Patency and Maturation Rates after Forearm Arteriovenous Fistulas: Systematic Review with Meta-analysis

Abstract

BACKGROUND The growing burden of Chronic Kidney Disease has significantly increased the demand for hemodialysis, with reliable vascular access being vital for treatment success. Although the radiocephalic arteriovenous fistula (RCAVF) remains the first option as a long term hemodialysis access, substantial challenges related to aging patient population and prevalence of comorbidities may compromise maturation and durability. Therefore, this systematic review with meta-analysis aims to determine the patency and maturation rates of RCAVF, with a particular focus on how different patient characteristics and surgical methodologies impact these rates. MATERIALS AND METHODS Three electronic databases (Pubmed, Web of Science and Cochrane) were used to search for studies assessing the patency and maturation rates of RCAVF. Primary and secondary patency rates, as well as incidence of maturation failure, early-thrombosis, aneurysm degeneration, infection, and local reintervention were pooled by random-effects meta-analysis, with sources of heterogeneity being explored by meta-regression. Assessment of studies' quality was performed using National Heart, Lung, and Blood Institute (NHLBI) Study Quality Assessment Tool for observational cohorts and cross-sectional studies. RESULTS Thirty-six cohort studies were selected, with 15 of them being prospective. A total of 4584 participants were included, with a mean age of 52 years old, 65% being males. The meta-analytical incidence of maturation failure was 24.7% at the end of follow-up, with high levels of heterogeneity. Regarding primary patency rates the meta analytical incidence at 30 days, and at 1, 2, and 3 years after fistula creation was 84.18%, 68.43%, 59.86% and 55.10%, respectively. Additionally, the meta-analytical incidence of secondary endpoints like infection, aneurysm degeneration, early-thrombosis and reintervention rates was 3,9%, 3,6%, 6,3% and 20,1%, respectively. All the variables previously referred had high levels of heterogeneity associated. Furthermore, meta-regression analysis identified previous vascular access construction and latero-lateral anastomosis as factors associated with higher maturation failure rates, while no significant associations were found with patient demographics, comorbidities, vessel diameters or fistula location. CONCLUSION This systematic review and meta-analysis reveals a maturation failure rate of 24,7% despite substantial variability among studies. The wide range of reported maturation failure rates, as well as the significant heterogeneity observed in primary patency, infection, thrombosis, aneurysm degeneration, and local reintervention rates, highlight the complexity of RCAVF management. These findings underline the need for standardized clinical practices and further large-scale studies to identify factors influencing RCAVF outcomes, which will be crucial for improving patient care and addressing the high variability observed in this analysis.