Right internal thoracic artery versus radial artery as the second best arterial conduit: Insights from a meta-analysis of propensity-matched data on long-term survival

Abstract

The present PSM data meta-analysis suggests that the use of RITA compared with RA was associated with superior long-term survival and freedom from repeat revascularization, with similar operative mortality and incidence of sternal wound complication when the skeletonized harvesting technique was used.

Why Don’t We Kill 2 Birds with 1 Stone?

“…7,11 With regard to comparative studies of RA versus RITA grafting, the RAPCO trial (Radial Artery Patency and Clinical Outcomes) reported similar angiographic and clinical outcomes associated with both procedures, 9 and observational studies have reported mixed results. 12,13 We recently reported similar perioperative and long-term outcomes of RA and RITA grafting in patients with diabetes and view them as superior conduits to veins.…”

The 3 R's: The radial artery, the right internal thoracic artery, and the race for the second best

“…23,24 There are some important points worth discussing about the article of Benedetto and colleagues. 22 For the primary analysis of long-term mortality, although the RITA was found to have a strong protective effect relative to the RA, there was a moderate amount of statistical heterogeneity for this outcome (I 2 ¼ 66.5%; 95% confidence interval, 29.1%-84.2%), indicating a great deal of variability among the 8 studies. Such heterogeneity could have been due to differential baseline characteristics, institutional differences in surgical decision making, postoperative management, or follow-up among the included studies.…”

“…To this end, there have been 2 RCTs comparing RITA with RA 16,17 and numerous conflicting observational studies. [18][19][20][21] In this issue, Benedetto and colleagues 22 performed a meta-analysis of 8 observational, propensity matched studies that specifically compared RITA to the RA as the second arterial conduit. Of the potential 15,374 patients (RITA, n ¼ 6739; RA, n ¼ 8635), matching resulted in 2992 pairs with a follow-up ranging from 45 to 168 months.…”

“…Other indirect evidence of bias in the original studies is that of the 15,374 patients studied, only 2992 well matched pairs were identified. Furthermore, Benedetto and colleagues 22 aggregated the hazard ratios and confidence intervals, whereas having individual patient level data would have been ideal for this research question. The statistical plan that was used requires that the original propensity matches were satisfactory and that the summary statistics adjusted for the matched nature of the data.…”

Radial artery and right internal thoracic artery: jousting for the throne of coronary artery bypass grafting

“…However, the RITA had a higher probability of being the best conduit (75% at rank probability analysis) and at ≥4 years followup, the RITA was associated with a non-significant 27% absolute risk reduction for functional graft occlusion compared to the RA. A meta-analysis of propensity-matched studies (PMS) (12) showed that the operative mortality was not different between the RA and RITA [odds ratio (OR) 1.53, P=0.07], but demonstrated a statistically significant 25% risk reduction of late death and a lower risk of repeat revascularization for the RITA when compared to the RA (HR 0.75, P=0.028 and 0.37, P=0.03 respectively). In a subsequent PMS study (13) comparing the RITA and RA as second arterial conduits in CABG, Benedetto and colleagues demonstrated a comparable mortality between the two groups during the first 4 years of follow-up (HR 1.00, P=0.98).…”