Comparative efficacy and safety of four common balloon angioplasty techniques for an arteriovenous fistula or graft stenosis: a systematic review and network meta-analysis of randomized controlled trials

Abstract

Background: Balloon angioplasty could decrease restenosis of hemodialysis vascular access. The present study investigated the comparative effects and safety of commonly available balloon angioplasty techniques for treating patients with failing autogenous arteriovenous fistulas (AVFs) and grafts (AVGs) stenosis.

Methods: A comprehensive literature search, including an updated search of PubMed and Embase (via Ovid) and screening of published meta-analyses, was conducted. Primary patency at 6 and 12 months was the primary outcome, and the incidence of complications was the secondary outcome. The random-effects model was used to conduct all statistical analyses, which were performed using RevMan 5.3 and ADDIS 1.16.8.

Results: A total of 20 eligible studies involving four balloon angioplasty techniques were entered into the final analysis. Although the direct meta-analysis indicated that cutting balloon angioplasty (CtBA) significantly improved primary patency at 6 [odds ratio (OR), 1.91; 95% confidence interval (CI): 1.27 to 2.86] and 12 (OR, 1.56; 95% CI: 1.13 to 2.15) months compared with conventional balloon angioplasty (CBA), this was not supported by network meta-analysis, which suggested that CtBA was associated with a higher risk of complications compared with drug-coated balloon angioplasty (DcBA) [OR, 0.05; 95% credible interval (CrI): 0.00 to 0.83], high-pressure balloon angioplasty (HBA) (OR, 0.04; 95% CrI: 0.00 to 0.69), and CBA (OR, 0.11; 95% CrI: 0.02 to 0.59). Subgroup analysis of AVFs did not detect any significant differences.

Conclusions: In failing AVF and AVG stenosis, HBA might be a preferential option as it is related to a lower risk of complications and has numerically higher primary patency than DcBA and CBA. Further studies are needed to confirm these findings.

Keywords: Arteriovenous fistula (AVF); balloon angioplasty; cutting balloon; drug-coated balloon; high-pressure balloon.

Figure 1

PRISMA flow chart of identification and selection of studies.

Figure 2

Evidence structure plots of primary patency at 6 (A) and 12 (B) months, and the risk of complications (C). The accumulated sample size weighted the size of the circle size, and the accumulated number of eligible studies weighted the width of the line. CBA, conventional balloon angioplasty; CtBA, cutting balloon angioplasty; HBA, high-pressure balloon angioplasty; DcBA, drug-coated balloon angioplasty.

Figure 3

Pooled results and rankings of primary patency at 6 (A) and 12 (B) months, and the risk of complications (C). Data are shown as OR (95% CrI). A bold numerical value indicates statistical significance. TLPP, target lesion primary patency; CBA, conventional balloon angioplasty; CtBA, cutting balloon angioplasty; HBA, high-pressure balloon angioplasty; DcBA, drug-coated balloon angioplasty; n.a., not applicable; OR, odds ratio; CrI, credible interval.