Background There remains uncertainty regarding the second‐best conduit after the internal thoracic artery in coronary artery bypass grafting. Few studies directly compared the clinical results of the radial artery ( RA ), right internal thoracic artery ( RITA ), and saphenous vein ( SV ). No network meta‐analysis has compared these 3 strategies. Methods and Results MEDLINE and EMBASE were searched for adjusted observational studies and randomized controlled trials comparing the RA , SV , and/or RITA as the second conduit for coronary artery bypass grafting. The primary end point was all‐cause long‐term mortality. Secondary end points were operative mortality, perioperative stroke, perioperative myocardial infarction, and deep sternal wound infection ( DSWI ). Pairwise and network meta‐analyses were performed. A total of 149 902 patients (4 randomized, 31 observational studies) were included ( RA , 16 201, SV , 112 018, RITA, 21 683). At NMA , the use of SV was associated with higher long‐term mortality compared with the RA (incidence rate ratio, 1.23; 95% CI , 1.12–1.34) and RITA (incidence rate ratio, 1.26; 95% CI , 1.17–1.35). The risk of DSWI for SV was similar to RA but lower than RITA (odds ratio, 0.71; 95% CI , 0.55–0.91). There were no differences for any outcome between RITA and RA , although DSWI trended higher with RITA (odds ratio, 1.39; 95% CI , 0.92–2.1). The risk of DSWI in bilateral internal thoracic artery studies was higher when the skeletonization technique was not used. Conclusions The use of the RA or the RITA is associated with a similar and statistically significant long‐term clinical benefit compared with the SV . There are no differences in operative risk or complications between the 2 arterial conduits, but DSWI remains a concern with bilateral ITA when skeletonization is not used.

Background AngioVac is a new device for filtering intravascular thrombi and emboli. Publications on the device are limited and underpowered to objectively estimate its safety and efficacy. We aimed to overcome this by performing a meta‐analysis on the results of AngioVac for treating venous thromboses and endocardial vegetations. Methods A systematic literature review was performed to identify all articles reporting cardiac vegetation and/or thrombosis extraction using AngioVac. Endpoints were successful removal, operative mortality, conversion to open surgery, hospital stay, recurrent thromboembolism, and follow‐up mortality. Random effect model was used, and pooled event rates (PERs) and incidence rate (IR) were calculated. Results A total of 42 studies with 182 patients (81 vegetation and 101 thrombosis) were included. Overall mean follow‐up times were 3.1 and 0.7 years in vegetation and thrombosis patients, respectively. The PERs for successful removal were 74.5 (confidence interval [CI]: 48.2‐90.2), 80.5 (CI: 70.0‐88.0), and 32.4 (CI: 17.0‐52.8) in vegetation, right atrial/caval venous thrombi, and pulmonary emboli (PE) patients, respectively. The PERs for operative mortalities were 14.6 (CI: 7.7‐25.8), 14.8 (CI: 8.5‐24.5), and 32.3 (CI: 15.1‐56.3), respectively. The PERs for conversion to open surgery were 25.0 (CI: 9.3‐51.9) and 12.3 (CI: 5.4‐25.6) in vegetation and thrombosis patients, respectively. The IR of recurrent thromboembolism was 0.18 per person per year (PPY) (CI: 0.00‐14.69) in vegetation and 0.19 PPY (CI: 0.08‐0.48) in thrombosis patients. IR of follow‐up mortality was 0.37 PPY (CI: 0.11‐1.21) in thrombosis patients. Conclusions AngioVac is a viable option for extracting right‐sided vegetations and right atrial/caval venous thrombi. Rates of successful extraction and mortality are significantly worse for PE.

Objective: Individual studies may be limited by sample size to detect differences in late survival between radial artery (RA) or saphenous vein graft (SVG) as a second conduit for coronary artery bypass surgery. Here we undertook a meta-analysis of the best evidence available on the comparison of early and late clinical outcomes of the RA and the SVG.Methods: MEDLINE and EMBASE were searched for studies comparing use of the RA versus SVG for isolated coronary artery bypass surgery. Time-to-event outcomes for long-term mortality, repeat revascularization, and myocardial infarction (MI) were extracted as incidence rate ratios (IRR) with 95%confidence intervals (95% CI). Odds ratios (OR) were extracted for perioperative mortality, stroke, and MI. A random effects meta-analysis was performed. Sensitivity analyses included leave-one-out-analyses and meta-regression.Results: Among 1201 articles, 14 studies (20,931 patients) were included (mean follow-up: 6.6 years). Operative mortality was 1.25% in the RA versus 1.33% in the SVG group (OR, 0.93; 95% CI, 0.68-1.28). No difference in perioperative MI (OR, 0.96; 95% CI, 0.59-1.56) or stroke (OR, 0.70; 95% CI, 0.43-1.13) was found between RA and SVG. Long-term mortality (mean follow-up 6.6 years) was 24.5% in RA versus 34.2% in SVG group (IRR, 0.74; 95% CI, 0.63-0.87, P <.001). No difference in follow-up MI or repeat revascularization was found (IRR, 0.76; 95% CI, 0.42-1.36 and IRR, 0.68; 95% CI, 0.42-1.09 respectively). At meta-regression, RA survival advantage was independent of age, sex, diabetes, and ventricular function.Conclusions: Compared with the SVG, using the RA as the second conduit is associated with a 26% relative risk reduction in mortality at 6.6-year follow-up.

RB significantly increases in-hospital mortality and morbidity after cardiac surgery.

Background The debate on the relative benefits of off‐pump and on‐pump coronary artery bypass surgery ( OPCABG and ONCABG ) is still open. We aimed to provide an updated and complete summary of the evidence on the differences between OPCABG and ONCABG and to explore whether the length of the follow‐up and the surgeons’ experience in OPCABG modify the comparative results. Methods and Results All randomized clinical trials comparing OPCABG and ONCABG were included. Primary outcome was follow‐up mortality. Secondary outcomes were operative mortality, perioperative stroke, perioperative myocardial infarction, and late repeated revascularization. Subgroup analyses were performed based on the length of the follow‐up and the percentage of crossover from the OPCABG group (used as a surrogate of surgeon experience with OPCABG ). One hundred four trials were included (20 627 patients, OPCABG : 10 288; ONCABG : 10 339). Weighted mean follow‐up time was 3.7 years (range 1–7.5 years). OPCABG was associated with a higher risk of follow‐up mortality (incidence rate ratio 1.11, 95% confidence interval 1.00–1.23, P =0.05). The difference was significant only for trials with mean follow‐up of ≥3 years and for studies with a crossover rate of ≥10%. There was a trend toward lower risk of perioperative stroke and higher need for late repeated revascularization in the OPCABG arm. Conclusions OPCABG is associated with a higher incidence of incomplete revascularization, an increased need for repeated revascularization, and decreased midterm survival compared with ONCABG . Surgeon inexperience in OPCABG is associated with late mortality.