As a profession, surgery is well into its fourth decade of experience with bilateral internal thoracic artery (BITA) grafting for the treatment of ischemic cardiovascular disease. Numerous compelling retrospective analyses appear to have documented a clear benefit for BITA grafting over the use of a single internal thoracic artery (SITA) graft in reducing the long-term risk of mortality, cardiac mortality, and cardiac events. Despite this wealth of literature and scientific as well as clinical investigation, the chilling fact remains that the STS database reports that less than 4% of coronary bypass (CABG) operations involve the use of BITA grafting. The historic, physiologic, and clinical aspects of BITA grafting are reviewed. Clinical challenges and technical advances are addressed. The future of BITA grafting is explored, both from a research perspective and from a clinical point of view.