Covered stents versus balloon angioplasty for failure of arteriovenous access: a systematic review and meta-analysis

Abstract

IntroductionPatients with end-stage renal disease may require arteriovenous (AV) access in the form of arteriovenous fistulae (AVFs) or arteriovenous grafts (AVGs) for haemodialysis. AV access dysfunction requires intervention such as plain balloon angioplasty or covered stents to regain patency.AimTo systematically review and meta-analyse the patency outcomes of covered stents in failing haemodialysis AV access, compared with balloon angioplasty.MethodsThe review was first registered on the International Prospective Register of Systematic Reviews (CRD42018069955) before data collection. We searched six electronic databases to identify relevant randomised controlled trials (RCTs) up until August 2020, without language restriction. Two reviewers assessed the suitability and quality of studies for inclusion using the Consolidated Standards of Reporting Trials guidelines. We meta-analysed data using a random-effects model.ResultsWe included seven studies including 1147 patients in the systematic review, of which 867 had AVGs and 280 had AVFs. One study was an ongoing RCT. In the meta-analyses, we assessed patients with failing AVGs only. Overall risk of bias was moderate. Covered stents were associated with lower loss of patency versus angioplasty alone at 6, 12 and 24 months (OR 4.48, 95% CI 1.98 to 10.14, p<0.001; OR 4.07, 95% CI 1.74 to 9.54, p=0.001; OR 2.24, 95% CI 1.17 to 4.29, p=0.01, respectively). Covered stents afforded superior access circuit primary patency compared with angioplasty alone at 6 and 12 months (OR 1.91, 95% CI 1.31 to 2.80, p<0.001; OR 1.97, 95% CI 1.14 to 3.41, p=0.02, respectively). This was not significant at 24 months. There was no significant difference in loss of secondary patency between groups at 12 or 24 months (OR 0.74, 95% CI 0.45 to 1.23, p=0.25; OR 0.67, 95% CI 0.29 to 0.154, p=0.34, respectively).ConclusionOur results support use of covered stents over angioplasty alone, at 6, 12 and 24 months in failing AVGs. Further clinical trials are warranted.

Longitudinal micro‐incision creation prior to balloon angioplasty for treatment of arteriovenous access dysfunction in a real‐world patient population: 6‐month cohort analysis

“…21 Supporting Information Table S1 summarizes the literature comparison results. 6,[20][21][22][23] The observation of comparable target lesion primary patency in the FLEX-AV registry relate to those reported by RCTs is remarkable given that inclusion criteria for RCTs are more stringent than those for this allcomers registry. Thus, the results provide reinforcement for the benefit of FLEX VP prior to PTA for vascular access treatment.…”

“…6,[19][20][21][22] Ng et al reviewed seven studies that reported a cumulative 1147 subjects (867 AVGs, 280 AVFs) with a range of target lesion patency at 6 months of 8%-34% for subjects treated with PTA. 20 Liao et al conducted a meta-analysis of 11 RCTs PTA in AVF that pooled 976 subjects and reported 6-month patency of 51.7% (236/489) for a PTA cohort. 6 A study by Hu et al conducted a meta-analysis of 18 RCTs of DCB versus PTA in AVF that pooled 1898 subjects with the PTA cohort associated with a 6-month primary patency of 58.6% (499/851).…”

“…There have been recent meta-analyses that pool results of multiple randomized control trials (RCTs) that assess outcomes of stand-alone PTA to treat dysfunctional AV access. 6,[19][20][21][22] Ng et al reviewed seven studies that reported a cumulative 1147 subjects (867 AVGs, 280 AVFs) with a range of target lesion patency at 6 months of 8%-34% for subjects treated with PTA. 20 Liao et al conducted a meta-analysis of 11 RCTs PTA in AVF that pooled 976 subjects and reported 6-month patency of 51.7% (236/489) for a PTA cohort.…”

Cephalic arch restenosis rates in hemodialysis patients with brachiocephalic fistulae: a retrospective multicenter analysis of 3301 patients

“…These include stents, with stent grafts appearing to have the most favorable outcomes in our analysis. Stent grafts have also been previously shown to be more effective in the treatment of lesions in AVFs and AVGs, as compared to bare metal stents and angioplasty alone [ 12 – 15 , 21 – 23 ]. Stent grafts can be constructed from various materials (e.g.…”

Manual compression technique improves the success rate in the treatment of thrombosed aneurysmal arteriovenous fistula: A single‐center experience

“…The patency rate in our study was also similar to that in previous studies, which ranged from 67% to 82% patency at 3 months. 11,12,16 To improve AVF patency, many devices, including drug-coated balloons, 17 covered stents, 18 and drug-eluting stents, 19 have been developed and published, but more evidence is still needed. In addition, this study also analyzed the risk factors associated with patency and showed that aneurysm size, the use of drugs, and comorbidities were not associated with patency.…”