A Systematic Review and Meta-Analysis of Randomized Trials Comparing Two-Stage with One-Stage Brachio-Basilic Vein Fistulas

Abstract

Purpose: There is currently debate if brachio-basilic vein fistula (BBVF) should be performed as a one-stage or two-stage procedure. The aim of the present study was to perform a systematic review and meta-analysis on BBVF staging.

Materials and methods: On February 25, 2016, a search for randomized-controlled trials (RCTs) on BBVF procedures was performed in MEDLINE and Scopus databases. Meta-analyses were performed with fixed-effect or random-effects models as appropriate with risk ratios (RRs). The primary efficacy and safety outcome measures were BBVF maturation and development of complications, respectively. Specific types of complications, including loss of functional secondary patency and long-term complications were all secondary outcome measures.

Results: We identified three RCTs reporting on 126 patients. Maturation failure of two-stage BBVFs (3/47, 6.4%) was less frequent than one-stage BBVFs (16/79, 20.3%; RR, 0.27; P=0.02). Complication rates of two-stage and one-stage BBVFs were similar (RR, 0.80; P=0.54), but on sensitivity analysis these were less likely to occur with two-stage BBVFs (37% vs. 69% for one-stage BBVFs; RR, 0.57; P=0.03). Two-stage BBVFs were less likely to lose their functional secondary patency (21.3% vs. 31.6% for one-stage BBVFs; RR, 0.61; P=0.11). This non-significant trend became significant (RR, 0.36; P=0.02) on sensitivity analysis. There was no difference in specific complication rates of the two study groups.

Conclusion: Among candidates for BBVF fistula, there is evidence to suggest that two-stage BBVFs achieve higher maturation rates compared to one-stage BBVFs. The evidence for difference in long-term secondary patency is less robust, calling for further research.

Keywords: Arteriovenous fistula; Brachio-basilic; Renal dialysis; Surgical technique.

Fig. 1

PRISMA flow diagram showing the selection process of suitable randomized controlled trials for meta-analysis.

Fig. 2

(A) Risk of bias graph and (B) summary demonstrating a low risk of bias in most attributes. Risk was high for performance bias of these surgery trials.

Fig. 3

(A) Two-stage brachio-basilic vein fistulas (BBVFs) achieved better early results (reduced maturation failures) and (B) long-term functional secondary patency (reduced abandonment rates) (C) compared to one-stage BBFV, however, long-term failure of one-stage BBVFs was similar with two-stage BBVFs after excluding early/maturation failures. RR, risk ratio; M-H, Mantel-Haenszel; CI, confidence interval; df, degrees of freedom.

Fig. 4

Results of sensitivity analysis are shown in this figure. (A) Maturation failure of one-stage brachio-basilic vein fistulas (BBVFs) was significantly worse compared to two-stage BBVFs and (B) similarly two-stage BBVFs were less likely than one-stage BBVFs to lose their functional secondary patency. (C) Long-term complications (excluding postoperative events) showed a non significant trend to occur more often with one-stage BBVFs than two-stage BBVFs, (D) however all complications were significantly more likely to occur with one-stage BBVFs compared to two-stage BBVFs. RR, risk ratio; M-H, Mantel-Haenszel; CI, confidence interval; df, degrees of freedom.