Patency and adverse outcomes of sequential vs. individual saphenous vein grafts in coronary artery bypass: A meta-analysis

Abstract

Objectives: To undertake a systematic review and meta-analysis of cohort studies to compare the patency and adverse outcomes of sequential and individual saphenous vein grafts (SVGs) in coronary artery bypass grafting (CABG).

Methods: We searched PubMed, Embase, and the Cochrane Library for cohort studies. Endpoints for vein graft failure, perioperative and follow-up adverse events were extracted as risk ratio (RR) with 95% confidence intervals (95% CI). Statistical heterogeneity across the studies was examined using the I² statistic. Potential of publication bias was evaluated quantitatively by the Egger's test. Sensitivity analysis was also performed to assess the robustness of our outcomes.

Results: The 15 studies were analyzed, including 22,004 patients, 4,580 grafts, and seven different adverse events under individual or sequential CABG. The sequential group had inferior graft failure (RR = 0.68; 95% CI, 0.60-0.77) and long-term mortality (RR = 0.76; 95%CI, 0.61-0.95), but with an increased risk of perioperative repeat revascularization (RR = 1.58; 95%CI, 1.16-2.14) than the individual group.

Conclusion: Taken together, our analysis of the aggregated evidence comparing the sequential and individual saphenous vein grafts for coronary heart disease patients showed that the use of the sequential graft was associated with inferior graft failure and long-term mortality respectively, but with an increased risk of perioperative repeat revascularization. According to our study, both surgical techniques have their own advantages in efficacy and safety, and the selection of surgical techniques should be based on patients and surgeons. Sequential saphenous vein grafts should be more recommended to experienced surgeons in order to both reduce perioperative adverse events and improve long-term patency.

Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022326992.

Keywords: all-cause mortality; coronary artery bypass graft; graft failure; individual; revascularization; sequential.

Figure 1

MeSH search terms used when searching databases.

Figure 2

Study selection flow diagram.

Figure 3

Forest plot for graft failure. Nine studies reported the failure of the saphenous vein grafts, revealing that sequential group (16.2%) was associated with a significantly lower risk of graft failure (RR = 0.68; 95% CI, 0.60–0.77, P < 0.001) compared with individual group (20.6%).

Figure 4

Sensitivity analysis for graft failure (Leave-one-out analysis). By sequentially eliminating each study from nine studies reporting graft failure, sensitivity analysis showed that no particular study could largely influence the result.

Figure 5

Forest plot for perioperative repeat revascularization. Three studies reported perioperative repeat revascularization, revealing that sequential group (1.5%) was associated with a significantly higher risk of perioperative repeat revascularization (RR = 1.58; 95% CI, 1.16–2.14, P = 0.003) compared with individual group (0.7%).

Figure 6

Forest plot for long-term mortality. Three studies reported long-term mortality (>5 years), with a high statistical heterogeneity between the included studies (I² = 86%, P = 0.0006). By using a random-effect model, results revealed that sequential group (16.8%) was with a lower risk of long-term mortality (RR = 0.76; 95% CI, 0.61–0.95, P = 0.01) compared with individual group (23.9%).