Cardiovascular Medicine, University of Toledo Health Sciences, OH, USA.
Cardiothoracic Surgery, University of Toledo Health Sciences, OH, USA.
Am J Cardiol. 2020 Sep 1;130:46-55. doi: 10.1016/j.amjcard.2020.06.012. Epub 2020 Jun 16.
Observational studies and randomized controlled trials (RCTs) have shown conflicting outcomes for multiple arterial graft (MAG) coronary artery bypass graft surgery compared with single arterial grafts (SAGs). The predominant evidence supporting the use of MAGs is observational. The aim of this meta-analysis of RCTs is to compare outcomes following MAG and SAG. We searched multiple databases for RCTs comparing MAG versus SAG. The clinical outcomes studied were all-cause mortality, cardiac mortality, myocardial infarction (MI), revascularization, stroke, sternal wound complications, and major bleeding. We used hazard ratio (HR), relative risk (RR), and corresponding 95% confidence interval (CI) for measuring outcomes. Ten RCTs (6392 patients) were included. The average follow-up in the studies was 4.2 years. The average age of the patients in the studies ranged from 56.3 years to 74.6. No significant difference was seen between MAG and SAG groups for all-cause mortality (11.8% vs 12.7%, HR 0.94, 95% CI 0.81 to 1.09, p 0.36), cardiac mortality (4.1% vs 4.5%, HR 0.96 95% CI 0.74 to 1.26, p 0.77), MI (3.5% vs 5.1%, HR 0.87 95% CI 0.67 to 1.12, p 0.28), and major bleeding (3.3% vs 4.9%, RR 0.85 95% CI 0.64 to 1.13, p 0.26). Repeat revascularization in MAG showed a lower RR than SAG when one of the confounding studies was excluded (RR 0.63, 95% CI 0.4 to 0.99, p 0.04). The incidence of stroke was lower in MAG than SAG (2.9% vs 3.9%, RR 0.74 95% CI 0.56 to 0.98, p 0.03). MAG had higher incidence of sternal wound complications than SAG (2.9% vs 1.7%, RR 1.75 95% CI 1.19 to 2.55, p 0.004). In conclusion, MAG does not have a survival advantage compared with SAG but is better in revascularization and risk of stroke. This benefit may be set off by a higher incidence of sternal wound complications in MAG.
观察性研究和随机对照试验（RCT）已经显示出在多动脉移植物（MAG）冠状动脉旁路移植手术与单动脉移植物（SAG）相比存在相互矛盾的结果。支持使用 MAG 的主要证据是观察性的。本项对 RCT 的荟萃分析旨在比较 MAG 和 SAG 的结果。我们在多个数据库中搜索了比较 MAG 与 SAG 的 RCT。研究的临床结局包括全因死亡率、心源性死亡率、心肌梗死（MI）、血运重建、卒中和胸骨伤口并发症以及大出血。我们使用风险比（HR）、相对风险（RR）和相应的 95%置信区间（CI）来衡量结局。共纳入 10 项 RCT（6392 例患者）。研究中的平均随访时间为 4.2 年。研究中患者的平均年龄范围为 56.3 岁至 74.6 岁。MAG 和 SAG 组之间的全因死亡率（11.8%对 12.7%，HR 0.94，95%CI 0.81 至 1.09，p 0.36）、心源性死亡率（4.1%对 4.5%，HR 0.96，95%CI 0.74 至 1.26，p 0.77）、MI（3.5%对 5.1%，HR 0.87，95%CI 0.67 至 1.12，p 0.28）和大出血（3.3%对 4.9%，RR 0.85，95%CI 0.64 至 1.13，p 0.26）均无显著差异。排除一项混杂研究后，MAG 组的再次血运重建 RR 低于 SAG 组（RR 0.63，95%CI 0.4 至 0.99，p 0.04）。MAG 组的卒中发生率低于 SAG 组（2.9%对 3.9%，RR 0.74，95%CI 0.56 至 0.98，p 0.03）。MAG 组胸骨伤口并发症的发生率高于 SAG 组（2.9%对 1.7%，RR 1.75，95%CI 1.19 至 2.55，p 0.004）。总之，MAG 与 SAG 相比并没有生存优势，但在血运重建和卒中风险方面具有优势。这种益处可能被 MAG 中更高的胸骨伤口并发症发生率所抵消。
