Shimamura Yoshinosuke, Kuniyoshi Yasutaka, Ueta Hiroshi, Miyauchi Takamasa, Yamazaki Hajime, Tsujimoto Yasushi
Nephrology, Teine Keijinkai Medical Center, Sapporo, JPN.
Pediatrics, Tsugaru Hoken Medical Kensei Hospital, Hirosaki, JPN.
Cureus. 2022 May 17;14(5):e25091. doi: 10.7759/cureus.25091. eCollection 2022 May.
An endovascular arteriovenous fistula is a recent technological advancement in hemodialysis vascular access. This systematic review and meta-analysis aimed to investigate the efficacy and safety of endovascular arteriovenous fistula (eAVF) creation compared with surgical arteriovenous fistula (sAVF) creation among patients with chronic kidney disease. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Clinical Trials.gov, and the WHO International Clinical Trials Registry Platform until May 2021 to perform meta-analyses using random-effects models. Pre-specified primary outcomes were fistula maturation, procedure-related complications, and patient satisfaction. Secondary outcomes were procedural technical success, procedure time, all adverse events, and medical expenditure. The risk of bias in non-randomized studies of the interventions assessment tool, and the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach were used to assess the quality of individual studies and the body of evidence, respectively. In seven studies including 860 patients, endovascular arteriovenous fistula creation had little to no effect on fistula maturation (odds ratio, 0.58; 95% confidence intervals, 0.05 to 6.91). Meta-analysis could not be performed for procedure-related complications and patient satisfaction due to insufficient data. For secondary outcomes, endovascular arteriovenous fistula resulted in a slight to no difference in procedural technical success (odds ratio, 0.69: 95% confidence intervals, 0.04 to 11.98) and all adverse events (odds ratio, 6.31; 95% confidence intervals, 0.64 to 62.22). Endovascular fistula creation incurred less medical expenditure than sAVF (mean difference, USD 12760; 95% confidence intervals, -19710 to -5820). Meta-analysis for procedure time was not performed because one of the studies had a critical risk of bias. All of these outcomes were of low certainty of evidence or very low certainty of evidence. There was limited evidence for supporting endovascular arteriovenous fistula creation over conventional surgical arteriovenous fistula creation for patients with chronic kidney disease. Multicenter randomized controlled trials are needed to confirm the efficacy and safety of eAVFs in selected populations.
血管内动静脉内瘘是血液透析血管通路方面一项最新的技术进展。本系统评价和荟萃分析旨在研究与外科动静脉内瘘（sAVF）相比，慢性肾脏病患者创建血管内动静脉内瘘（eAVF）的有效性和安全性。我们检索了Cochrane对照试验中心注册库（CENTRAL）、MEDLINE、EMBASE、ClinicalTrials.gov以及世界卫生组织国际临床试验注册平台，检索截至2021年5月的数据，使用随机效应模型进行荟萃分析。预先设定的主要结局为内瘘成熟、与手术相关的并发症以及患者满意度。次要结局为手术技术成功率、手术时间、所有不良事件以及医疗费用。采用干预评估工具的非随机研究中的偏倚风险，以及推荐分级、评估、制定与评价（GRADE）方法分别评估个体研究的质量和证据的整体质量。在纳入860例患者的7项研究中，创建血管内动静脉内瘘对内瘘成熟几乎没有影响（比值比，0.58；95%置信区间，0.05至6.91）。由于数据不足，无法对与手术相关的并发症和患者满意度进行荟萃分析。对于次要结局，血管内动静脉内瘘在手术技术成功率（比值比，0.69：95%置信区间，0.04至11.98）和所有不良事件（比值比，6.31；95%置信区间，0.64至62.22）方面导致的差异轻微或无差异。与sAVF相比，创建血管内动静脉内瘘产生的医疗费用更低（平均差值，12760美元；95%置信区间，-19710至-5820）。由于其中一项研究存在严重的偏倚风险，因此未对手术时间进行荟萃分析。所有这些结局的证据确定性均较低或非常低。对于慢性肾脏病患者，与传统外科动静脉内瘘相比，支持创建血管内动静脉内瘘的证据有限。需要开展多中心随机对照试验来证实eAVF在特定人群中的有效性和安全性。
