ORIGINAL RESEARCH article
Front. Cardiovasc. Med.
Sec. Cardiovascular Surgery
The Pioneering Era of Bilateral Internal Mammary Artery Grafting for CABG in Europe
Dritan Useini 1
Marcus Franz 2
Ralf Degenhardt 3
Zulfugar Taghiyev 4
Brigitta Gahl 1
Ingo Kutschka 1
Hassina Baraki 1
1. Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
2. Department of Cardiology, Angiology and Intensive Care Medicine, Cardiovascular Center Hersfeld-Rotenburg, Rotenburg an der Fulda, Rotenburg an der Fulda, Germany
3. Institute for clinical research, Cardiovascular Center Hersfeld-Rotenburg, Rotenburg an der Fulda, Rotenburg an der Fulda, Germany
4. Department of Cardiac Surgery, Kerckhoff-Clinic, Campus Kerckhoff, Justus-Liebig-University of Giessen, Bad Nauheim, Germany
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Abstract
Objectives: 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. Methods: 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. Results: 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. Conclusions: 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.
Summary
Keywords
arterial, Bima, CABG, First European series, outcomes
Received
26 December 2025
Accepted
31 January 2026
Copyright
© 2026 Useini, Franz, Degenhardt, Taghiyev, Gahl, Kutschka and Baraki. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Dritan Useini
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