Approaches to improve 12-month circuit primary patency and target lesion primary patency in arteriovenous fistulae: An umbrella review of systematic reviews and meta-analyses

Abstract

Background:

Clinical practice guidelines endorse arteriovenous fistulae (AVF) as the preferred form of vascular access. Despite recent advancements, concerns persist regarding variable AVF patency rates. This umbrella review aimed to evaluate and synthesize evidence on interventions and strategies associated with improved 12-month patency rates in AVF.

Methods:

Systematic review and meta-analyses of randomized control trials (RCTs) providing data regarding primary patency (PP) and target-lesion primary patency (TLPP) of AVF (not grafts) were included. Covidence was used for screening and data extraction, while the AMSTAR-2 rating assessed the methodological quality. Credibility assessment followed Papatheodorou’s criteria. Medline, EMBASE, CENTRAL and CINAHL were searched using a bespoke search strategy from inception to December 2024.

Results:

Twenty-two reviews that included 136 RCTs involving 13,522 patients were included in the final review. Highly suggestive evidence supports functional end-to-side anastomosis (effect estimate (EE) 1.7) for improving PP. Drug-coated balloon angioplasty (DCB) showed varied results across nine reviews, with effect estimates ranging from 0.49 to 2.47. For TLPP, one review reported significant improvement (EE 2.47, 95% CI 1.53-3.99). Suggestive evidence favours flow-based access monitoring (RR 0.51-0.66), antithrombotic medication (EE 0.53), antiplatelet therapy (EE 0.54), far infrared therapy (EE 1.24-1.27) and pre-emptive correction of ‘at-risk’ AVF (EE 0.5) for prolonging PP. Button hole cannulation and side-to-side anastomosis showed mixed or non-significant results. Heterogeneity varied widely across reviews, ranging from 0% to 81%, and AMSTAR-2 ratings ranged from moderate to high.

Conclusion:

This umbrella review synthesizes evidence on interventions for AVF patency, revealing varying levels of support for different strategies and highlighting areas requiring further investigation.