A systematic review and meta-analysis of one-stage versus two-stage brachiobasilic arteriovenous fistula creation

• Published in: Journal of vascular surgery 2018-07, Vol.68 (1), p.285-297
• Main Authors: Jun Yan Wee, Ian, Mohamed, Ismail Heyder, Patel, Amit, Choong, Andrew M.T.L.
• Format: Article
• Language: English
• Subjects: Adult; Aged; Arteriovenous Shunt, Surgical - adverse effects; Arteriovenous Shunt, Surgical - methods; Brachial Artery - surgery; Brachiobasilic arteriovenous fistulas; Brachiobasilic fistula; Chi-Square Distribution; end-stage renal disease; Female; Graft Occlusion, Vascular - etiology; Graft Occlusion, Vascular - physiopathology; Graft Occlusion, Vascular - therapy; Humans; Male; Middle Aged; Odds Ratio; Renal Dialysis; Risk Factors; Time Factors; Transposed basilic vein arteriovenous fistula; Treatment Outcome; Upper Extremity - blood supply; Vascular Patency; Veins - surgery
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2018.03.428

Long-term patency of arteriovenous fistulas (AVFs) is critical for hemodialysis vascular access. We compared the efficacy of a one-stage vs two-stage approach to brachiobasilic AVF creation by primarily investigating primary and secondary patency rates. We hypothesize that the two-stage is superior to the one-stage procedure in terms of efficacy and safety. This review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on MEDLINE, EMBASE, Google Scholar, and Cochrane Database. Risk of bias and quality assessment scores were both performed based on previously validated tool. The systematic search revealed a total of 242 publications for possible inclusion. On the basis of title and abstract review, two randomized controlled trials and nine case-cohort series fit our inclusion criteria. There were no statistically significant differences in failure rates (pooled risk ratio [RR], 1.10; 95% confidence interval [CI], 0.79-1.55; P = .25), 1-year primary patency rates (RR, 1.31; 95% CI, 0.83-2.06; P = .24), 1-year secondary patency rates (RR, 0.97; 95% CI, 0.54-1.77), 2-year primary patency rates (RR, 1.68; 95% CI, 0.99-2.83; P = .05), and 2-year secondary patency rates (RR, 1.19; 95% CI, 0.54-2.63; P = .67) between both groups. However, the two-stage procedure had significantly improved 2-year primary patency rates (RR, 2.50; 95% CI, 1.66-3.74; P < .00001). There were no differences in steal syndrome, hematoma, infection, pseudoaneuryms, or stenosis, although there was a trend toward an increased incidence of postoperative thrombosis (RR, 1.81; 95% CI, 0.95-3.45; P = .07) in one-stage procedures. With improved 2-year primary patency rates that trend toward statistical significance and the absence of significant differences in complications, this study suggests potential benefit of a two-stage over a one-stage procedure for brachiobasilic AVF creation. However, rather than being a definitive answer, our results merely highlight the continuing need for an adequately powered, well-designed, randomized controlled trial to interrogate this question further.