LIMA/BIMA Grafting in Bypass Surgery
The Gold Standard of Coronary Revascularisation
In coronary bypass surgery, the choice of graft material is one of the most important determinants of how long the benefits of surgery last. Not all bypass grafts are equal – and the gap between an arterial graft and a vein graft widens significantly with time. At EPIC Multispecialty Hospital, Ahmedabad, our cardiac surgeons have built a bypass programme centred on LIMA and BIMA grafting – prioritising the use of internal mammary arteries to deliver revascularisation that is built to last.
Understanding Bypass Grafts – Why the Choice Matters
The Problem with Saphenous Vein Grafts
The saphenous vein from the leg has been used in bypass surgery since the very beginning of CABG. It is readily available, easy to harvest, and technically straightforward to use. Its limitation is durability. Vein grafts are susceptible to early thrombosis, intimal hyperplasia, and accelerated atherosclerosis – a process that mirrors the coronary disease they were meant to bypass. By 10 years, approximately 50% of saphenous vein grafts have significant disease and may require repeat intervention.
The Internal Mammary Artery – A Fundamentally Different Conduit
The internal mammary artery (IMA) – also called the internal thoracic artery – is a vessel with biological properties that make it uniquely well-suited to functioning as a bypass conduit. It produces nitric oxide, resists atherosclerosis, and responds to demand – dilating when the heart needs more blood. These properties translate directly into superior clinical outcomes: LIMA-to-LAD grafts remain patent in over 90% of patients at 10 years and have been shown to provide a significant survival advantage.
LIMA Grafting – The Cornerstone of Every CABG
The Left Internal Mammary Artery (LIMA) is the single most important graft in bypass surgery. It is used to bypass the Left Anterior Descending (LAD) coronary artery – the most critical vessel supplying the anterior wall of the left ventricle. LIMA-to-LAD is not merely a preference – it is the standard of care in every guideline-endorsed bypass programme. EPIC Hospital’s surgeons use LIMA-to-LAD as the foundation of every CABG operation they perform.
BIMA Grafting – When Both Arteries Are Used
What Is BIMA Grafting?
Bilateral Internal Mammary Artery (BIMA) grafting uses both the left and right internal mammary arteries as bypass conduits – providing complete arterial revascularisation for the heart’s most important vessels. Multiple landmark studies – including the ART (Arterial Revascularisation Trial) – have investigated BIMA grafting, with evidence pointing to improved long-term survival, fewer repeat revascularisations, and better freedom from major cardiac events compared to LIMA-only grafting with additional vein grafts.
Who Benefits Most from BIMA Grafting?
BIMA grafting provides the greatest benefit in younger patients – typically under 70 – and in diabetic patients with multi-vessel coronary disease. In these groups, the long-term survival advantage of complete arterial revascularisation over supplementary vein grafting is most clinically meaningful. EPIC Hospital’s surgeons individualise graft selection based on age, anatomy, risk factors, and patient preference.
The Technical Challenge – and How EPIC Manages It
BIMA grafting is technically more demanding than single IMA use. Harvesting both internal mammary arteries increases the risk of sternal wound complications – particularly in diabetic and obese patients, where sternal blood supply is more critical. EPIC Hospital’s surgeons perform BIMA grafting using the skeletonised harvesting technique – removing only the artery itself while preserving the surrounding tissue and vessels that supply the sternum. This technique substantially reduces wound complications and is essential to safe BIMA grafting in higher-risk patients.
Additional Arterial Graft Options
The Radial Artery
The radial artery from the non-dominant forearm is an excellent additional arterial conduit, with patency rates superior to saphenous vein when used to bypass high-grade coronary stenoses. EPIC Hospital uses the radial artery routinely to supplement LIMA or BIMA grafting and extend complete arterial revascularisation to three or four vessels where anatomy allows.
Know Your Signs
Chest Pain / Discomfort
Heart Palpitations
Fainting (Syncope)
Uncontrolled high blood pressure
Shortness of Breath
Dizziness or Lightheadedness
Changes in Exercise Tolerance
Swelling (Edema)
Emergency Services
Our dedicated emergency team is available 24/7 to provide immediate medical care and support in critical situations.
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Patient Testimonial – Dr. Anil Jain
Talks By Our Expert Cardiac Doctors
Patient Testimonial – Dr. Anil Jain
Bypass and Valve Replacement Surgery – Dr. Anil Jain
Bypass surgery – Patient Testimonial by Dr. Anil Jain
CABG Surgery – Dr. Anoop Gupta and Dr. Anil Jain & Team
Patient Testimonial:- Heart Valve Replacement Surgery
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LIMA/BIMA Grafting in Bypass Surgery - Frequently Asked Questions
What is LIMA grafting in bypass surgery and why is it important?
LIMA (Left Internal Mammary Artery) grafting uses the internal chest wall artery to bypass the most important coronary vessel – the LAD. LIMA grafts remain open in over 90% of patients at 10 years, providing a long-term patency advantage that significantly impacts survival and reduces the need for repeat procedures.
What is BIMA grafting in CABG surgery?
BIMA (Bilateral Internal Mammary Artery) grafting uses both left and right internal mammary arteries as bypass grafts – providing complete arterial revascularisation. It has been associated with improved long-term survival and fewer repeat interventions compared to LIMA-only bypass with saphenous vein supplementation.
Is BIMA grafting suitable for all patients?
BIMA is most beneficial in younger patients and diabetic patients with multi-vessel disease. In patients with significant obesity, poorly controlled diabetes, or other risk factors for wound infection, the decision requires careful consideration – and the use of skeletonised harvesting technique to reduce sternal wound risk.
How do arterial grafts compare to vein grafts in terms of longevity?
Arterial grafts – LIMA, RIMA, and radial artery – are far more durable than saphenous vein grafts. Arterial grafts resist the atherosclerosis that affects vein grafts over time, maintaining function for decades. Vein grafts may develop significant disease within 10 years of bypass surgery.
Is LIMA/BIMA grafting available in Ahmedabad?
Yes. EPIC Multispecialty Hospital, Ahmedabad offers LIMA and BIMA grafting as part of its coronary bypass programme. Not all centres in Gujarat offer BIMA grafting – speak to our cardiac surgery team to determine whether complete arterial revascularisation is appropriate for your case.
What is skeletonised IMA harvesting?
Skeletonised harvesting is a technique where the internal mammary artery is dissected free without the surrounding tissue pedicle. This preserves the blood supply to the sternum and significantly reduces the risk of deep sternal wound infection – particularly important in patients undergoing BIMA grafting.
Can BIMA grafting be done off-pump?
Yes. In selected patients, BIMA grafting can be performed as part of off-pump CABG (OPCAB) – combining the long-term graft patency benefits of arterial grafting with the avoidance of cardiopulmonary bypass.
What is the radial artery graft and how does it compare to LIMA?
The radial artery provides excellent long-term patency when used to bypass high-grade coronary stenoses – superior to saphenous vein, though typically considered slightly below LIMA in durability based on available evidence. It is the preferred third arterial conduit after LIMA and RIMA in complete arterial revascularisation strategies.