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

Abstract

Background: 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.

Methods: 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.

Results: 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) 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.

Conclusions: With improved 2-year primary patency rates 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.

Keywords: Brachiobasilic arteriovenous fistulas; Brachiobasilic fistula; Transposed basilic vein arteriovenous fistula; end-stage renal disease.