Total Arterial Coronary Bypass Graft Surgery is Associated with Better Long-Term Survival in Patients with Multivessel Coronary Artery Disease: a Systematic Review with Meta-Analysis

Abstract

Introduction The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients. Methods The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed. Results Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P <0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome. Conclusion This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

Outcomes of total arterial revascularization vs conventional revascularization in patients undergoing coronary artery bypass graft surgery: A narrative review of major studies

“…Three recent meta-analysis have been published in this topic. 4 , 5 , 24 In a recent meta-analysis that pooled 12 small matched/adjusted observational studies of 33597 patients, TAG was associated with reduced all-cause mortality compared with conventional CABG (HR 0.85, 95% CI, 0.81-0.89). 4 Other authors, including different studies, concluded that TAG with BIMA may offer a higher protective long-term survival effect at the expense of a higher risk of DSWI (relative risk 1.44, 95% CI 1.17-1.77).…”

“… 4 Other authors, including different studies, concluded that TAG with BIMA may offer a higher protective long-term survival effect at the expense of a higher risk of DSWI (relative risk 1.44, 95% CI 1.17-1.77). 5 The most recent papers summarizing outcomes of 14 studies and 22746 patients (8941 TAG and 13805 non-TAG) showed that the pooled hazard ratio for long-term mortality (>10 years) was lower in TAG (HR 0.68; 95 %CI 0.59-0.78, P<0.001), 24 but prospectively hi-quality evidences are still awaited to confirm those findings. An ongoing trial with a target sample size of 4300 patients comparing multiple arterial graft with single arterial graft, the Randomization of Single vs Multiple Arterial Grafts (ROMA) trial (NCT03217006) will hopefully provide a definitive answer as to whether using more arterial grafts will lead to better survival and lower number of adverse events in the long term.…”

“…Total arterial grafting is more beneficial in both short and long-term outcomes and its use should be encouraged. 4 , 5 , 24 , 26 This technique minimizes the risk of stroke and has better patency. Drawbacks of this approach include DSWI and longer procedural time, as total arterial grafting is a more challenging surgical technique.…”

A predictive patient-specific computational model of coronary artery bypass grafts for potential use by cardiac surgeons to guide selection of graft configurations

“…where A is the cross-sectional area of the vessel in cm 2 , Q is the flow rate in cm 3 /s, P is the pressure in dyne/cm 2 , x is the axial dimension along the vessel in cm, ρ is the density of blood assumed essentially incompressible with a constant value ρ ≈ 1.06 g/cm 3 , ν is the kinematic viscosity (ν = µ ρ ), µ is dynamic viscosity with µ = 0.046 dyn•s/cm 2 (32, 33) and α is the momentum correction coefficient (Coriolis coefficient) that accounts for the non-linear integration of cross-sectional radial velocities and determines the shape of the velocity profile, φ (r), through Equation (3), R is the lumen radius and r is the radial coordinate (34):…”

“…internal mammary arteries (BIMA) and radial arteries (RA), on account of their longevity (3,4). However, there still exists significant variability in grafting strategy among cardiac surgeons and there remains controversy as to the optimal grafting configuration for a given patient (5).…”