Should saphenous vein grafts be the conduits of last resort for coronary artery bypass surgery?

There is overwhelming evidence that internal mammary artery grafts improve survival and clinical outcomes after coronary artery bypass graft surgery. It has therefore become standard practice to use the left internal mammary artery as the graft of first choice. Given the overwhelming evidence for the superiority of internal mammary artery grafts, the question that naturally follows is whether the conduit of second choice should be the contralateral internal mammary artery, rather than a saphenous venous graft. This article reviews the evidence supporting the superiority of internal mammary artery grafts over other available conduits and addresses the selection of the second conduit after the left internal mammary artery. The current body of evidence, encompassing multiple clinical studies and employing different methodologies consistently, demonstrates that bilateral internal mammary artery grafting improves survival and long-term clinical outcome. The increasing longevity of postcoronary bypass patients with modern advances in medical and electrical therapies would augment the benefit of this procedure and argue for its greater utilization. Higher patency of arterial grafts may translate to a decreased need for repeat target vessel revascularization and may increase the cost-effectiveness of bilateral internal mammary artery use. However, in 2003, only 3% to 4% of patients undergoing surgical coronary revascularization received bilateral internal mammary artery grafts. There appears to be a potential to increase utilization of this procedure above the current rate. Increased utilization of this procedure would need a concerted effort by the cardiology and cardiac surgery community.