Multiple versus single arterial grafting in coronary artery bypass grafting: a meta-analysis of randomized controlled trials and propensity score studies

Abstract

Objectives: We conducted a meta-analysis of randomized controlled trials (RCTs) and propensity score (PS) observational studies comparing survival and major adverse cardiac and cerebrovascular events (MACCEs) of patients who underwent coronary artery bypass grafting with multiple versus single arterial grafting. Methods: MEDLINE and ISI Web of Science were used to find relevant literature (1960-2018). We included RCTs and PS cohort studies with at least 200 patients that reported survival at a mean follow-up ≥ 1 year. Follow-up MACCEs and early outcomes were also evaluated. Survival and MACCEs were collected through hazard ratio (HR) along with their variance, and the other endpoints using frequencies from matched sample or adjusted odds ratios. Random effect models were used to compute statistical combined measures and 95% confidence intervals (CI) through generic inverse variance method (time-to-event) or Mantel-Haenszel method (binary events). Results: Twenty-seven propensity score (PS) cohorts and 8 randomized controlled trials (RCT) comprising 106 053 patients (49 915 MAG and 56 138 SAG) were included in this meta-analysis. The mean follow-up time ranged from 1 to 16 years. MAG was associated with statistically significant lower risk for long-term mortality (HR: 0.76, 95%CI: 0.73-0.80, p<0.01) and MACCEs (HR: 0.84, 95%CI: 0.78-0.89, p<0.01), mainly within longer follow-up studies (> 10-years, HR survival: 0.72, CI95%: 0.67-0.78). MAG was also related to lower risk for early mortality (OR: 0.83, 95%CI: 0.72-0.98, p=0.02) although it significantly increased the risk of sternal wound complications, which is largely attributed to MAG with BIMA configuration (OR MAG BIMA: 2.0, 95%CI: 1.4-3.0). Conclusion: The use of MAG in coronary artery bypass grafting improve both long-term survival and MACCEs. Although it is associated with higher risk of sternal wound complications, MAG should be considered a safe option since it has lower early mortality rates, compared with SAG.