Effectiveness of total arterial revascularization…

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Twenty-one reports (3 RCTs; 18 observational reports from 15 cohorts; 18 unique cohorts; approximately 73,700 patients from 14 countries) were included. In non-randomised cohorts, TAR was associated with lower long-term all-cause mortality (5 independent estimates; HR 0.87, 95% CI 0.76-0.99; p = 0.041; I² = 35.4%), but the association lost significance after HKSJ adjustment (95% CI 0.71-1.06) and the prediction interval crossed unity (0.61-1.24). Randomised comparisons of arterial versus venous conduits to the second target showed no mortality difference (HR 0.93, 0.62-1.40; I² = 75.2%), although RAPCO-SV demonstrated fewer 15-year major adverse cardiac events (HR 0.71, 0.52-0.98). Across all seven estimates the pooled HR was 0.89 (0.78-1.03). Within the Australian and New Zealand registry, the benefit was consistent in men (HR 0.86) and women (0.82), in patients aged 70 years or older (0.87) and younger (0.80), but not demonstrable when LVEF was below 30% (0.87, 0.67-1.13). Early outcomes favoured TAR in small cohorts (in-hospital death/MACCE RR 0.35, 0.15-0.80), with shorter ventilation, intensive care and hospital stay. No small-study effect was detected (Egger p = 0.91). Certainty of evidence was low to very low.8–13 Discussion: The survival signal favouring TAR is modest, driven predominantly by one large binational registry, susceptible to residual confounding and surgeon-selection bias, and is not confirmed by randomised conduit trials; conversely, no signal of harm emerged, and arterial strategies appeared safe with favourable perioperative profiles in experienced centres. Benefit appears most plausible in patients with long life expectancy and high-grade non-LAD target stenoses.2,14,15 Conclusion: Contemporary evidence supports TAR as a safe strategy associated with a modest long-term survival advantage in observational data, but high-certainty proof of superiority over SVG-containing CABG is lacking. Individualised conduit selection by an experienced heart team is recommended pending adequately powered RCTs such as the Total Arterial (TA) Trial.1,3

Effectiveness of total arterial revascularization compared to saphenous vein graft in multivessel coronary artery bypass surgery : A systematic review of randomized controlled trials and primary studies

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