Repair of Aneurysmal Arteriovenous Fistulae: A Systematic Review and Meta-analysis

Abstract

WHAT THIS PAPER ADDSThe present study brings important additional information to current aneurysmal access guidelines.Objective: Aneurysms arising from arteriovenous fistulae are a common finding among dialysed patients and pose a risk of acute bleeding. The aim of this study was to perform a systematic review and meta-analysis evaluating the surgical options for the treatment of aneurysmal arteriovenous fistulae. Methods: A systematic review and meta-analysis of articles published between January 1973 and March 2019 describing the surgical treatment of arteriovenous fistulae aneurysms. Results: A total of 794 records were identified. After duplicate and low quality studies were removed, 72 full text articles were reviewed and from these 13 were included in the meta-analysis. The total number of patients was 597. Aneurysms were located in the upper arm in 289 (59%) cases and the smallest diameter of a treated aneurysm was 15 mm. The most frequent indication for treatment was bleeding prevention in 513 (86%) cases. Aneurysmorrhaphy was the surgical method of choice in all 13 studies. The pooled primary patency at 12 months was 82% (95% CI 69%e90%, 12 studies, I 2 ¼ 84%, p < .01). The 12 month primary patency rates were similar for aneurysmorrhaphy with external prosthetic reinforcement (85%, 95% CI 71%e93%, two studies, I 2 ¼ 0%, p ¼ .33) and aneurysmorrhaphy performed using a stapler (74%, 95% CI 61%e83%, four studies, I 2 ¼ 0%, p ¼ .48) and without a stapler (82%, 95% CI 60%e94%, six studies, I 2 ¼ 92%, p < .01). Conclusion: Aneurysmorraphy of arteriovenous fistulae is a procedure with acceptable short and long term results, with a low complication and aneurysm recurrence rate.

Hybrid procedures in the dialysis fistula aneurysm treatment

“…Slightly better results were obtained after aneurysmorraphy -partial resection of the aneurysm sac, with the 12-month primary patency rate 50-93%. 12,13 Aneurysmorraphy could be regarded as the preferred option for dialysis fistula aneurysm treatment according to literature 14 and due to the character of native material in comparison with a prosthesis. However, we preferred to excise dialysis fistula aneurysm and use bypass prosthesis instead of aneurysmorraphy in our hybrid procedure because of frequent significant elongations and kinking of dialysis fistula observed in studied patients.…”

Aneurysm Excision With Arteriovenous Anastomosis Proximalization for Dialysis Fistula Aneurysm Treatment

“…Dialysis fistula aneurysm formation is a quite frequent complication. 7 The aneurysmorrhaphy–partial longitudinal aneurysm resection and remodeling or excision of the aneurysms with the implantation of a prosthesis are the most often used methods as treatment of dialysis fistula aneurysms. Our research indicates, that in some cases it is possible to perform aneurysm excision with arteriovenous anastomosis proximalization.…”

“…In a recently published meta-analysis pooled 12-months aneurysmorrhaphy primary patency was 82%. 7 In addition to the undoubted advantages of aneurysmorrhaphy—all-native vessel reconstruction without the use of a vascular prosthesis and good long-term patency, its major disadvantages must be noted. First, to correct the concurrent stenosis that often causes an aneurysm, additional reconstruction and sutures lines are necessary.…”

“…The second commonly used method dialysis fistula aneurysm resection with prosthesis bypass usually has worse long-term patency with 12-months primary patency less than 60%, 11 mainly due to complications related to vascular prosthesis implantation–neointimal hyperplasia, infections. Aneurysmorrhaphy is regarded as the preferred option for dialysis fistula aneurysm treatment according to literature, 7 due to better patency rate and reconstruction with solely native vessels. However, we are of the opinion that if dialysis fistula aneurysm reconstruction can be performed by aneurysm excision and proximalization of arteriovenous anastomosis, such an option should be considered as the treatment of choice.…”

“…A recent meta-analysis indicates better results of aneurysmorrhaphy compared to resection with prosthetic bypass. 7 In some cases of short dialysis fistula aneurysms, it is possible to perform primary reconstruction by the aneurysm excision and proximalization of the arteriovenous anastomosis. This kind of reconstruction has significant advantages—no prosthesis, short lines of vascular anastomoses.…”