Endoscopic versus open radial artery harvesting for coronary artery bypass grafting: an updated systematic review, meta-analysis, and GRADE assessment

Background: Endoscopic radial artery harvesting (ERAH) is a minimally invasive alternative to open radial artery harvesting (ORAH) for coronary artery bypass grafting (CABG), though concerns persist regarding graft patency and neurological outcomes. Methods: PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched through February 21, 2026. Randomized controlled trials and propensity-matched observational studies were included. Risk of bias was assessed using ROB 2 and the Newcastle-Ottawa Scale; certainty of evidence was evaluated using GRADE. Pooled risk ratios and mean differences with 95% confidence intervals were calculated using a random-effects model. Results: ERAH significantly reduced wound complications (RR = 0.61, 95% CI: 0.39–0.96) and wound infections (RR = 0.57, 95% CI: 0.35–0.93), though this benefit did not persist in RCT-only analysis. Neurological complications were reduced after sensitivity analysis (RR = 0.44, 95% CI: 0.34–0.57). Graft patency was comparable (RR = 1.01, 95% CI: 0.90–1.14), with no significant differences in mortality, MACCE, or myocardial infarction. Observational data showed modest reductions in cardiopulmonary bypass time and hospital stay. Conclusions: ERAH demonstrates comparable graft patency and major clinical outcomes to ORAH. Donor-site benefits suggested by observational studies are not consistently supported by randomized evidence. Large trials with standardized outcomes and long-term follow-up are needed. Trial registration: PROSPERO, CRD420261334767.