Clinical outcomes in various coronary artery bypass grafting techniques: A systematic review and network meta-analysis

Introduction: There are different coronary artery bypass grafting (CABG) techniques, conventional (C-CABG), minimally invasive (MI-CABG), and robotic (R-CABG), each with its respective advantages and drawbacks. This study aimed to compare all three techniques and their nine sub-technique variations to provide a reference for the clinical selection of the most suitable surgical approach. Methods: A systematic search was applied to seven databases to find observational studies or randomized controlled trials (RCTs) that compared outcomes between CABG techniques in patients. Critical appraisal of observational studies (Newcastle–Ottawa Scale) and RCTs (Cochrane Risk of Bias 2.0) was performed. We used frequentist network meta-analysis to rank and analyze the pooled odds ratios and mean differences of each intervention. Primary outcomes were mortality and complete revascularization, while the rest were secondary outcomes. The protocol was registered with the ID CRD42023480325. Results: A total of 132 studies with 779,773 patients were included. All three techniques were associated with comparable revascularization rates. However, in the comparison of the nine sub-techniques port access (PA)-CABG was associated with a significantly higher rate compared to C-ONCAB. R-CABG demonstrated the most favorable outcomes in terms of ICU stay, overall hospital stay, mortality, and ventilation time compared to MI-CABG and C-CABG. Additionally, R-CABG was associated with lower rates of wound infection, cerebrovascular accident, and renal failure. Both R-CABG and MI-CABG were associated with lower rates of non-sinus rhythm compared to C-CABG. While MI-CABG was associated with the highest reoperation rate. Conclusion: R-CABG suggested promising outcomes over MI-CABG and C-CABG. However, as this exploratory NMA was predominantly based on observational data, these findings should be regarded as a hypothesis-generating framework for future research. Clinicians should interpret results cautiously, prioritizing patient-specific factors and institutional experience until higher-level evidence emerges.