Background Several bilateral internal thoracic artery (ITA) grafting patterns have been proposed to enhance 3-vessel coronary artery revascularization. We present the outcomes of sequential in situ left ITA grafting to the circumflex and right coronary artery (RCA) areas. Methods Between January 2001 and September 2007, 102 patients with 3-vessel coronary artery disease underwent arterial myocardial revascularization with bilateral in situ ITA grafts. The circumflex and distal RCA branches were revascularized sequentially with the left ITA. The left anterior descending artery area was grafted with the right ITA. Results Ninety-nine patients (97.0%) were monitored for 37.2 ± 2.9 months, and 77 (75.4%) underwent postoperative coronary imaging after 27.8 ± 5.8 months. The bilateral ITA grafts were 97.1% patent (FitzGibbon grade A+B) overall. The sequential anastomoses of the left ITA to the circumflex and RCA territories were 96.7% patent overall, with competitive flow (FitzGibbon grade B) in 3 patients. The patency rates of sequential anastomoses to the circumflex and RCA branches were 98.0% and 95.0%, respectively. The right posterolateral and right descending posterior artery anastomoses were 91.8% and 100% patent, respectively. The in situ right ITA grafts to the left anterior descending artery area were 98.0% (FitzGibbon grade A+B) patent overall. Angina recurred in 1 patient (0.9%) 6 months after the operation. Percutaneous coronary interventions were performed in 3 patients (3.8%). No cardiac deaths occurred during the follow-up period. Conclusions Sequential in situ left ITA grafting to the circumflex and RCA areas yields acceptable midterm results in selected patients with 3-vessel disease.