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better than 1,5–7 the passion for multiple arterial grafting or total arterial grafting has been increasing. However, usage of BITA in the USA or in European countries is not high at around 5–10%.8 The reasons for the low usage of BITA are long duration of operation, more bleeding and concern about sternal infections. In the European guideline, usage of the right ITA is limited to patients who do not have a high risk of sternal infection.2 Gaudino et al began using systematic BITA grafting, but concluded that in the realworld setting it was associated with a higher incidence of perioperative adverse events (particularly sternal complications) and they stopped the study.9 Because there had not been a randomized study of comparison between SITA and BITA until the Arterial Revascularization Trial (ART)10 was designed, it was controversial and the usage of BITA depended on surgeon’s preference. ART is an international multicenter randomized study enrolling more than 31,000 patients. Recently the 10-year outcomes were published and concluded there was no difference in the primary endpoint of death at 10 years (20.3% in the BITA group and 21.2% in the SITA group: P=0.62) (Figure 2). It was a sort of shocking report, indicating there is no rationale to use BITA in CABG. There are, however, some confusing methodological problems with that study: 40% of the patients in ART actually T he grafting of the internal thoracic artery (ITA) to the left anterior descending artery brings better long-term survival results compared with the usage of saphenous vein graft after coronary artery bypass graft surgery (CABG),1 and it is strongly recommended in guidelines (Figure 1).2 ITA usage in CABG is >97% in Japan.3 Usually, the cardiac surgeon would not hesitate to use 1 ITA graft even when required to do a concomitant cardiac operation (e.g., valve operation, aortic operation). However, nobody would be certain about using bilateral ITA (BITA) for patients with multivessel disease. In this issue of the Journal, Gatti et al report on the safety of using BITA concomitant with other cardiac operations.4 They note that although the use of BITA in such cases is risky and the increased operation duration, risk of bleeding and sternal complications because of BITA harvest might outweigh the potential benefits of BITA, such as reduced manipulation of the ascending aorta and long-term survival rate, it can be performed with satisfactory results. Also, the long-term outcomes mostly depend on sex, preoperative comorbidities and baseline cardiac function. They collected data from 3 European institutes for 1,123 patients who underwent combined CABG using BITA with other cardiac surgery, valve operation, left ventricular or thoracic aortic operations. It is still controversial whether BITA usage even in isolated CABG brings better long-term results compared with SITA usage. Since the reports that 2 ITA grafts are Article p ????

What Is the Rationale for Utilizing Bilateral Internal Thoracic Arteries in Concomitant Cardiac Operations?