Effectiveness of Total Arterial Revascularization Compared to Saphenous Vein Graft in Multivessel Coronary Artery Bypass Surgery : A Systematic Review of Randomized Controlled Trials and Primary Studies

Introduction: Coronary artery bypass grafting (CABG) remains the preferred revascularisation strategy for complex multivessel coronary artery disease, yet the great saphenous vein graft (SVG) is still used in the vast majority of operations despite its progressive late attrition. Total arterial revascularization (TAR), the complete avoidance of SVG, has been proposed to eliminate vein-graft failure, but its superiority rests largely on observational data. This review synthesised contemporary (2021-2026) randomised and primary evidence comparing TAR, or arterial-for-venous conduit substitution, with SVG-containing CABG.1–3 Methods: The study strictly adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines. Randomised controlled trials (RCTs), prospective and retrospective cohort, case-control and cross-sectional studies comparing TAR (or an arterial conduit replacing SVG) with SVG-containing CABG in multivessel disease were eligible. Results: Twenty-one reports (3 RCTs; 18 observational reports from 15 cohorts; 18 unique cohorts; approximately 73,700 patients from 14 countries) were included. In non-randomised cohorts, TAR was associated with lower long-term all-cause mortality (5 independent estimates; HR 0.87, 95% CI 0.76-0.99; p = 0.041; I² = 35.4%), but the association lost significance after HKSJ adjustment (95% CI 0.71-1.06) and the prediction interval crossed unity (0.61-1.24). Randomised comparisons of arterial versus venous conduits to the second target showed no mortality difference (HR 0.93, 0.62-1.40; I² = 75.2%), although RAPCO-SV demonstrated fewer 15-year major adverse cardiac events (HR 0.71, 0.52-0.98). Across all seven estimates the pooled HR was 0.89 (0.78-1.03). Within the Australian and New Zealand registry, the benefit was consistent in men (HR 0.86) and women (0.82), in patients aged 70 years or older (0.87) and younger (0.80), but not demonstrable when LVEF was below 30% (0.87, 0.67-1.13). Early outcomes favoured TAR in small cohorts (in-hospital death/MACCE RR 0.35, 0.15-0.80), with shorter ventilation, intensive care and hospital stay. No small-study effect was detected (Egger p = 0.91). Certainty of evidence was low to very low.8–13 Discussion: The survival signal favouring TAR is modest, driven predominantly by one large binational registry, susceptible to residual confounding and surgeon-selection bias, and is not confirmed by randomised conduit trials; conversely, no signal of harm emerged, and arterial strategies appeared safe with favourable perioperative profiles in experienced centres. Benefit appears most plausible in patients with long life expectancy and high-grade non-LAD target stenoses.2,14,15 Conclusion: Contemporary evidence supports TAR as a safe strategy associated with a modest long-term survival advantage in observational data, but high-certainty proof of superiority over SVG-containing CABG is lacking. Individualised conduit selection by an experienced heart team is recommended pending adequately powered RCTs such as the Total Arterial (TA) Trial.1,3