Impact of total arterial revascularization on long term survival: A systematic review and meta-analysis of 130,305 patients.

OBJECTIVES: This meta-analysis compares total arterial revascularization (TAR) versus conventional coronary artery bypass and additionally to two arterial grafts. METHODS: We searched MEDLINE and EMBASE Databases from 1996-to-2016 for studies comparing TAR versus non-TAR for multi-vessel surgical revascularization. Data were extracted by 2 independent investigators. Meta-analysis used random effects, which incorporates heterogeneity. RESULTS: There were 4 smaller shorter follow-up randomized controlled trials (RCTs), plus 15 matched/adjusted and 6 unmatched/unadjusted larger longer follow-up observational studies that met inclusion criteria (N=130.305 patients; mean follow-up range: 1-15years). There were no differences in perioperative stroke, myocardial infarction or mortality. However, TAR was associated with lower long term all-cause mortality in observational studies matched/adjusted for confounders (incident rate ratio 0.85, 95% CI: 0.81-0.89, p<0.0001; I2=0%) and unmatched/unadjusted (incident rate ratio 0.67, 95% CI: 0.59-0.76, p<0.0001; I2=67%) for TAR. Decreases in major cardiovascular outcomes and revascularization did not achieve statistical significance. There were greater sternal complications with TAR in the matched/adjusted studies (pooled risk ratio 1.21, 95% CI: 1.03-1.42, p=0.02; I2=0%). When compared to patients with two arterial grafts, TAR was still associated with reduced long-term all-cause mortality (incident rate ratio 0.85, 95% CI: 0.73-0.99, p=0.04) with minimal heterogeneity (I2=5%). CONCLUSIONS: Data from primarily observational studies suggest that TAR may improve long-term survival compared with conventional coronary bypass by 15-20% even when compared with two arterial grafts. Prospective randomized trials of TAR with long term follow-up are needed.