RT Journal Article
SR Electronic
T1 Covered stents versus balloon angioplasty for failure of arteriovenous access: a systematic review and meta-analysis
JF BMJ Open
JO BMJ Open
FD British Medical Journal Publishing Group
SP e044356
DO 10.1136/bmjopen-2020-044356
VO 11
IS 6
A1 Ng, Benjamin
A1 Fugger, Magnus
A1 Onakpoya, Igho Jovwoke
A1 Macdonald, Andrew
A1 Heneghan, Carl
YR 2021
UL http://bmjopen.bmj.com/content/11/6/e044356.abstract
AB Introduction Patients 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.Aim To systematically review and meta-analyse the patency outcomes of covered stents in failing haemodialysis AV access, compared with balloon angioplasty.Methods The 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.Results We 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).Conclusion Our results support use of covered stents over angioplasty alone, at 6, 12 and 24 months in failing AVGs. Further clinical trials are warranted.Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. Our protocol is published on International Prospective Register of Systematic Reviews (CRD42018069955). Our search strategy is available as a supplementary document. Full analysis data on Review Manager are available from the corresponding author (benjamin.ng1@nhs.net).