Recent trial data indicate that coronary artery bypass graft (CABG) surgery remains the most effective intervention for patients with severe coronary artery disease (CAD). Moreover, for over two decades it has been recognised that the use of a single internal mammary artery (SIMA) during CABG improves survival and freedom from myocardial infarction, recurrent angina and repeat intervention. While most patients need three or four bypass grafts, revascularisation can usually be effectively achieved with a combination of SIMA and supplementary vein grafts. However, while internal mammary arteries tend to remain patent almost indefinitely, there is a constant attrition of vein grafts such that by ten years after the operation half of the vein grafts are occluded and half of the remainder are severely diseased; by contrast more than 90% of the internal mammary arteries are still patent.
Observational data have also suggested that use of bilateral internal mammary arteries (BIMA) may provide superior revascularisation with improved long-term survival and reduced need for repeat CABG. However, studies indicate that few patients having CABG in Europe and the USA actually receive BIMA because of concerns that it is technically more challenging and may increase early mortality and major morbidity.
The Arterial Revascularisation Trial (ART), one of the largest trials ever conducted in cardiac surgery, was a randomised trial of BIMA grafts versus SIMA grafts whose primary outcome was survival at 10 years. Secondary end-points included clinical events, quality of life and cost effectiveness. Results reported today at the ESC Congress are on safety data in the whole cohort up to one year after randomisation.