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: 1–15 years). 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.