Multiple arterial grafting and the age threshold dilemma: a narrative review

Background and Objective: Multiple arterial grafting (MAG), particularly bilateral internal thoracic artery (BITA) use, has demonstrated superior long-term outcomes in coronary artery bypass grafting (CABG). However, its benefit in elderly patients remains debated, with age thresholds proposed to guide conduit selection. This review aims to synthesize current evidence on age-related efficacy of MAG and explore technical, physiological, and methodological factors influencing its application.

Methods: A literature search was conducted using PubMed and Embase for studies published between January 1990 and August 2025. Search terms included “multiple arterial grafting”, “bilateral internal thoracic artery”, “coronary artery bypass”, “age threshold”, “frailty”, and “surgical outcomes”. Only studies available in English were considered. Titles and abstracts were screened for relevance to age‑related outcomes in MAG, and full texts of eligible studies were reviewed. Key findings were extracted and synthesized, with particular attention to methodological approaches, statistical models, and clinical endpoints to ensure a critical and contextually informed appraisal of the evidence.

Key Content and Findings: Early observational studies suggested diminished BITA benefit beyond 60–70 years, but recent registry analyses challenge this notion, showing survival advantages even in older cohorts. Technical refinements—such as skeletonized harvesting, composite grafting, and radial artery integration—have expanded MAG’s feasibility. Frailty and comorbidity burden are increasingly recognized as more predictive than chronological age. Emerging tools, including artificial intelligence-based risk models and decision aids, may further personalize conduit strategy.

Conclusions: Chronological age alone is insufficient to guide MAG decisions. Individualized assessment incorporating physiologic reserve, surgical expertise, and patient preferences is essential. Future research should prioritize age-stratified trials, functional outcomes, and implementation strategies to optimize MAG use across the age spectrum.