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