# The pioneering era of bilateral internal mammary artery grafting for CABG in Europe

## TL;DR

This study examines long-term outcomes of a pioneering European heart surgery technique using bilateral internal mammary artery grafts before stents were common.

## Contribution

Provides unique long-term evidence from early European use of BIMA grafting in coronary artery bypass surgery.

## Key findings

- Patients had 19.1-year mean survival with minimal repeat revascularization.
- 20-year revascularization rate was 11.6%, all treated percutaneously.
- BIMA grafting in the pre-stent era showed excellent long-term outcomes.

## Abstract

Bilateral internal mammary artery (BIMA) grafting for coronary artery bypass surgery (CABG) was uncommon in Europe before routine coronary stenting. This study evaluates long-term outcomes from one of the earliest systematic European BIMA experiences, providing historical, epidemiological, and clinical insight.

We retrospectively identified 427 patients who underwent BIMA-CABG at a single German center between 1989 and 1993. Seventy-three patients were lost to follow-up, leaving 354 for analysis. The primary endpoint was overall survival; secondary endpoints included composites of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization. Mean follow-up was 18.4 ± 0.8 years.

Patients had a mean age of 57 ± 8.8 years; 88% were men. Preoperative risk factors included hyperlipidemia (78%) and smoking (71%). No patient had prior coronary stenting; 18% underwent balloon dilation or thrombolysis. Kaplan–Meier estimates a mean survival probability of 19.1 ± 0.2 years [95% confidence interval (CI) 18.6–19.6], freedom from mortality/MI/stroke 18.8 ± 0.2 years (95% CI 18.2–19.3), and from mortality/MI/revascularization 17.8 ± 0.3 years (95% CI 17.2–18.4). The overall 20-year revascularization rate was 11.6%, all treated percutaneously; no patient required repeat CABG.

Early German BIMA-CABG, performed as first-line therapy for coronary artery disease prior to the stent era, achieved excellent 20-year survival and minimal repeat revascularization. This cohort provides unique long-term evidence from the pioneering era of arterial revascularization in Europe, highlighting clinical, epidemiological and historical significance and underscore the pioneering role of BIMA grafting in shaping modern arterial revascularization strategies.