Yanagawa Bobby, Verma Subodh, Mazine Amine, Tam Derrick Y, Jüni Peter, Puskas John D, Murugavel Shamini, Friedrich Jan O
Division of Cardiac Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Division of Cardiac Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Int J Cardiol. 2017 Apr 15;233:29-36. doi: 10.1016/j.ijcard.2017.02.010. Epub 2017 Feb 5.
This meta-analysis compares total arterial revascularization (TAR) versus conventional coronary artery bypass and additionally to two arterial grafts.
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.
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; I=0%) and unmatched/unadjusted (incident rate ratio 0.67, 95% CI: 0.59-0.76, p<0.0001; I=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; I=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 (I=5%).
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.
本荟萃分析比较了全动脉血管重建术（TAR）与传统冠状动脉搭桥术，并额外对比了使用两支动脉移植物的情况。
我们检索了1996年至2016年的MEDLINE和EMBASE数据库，以查找比较TAR与非TAR用于多支血管手术血管重建的研究。数据由两名独立研究人员提取。荟萃分析采用随机效应模型，该模型纳入了异质性因素。
有4项随访时间较短的小型随机对照试验（RCT），以及15项匹配/调整和6项未匹配/未调整的随访时间较长的大型观察性研究符合纳入标准（N = 130305例患者；平均随访时间范围：1至15年）。围手术期卒中、心肌梗死或死亡率无差异。然而，在针对混杂因素进行匹配/调整的观察性研究中，TAR与较低的长期全因死亡率相关（发病率比0.85，95%可信区间：0.81 - 0.89，p < 0.0001；I² = 0%），在未匹配/未调整的研究中也是如此（发病率比0.67，95%可信区间：0.59 - 0.76，p < 0.0001；I² = 67%）。主要心血管结局和血管重建的降低未达到统计学意义。在匹配/调整的研究中，TAR的胸骨并发症更多（合并风险比1.21，95%可信区间：1.03 - 1.42，p = 0.02；I² = 0%）。与使用两支动脉移植物的患者相比，TAR仍与降低的长期全因死亡率相关（发病率比0.85，95%可信区间：0.73 - 0.99，p = 0.04），异质性最小（I² = 5%）。
主要来自观察性研究的数据表明，与传统冠状动脉搭桥术相比，TAR可能使长期生存率提高15%至20%，即使与使用两支动脉移植物的情况相比也是如此。需要进行长期随访的TAR前瞻性随机试验。
