Endovascular Versus Surgical Arteriovenous Fistulas: A Systematic Review and Meta-analysis

Rationale & Objective: To facilitate the process of dialysis for patients with kidney failure, an arteriovenous fistula (AVF) is created using either a surgical or percutaneous approach. We sought to compare the efficacy and procedural outcomes in creating an AVF percutaneously using Ellipsys (Avenu Medical) or WavelinQ (Becton Dickinson Medical) with surgery in all patients with kidney failure requiring a permanent AVF for dialysis. Study Design: Systematic review and meta-analysis. Setting & Study Populations: All patients requiring a permanent AVF for dialysis. Selection Criteria for Studies: We included studies that compared either the Ellipsys device or WavelinQ directly with surgery to create an AVF for long-term dialysis. Data Extraction: Two reviewers independently reviewed the studies and extracted the data. Conflicts were resolved with a discussion and approval from the senior author. Analytical Approach: Fixed-effects or random-effects models were used to pool the fixed sizes and 95% CIs based on the level of heterogeneity. Results: There was no statistically significant difference observed between surgical AVF and endovascular AVF when comparing the primary outcomes of procedural success (OR = 1.44; 95% CI, 0.35, 5.88; P = 0.61; I-2 = 0%), complications (OR = 0.28; 95% CI, 0.06, 1.46; P = 0.13; I-2 = 69%), and the secondary outcomes of interest that included follow-up time (mean difference [MD] = -17.71; 95% CI, -189.53, 154.12; P = 0.84; I-2 = 94%), failure rate (OR = 1.03; 95% CI, 0.21, 5.13; P = 0.97; I-2 = 85%), and time to 2-needle cannulation (MD = -5.40; 95% CI, -38.88, 28.08; P = 0.75; I-2 = 0%). However, a statistically significant difference was seen among the 2 groups for procedural time (MD = -54.25; 95% CI, -59.78, -48.71; P < 0.001; I-2 = 98%), number of interventions needed to maintain patency (OR = 1.73; 95% CI, 1.22, 2.45; P < 0.01; I-2 = 94%), and primary patency rate (OR = 0.34; 95% CI, 0.23,0.52; P < 0.001; I-2 = 0%). Limitations: The total number of studies included in this review was limited, with 3 of the 4 included studies being retrospective and only 1 being prospective. There was a lack of heterogeneity and randomization. Conclusions: Percutaneous fistula creation using Ellipsys or WavelinQ is a unique and safe alternative with outcomes comparable to surgery. Future studies are needed, including observational studies in current clinical practice, to evaluate the efficacy and outcomes of endovascular AVF creation in clinical populations.