4. CONCLUSIONS
This network meta-analysis aimed to assess which CABG strategy provides
better graft patency and long-term outcomes. Results from 32 studies
with a total of 1191 cases demonstrated that CABG for KD is a safe
procedure with satisfying long-term outcomes.
Our systematic review and meta-analysis showed a low early mortality
after CABG in KD, ranging between 0 and 1%. The excellent efficacy of
surgical revascularization was also demonstrated by 10-year survival
rates above 90%, with a 3.5-4% rate of interventional procedures or
surgical re-interventions during the follow-up.
The choice of conduits in coronary artery surgery remains a debated and
controversial issue, and the following points should be considered
before CABG: the growth potential of the graft relative to the somatic
growth of the patient, particularly in the pediatric age; the expected
long-term patency of the graft, considering that the factors that may
influence long-term patency are the presence of competitive flow from
native the vessel or collaterals, further development of
atherosclerosis, and abnormal coronary artery structure and function at
the site of the anastomosis; the potential need for future
revascularization of other coronary artery branches; the choice between
arterial revascularization with internal thoracic artery, free
gastro-epiploic artery or free radial artery versus venous coronary
artery bypass grafting with saphenous vein.
Recently published guidelines recommended a tailored approach to
individual practice [61, 62]. The standard surgical strategy of
myocardial revascularization used in adult patients was not been
adequately studied in patients with KD, giving rise to numerous
speculations. The use of bilateral thoracic artery was appealing in
younger patients although diabetes, obesity, chronic obstructive disease
and female sex remained adverse factors and should be taken into serious
consideration even in adult patients. The radial artery represented a
valid alternative to the saphenous vein with encouraging medium to
long-term results. The right gastro-epiploic and inferior epigastric
arteries remain of limited application with less supporting evidence for
their usage in the adults. Allografts and artificial grafts are very
rarely, if ever, used. The choice of conduit should be addressed for
each patient or group of patients and balance anatomical criteria,
patient background, conduit availability and surgical expertise [18,
61, 62].
In the next future we could assist at a rising number of KD cases due to
the potential association with pediatric COVID-19 [63], for which it
is even more actual and important to know the better strategy of
treatment for coronary complications after KD.
To assess the latter, in this study we compared graft patency of ITA, SV
and other arteries (gastroepiploic artery and radial artery); and we
compared patients treated with arterial, venous and mixed (arterial plus
second venous graft) CABG to assess long-term mortality.
Our meta-analysis demonstrated that arterial conduits provided better
patency rates at 10 years follow-up, with ITAs as the first most
effective surgical options, when compared to SV. Arterial or mixed
(arterial plus second venous graft) CABG, as a surrogate for the use of
arterial conduits for revascularization, has been shown to be associated
with higher patient’s survival rates. This result complies with to the
superiority of the arterial grafts when used for surgical myocardial
revascularization for KD patients.
LIMITS OF THE STUDY. We have identified the following limits. Network
meta-analyses for early mortality, need of interventional procedures and
surgical re-interventions were not conducted. Randomized clinical trial
evidences for graft patency following CABG after KD were not published.
We pooled observational studies results on the topic, including not
adjusted comparative studies. This is a potential source of
underpowering that increases heterogeneity where there is variability
between patency results. Nevertheless, this systematic review and
meta-analysis represents an overview of the surgical myocardial
revascularization in Kawasaki disease and may represent a starting point
for further studies and refinement of the technique.
Meta-regression has not been applied. It is unlikely that this represent
a source of bias since young patients with few comorbidities have been
included in this review. However, it cannot certainly be excluded. Graft
patency were compared regardless of the territory of revascularization.
“Grey literature” was not investigated. Furthermore, as the included
studies were published between 1981 and 2019, improvements in patency
outcomes or long-term mortality could be expected to vary over time due
to operative and therapeutic improvements.
In conclusion, our results demonstrated that CABG in KD is a safe and
effective procedure, with an overall early mortality rate of 0.28%, a
rate of re-interventions at follow-up of 3.47% and 3.97% for
interventional and surgical procedures, respectively. The use of
arterial conduits was associated with better patency rates and lower
mortality at follow-up.
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FIGURES TITLES AND CAPTIONSFigure 1. Flow diagram of the literature selection process
Figure 2A. Forest plot for graft patency; 2B. Sucra plot for graft
patency showing rank probability analysis
Figure 3. League table for graft patency
Figure 4A. Forest plot for long-term mortality compared to SV; 4B. Sucra
plot for long-term mortality showing rank probability analysis