Effectiveness of the various revascularization techniques in multivessel coronary artery disease: a systematic review with network meta-analysis.

BACKGROUND: Multivessel coronary artery disease (MVD) often requires revascularization. However, the effectiveness of various techniques in reducing stroke and achieving complete revascularization remains uncertain. This study aimed to address this gap by comparing key revascularization strategies in terms of early mortality, stroke, complete revascularization, postoperative atrial fibrillation (POAF), and renal failure. METHODS: This study is a systematic review and network meta-analysis of 32 studies including 65,861 patients. Five revascularization techniques were compared: on-pump coronary artery bypass (ONCAB), off-pump coronary artery bypass (OPCAB), OPCAB with proximal anastomotic device (OPCAB-PAD), anaortic OPCAB (anOPCAB), and percutaneous coronary intervention (PCI). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random effects model. Risk of bias was assessed using the RoB2 and ROBINS-I tools. RESULTS: Compared to ONCAB, early mortality was significantly lower with anOPCAB (OR: 0.57, 95% CI: 0.44-0.73), OPCAB-PAD (OR: 0.61, 95% CI: 0.40-0.92), and OPCAB (OR: 0.64, 95% CI: 0.47-0.87). Stroke risk was lowest with anOPCAB (OR: 0.29, 95% CI: 0.21-0.40) and OPCAB-PAD (OR: 0.32, 95% CI: 0.21-0.49). All surgical techniques achieved significantly more complete revascularization than PCI. Both POAF and renal failure were significantly lower with anOPCAB compared to ONCAB (POAF: OR: 0.72, 95% CI: 0.59-0.89; renal failure: OR: 0.63, 95% CI: 0.46-0.86). No significant publication bias was detected for mortality and stroke, though funnel plot asymmetry was noted for revascularization. CONCLUSION: Off-pump techniques, particularly anOPCAB, significantly reduce stroke risk while achieving comparable revascularization success to ONCAB. PCI remains limited by incomplete revascularization, supporting its use primarily in patients at high surgical risk.