoracic-artery grafts.N Engl J Med. 2016; 375: 2540-2549Crossref PubMed Scopus (278) Google Scholar]. Simultaneously, CABG rates decreased precipitously after Food and Drug Administration approval of drug-eluting coronary stents. Logically, these collective dynamics might have driven trends toward a “better” operation, with greater enthusiasm for multiple-arterial CABG. Instead, based on these and other data, procedures reverted toward fewer arterial grafts, especially the radial graft, even though guidelines clearly emphasized survival advantages of CABG [4Aldea G.S. Bakaeen F.G. Pal J. et al.Guidelines on arterial conduits for coronary artery bypass grafting.Ann Thorac Surg. 2016; 101: 801-809Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar]. Speculative explanation for such trends could be practical: multiple-arterial grafting may have been avoided because of the perceived impact of additional conduit harvesting on operative times or “rhythm.” Concerns regarding public reporting of CABG short-term outcomes could have also had an impact on decisions against multiple-arterial CABG as another possible “unintended consequence” of The Society of Thoracic Surgeons public reporting, coincidentally initiated during this investigation period [7Shahian D.M. Edwards F.H. Jacobs J.P. et al.Public reporting of cardiac surgery performance. Part 1: history, rationale, consequences.Ann Thorac Surg. 2011; 92: 2-11Abstract Full Text Full Text PDF PubMed Google Scholar]. Given the compelling evidence for long-term benefits of multiple-arterial CABG, how should the surgical community proceed? This study emphasizes mortality rates after BITA are optimized with an adequate experience (10% to 20% of CABG cases) and when used for select patient subgroups. If an equivalent enthusiasm were assumed for radial artery utilization, 60,000 to 80,000 more patients annually could realize the advantages of multiple-arterial CABG. Coronary artery disease remains the most lethal disease in the Western World. It remains our opportunity to provide the best surgical treatment for it. Operative Outcomes of Multiple-Arterial Versus Single-Arterial Coronary Bypass GraftingThe Annals of Thoracic SurgeryVol. 105Issue 4PreviewMore than 90% of coronary artery bypass grafting (CABG) is performed with a single-arterial bypass graft (SABG), based on the left internal thoracic artery (ITA) with supplemental vein grafts. This practice, often justified by safety concerns with multiple-arterial grafting (MABG), defies evidence of improved late survival achieved with bilateral ITA (BITA-MABG) or left ITA plus radial artery (RA-MABG). We hypothesized that MABG and SABG are equally safe. Full-Text PDF