title: Impact of total arterial revascularization on long term survival: A systematic review and meta-analysis of 130,305 patients.
abstract: OBJECTIVE
  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.
authors.affiliation: Division of Cardiac Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. Electronic address: yanagawab@smh.ca.
authors.forename: Bobby
authors.initials: B
authors.lastname: Yanagawa
authors.affiliation: Division of Cardiac Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Subodh
authors.initials: S
authors.lastname: Verma
authors.affiliation: Division of Cardiac Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Amine
authors.initials: A
authors.lastname: Mazine
authors.affiliation: Division of Cardiac Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Derrick Y
authors.initials: DY
authors.lastname: Tam
authors.affiliation: Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Jüni
authors.affiliation: Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: John D
authors.initials: JD
authors.lastname: Puskas
authors.affiliation: Division of Cardiac Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Shamini
authors.initials: S
authors.lastname: Murugavel
authors.affiliation: Critical Care and Medicine Departments, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jan O
authors.initials: JO
authors.lastname: Friedrich
mesh_terms: D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000379:methods*; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000601:surgery*; D005500:Follow-Up Studies; D014943:Global Health; D006801:Humans; D009204:Myocardial Revascularization / Q000379:methods*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors
keywords: Coronary artery bypass graft; Graft patency; Total arterial revascularization