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In 1999, a seminal paper from the Cleveland Clinic demonstrated that patients treated with two versus one internal thoracic artery (ITA) coronary grafts have better long-term survival and freedom from reoperation.1 This finding was later confirmed in a systematic review2 and in a number of more recent studies.3–5 Puskas and colleagues3 have reported an impressive (35%) reduction in the long-term hazard of death in patients with and without diabetes undergoing bilateral internal thoracic artery (BITA) grafting. In a propensity-matched analysis of 1856 patients Grau et al4 showed a 10% survival benefit at 10 years, and 18% at 15 years for BITA grafting. Glineur et al5 showed that the survival benefit following BITA grafting is sustained up to 25 years. The available data consistently show better survival with two ITA grafts, especially when the second graft is placed on the circumflex artery. The definitive answer to the question as to whether two ITA are …
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