Background: Total arterial revascularization (TAR) has gradually become
accepted and recognized, but its effect and safety in diabetic patients are not
clear. We performed a systematic review and meta-analysis to summarize the safety
and efficacy of TAR and additionally evaluated the clinical outcomes of arterial
revascularization using different arterial deployments in
patients with diabetes. Methods: PubMed, Embase, and the Cochrane
Library databases from inception to July 2022 for studies that studied the effect
of arterial revascularization in diabetic patients undergoing isolated coronary
artery bypass graft (CABG) were searched. The primary outcome was long-term
(12 months of follow-up) death by any cause. The secondary efficacy
endpoints were long-term (12 months) cardiovascular death, early sternal
wound infection (SWI) and death (30 days or in hospital). Risk ratios
(RRs), hazard ratios (HRs), and their corresponding 95% confidence intervals
(CIs) were calculated to describe short-term results and long-term survival
outcomes. Two different ways were used to analyze the effect of TAR and the
impact of diabetes on the clinical outcomes of TAR. Results: Thirty-five
studies were included in the study, covering 178,274 diabetic patients. Compared to conventional surgery with saphenous veins, TAR was not associated
with increased early mortality (RR 0.77, 95% CI 0.48–1.23) and risk of SWI (RR
0.77, 95% CI 0.46–1.28). The overall Kaplan–Meier survival curves based on
reconstructed patient data indicated a significant association between TAR and
reduced late mortality (HR 0.52, 95% CI 0.48–0.67) and the curves based on the
propensity-score matched (PSM) analyses suggested a similar result (HR 0.74,
95% CI 0.66–0.85). TAR could also effectively decrease the risk of
cardiovascular death (HR 0.42, 95% CI 0.24–0.75). Through comparing the effect
of TAR in patients with and without diabetes, we found that the presence of
diabetes did not elevate the risk of early adverse events (death: RR 1.50, 95%
CI 0.64–3.49; SWI: RR 2.52, 95% CI 0.91–7.00). Although diabetes increased
long-term mortality (HR 1.06; 95% CI 1.35–2.03), the cardiovascular death rate
was similar in patients with diabetes and patients without diabetes (HR 1.09;
95% CI 0.49–2.45). Regarding the selection of arterial conduits, grafting via
the bilateral internal mammary artery (BIMA) decreased the risk of overall death
(HR 0.67, 95% CI 0.52–0.85) and cardiovascular death (HR 0.55, 95% CI
0.35–0.87) without resulting in a significantly elevated rate of early death (RR
0.95, 95% CI 0.82–1.11). However, the evidence from PSM studies indicated no
difference between the long-term mortality of the BIMA group and that of the
single internal mammary arteries (SIMA) groups (HR 0.76, 95% CI 0.52–1.11), and
the risk of SWI was significantly increased by BIMA in diabetes (RR 1.65, 95% CI
1.42–1.91). The sub-analysis indicated the consistent benefit of the radial
artery (RA) application in diabetic patients (HR 0.71, 95% CI 0.63–0.79)
compared to saphenous vein graft. In two propensity-score-matched studies, the
evidence showed that the survival outcomes of the BIMA group were similar to that
of the SIMA plus RA group but that grafting via the RA reduced the risk of
sternal wound infection. Conclusions: Compared with conventional surgery
using SVG, TAR was associated with an enhanced survival benefit in diabetes and
this long-term gain did not increase the risk of early mortality or SWI. Given
the increased infection risk and controversial long-term survival gains of
grafting via the BIMA in diabetes, its wide use for grafting in this cohort
should be seriously considered. Compared to using the right internal
mammary artery (RIMA), RA might be a
similarly effective but safer option for patients with diabetes.
