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N Engl J Med. Author manuscript; available in PMC 2016 December 03. Published in final edited form as: N Engl J Med. 2016 September 8; 375(10): e22. doi:10.1056/NEJMc1608042#SA2.

Coronary-Artery Bypass Grafting Sajjad Raza, M.D., Eugene H. Blackstone, M.D., and Joseph F. Sabik III, M.D. Cleveland Clinic, Cleveland, OH Joseph F. Sabik: [email protected]

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TO THE EDITOR Alexander and Smith cover many of the important points regarding CABG, which is a commonly performed operation. However, the importance of the use of multiple arterial conduits, especially both internal thoracic arteries, is not discussed.

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The effectiveness of CABG is directly related to bypass graft patency, and internal-thoracicartery grafts have the best long-term patency of all CABG conduits. Therefore, it should not be surprising that bilateral-internal-thoracic-artery grafting is associated with a higher rate of long-term survival and fewer late ischemia-related events than single-internal-thoracic-artery grafting.1 We think that bilateral-internal-thoracic-artery grafting should be considered in all patients undergoing CABG. However, clinicians who contemplate the use of bilateralinternal-thoracic-artery grafting must weigh the benefits against the increased risk of deep sternal wound infection.2 We and others1,3 have found that harvesting the internal thoracic artery in a skeletonized manner without its surrounding tissue minimizes this risk.

Acknowledgments Dr. Sabik reports receiving consulting fees for serving on the scientific advisory board of Medtronic.


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1. Aldea GS, Bakaeen FG, Pal J, et al. The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting. Ann Thorac Surg. 2016; 101:801–9. [PubMed: 26680310] 2. Raza S, Sabik JF III, Masabni K, Ainkaran P, Lytle BW, Blackstone EH. Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus. J Thorac Cardiovasc Surg. 2014; 148:1257–64. [PubMed: 25260269] 3. Deo SV, Shah IK, Dunlay SM, et al. Bilateral internal thoracic artery harvest and deep sternal wound infection in diabetic patients. Ann Thorac Surg. 2013; 95:862–9. [PubMed: 23352296]

No other potential conflict of interest relevant to this letter was reported.

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