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Meta-Analysis
. 2020 Oct 15;1(12):1437-1446.
doi: 10.34067/KID.0003502020. eCollection 2020 Dec 31.

Patency of ePTFE Arteriovenous Graft Placements in Hemodialysis Patients: Systematic Literature Review and Meta-Analysis

Ronald J Halbert  1 , Gina Nicholson  2 , Robert J Nordyke  2 , Alison Pilgrim  3 , Laura Niklason  3   4
Affiliations
Meta-Analysis

Patency of ePTFE Arteriovenous Graft Placements in Hemodialysis Patients: Systematic Literature Review and Meta-Analysis

Ronald J Halbert et al. Kidney360. .

Abstract

Arteriovenous grafts (AVGs) are an appropriate option for vascular access in certain hemodialysis patients. Expanded polytetrafluoroethylene (ePTFE) has become the dominant material for such grafts, due in part to innovations in graft design and surgical interventions to reduce complications and improve patency rates. Comprehensive evidence syntheses have not been conducted to update AVG performance in an era in which both access choice and ePTFE graft functioning may have changed. We conducted a systematic review and meta-analysis summarizing outcomes from recent studies of ePTFE AVGs in hemodialysis, following PRISMA standards. Literature searches were conducted in multiple databases to identify observational and interventional studies of AVG patency and infection risk. Primary, primary-assisted, and secondary patency rates were analyzed at 6, 12, 18, and 24 months postplacement. Kaplan-Meier graft survival plots were digitized to recreate individual patient-level data. Patency rates were pooled using a random effects model. We identified 32 studies meeting our selection criteria that were published from 2004 through 2019. A total of 38 study arms of ePTFE grafts were included, representing 3381 AVG accesses placed. The mean primary, primary-assisted, and secondary patency rates at 1 year were 41% (95% CI, 35% to 47%), 46% (95% CI, 41% to 51%), and 70% (95% CI, 64% to 75%), respectively. Mean 24-month patency rates were 28% (95% CI, 22% to 33%), 34% (95% CI, 27% to 41%), and 54% (95% CI, 47% to 61%), respectively. A high degree of heterogeneity across studies was observed. Overall risk of infection was not consistently reported, but among available studies the pooled estimate was 9% per patient-year (95% CI, 6% to 12%). This meta-analysis provides an up-to-date estimate of the performance of ePTFE AVGs, within the context of improved graft designs and improved interventional techniques.

Keywords: arteriovenous graft; dialysis; hemodialysis; infection; patency; renal dialysis; vascular access.

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Conflict of interest statement

R.J. Halbert, G. Nicholson, and R.J. Nordyke were employees of Beta6 Consulting Group at the time of this study, which received a grant from Humacyte. L.E. Niklason is a founder and shareholder in Humacyte, Inc., which is a regenerative medicine company. Humacyte, Inc. produces engineered blood vessels from allogeneic smooth muscle cells for vascular surgery. L.E. Niklason’s spouse has equity in Humacyte, Inc., and L.E. Niklason serves on Humacyte, Inc.’s Board of Directors. L.E. Niklason is an inventor on patents that are licensed to Humacyte, Inc. and that produce royalties for L.E. Niklason. L.E. Niklason has received an unrestricted research gift to support research in her laboratory at Yale. A. Pilgrim is a former employee and a stockholder of Humacyte, Inc.

Figures

Figure 1.
Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram. ePTFE, expanded polytetrafluoroethylene.
Figure 2.
Figure 2.
Forest plot of secondary patency at 12 months. 95% CI, 95% confidence interval; ES, effect size; KM, Kaplan–Meier.
Figure 3.
Figure 3.
Forest plot of secondary patency at 24 months.
Figure 4.
Figure 4.
Aggregate Kaplan–Meier curves for primary, primary assisted, and secondary patency.
Figure 5.
Figure 5.
Forest plot of infection rate per patient per year.
Figure 6.
Figure 6.
Subgroup meta-analyses of secondary patency at 12 and 24 months. Obs-Pro, observational prospective; Obs-Retro, observational retrospective; RCT, randomized controlled trial.
See this image and copyright information in PMC

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