One-stage vs two-stage brachio-basilic arteriovenous fistula for dialysis access: a systematic review and a meta-analysis

Introduction: A brachiobasilic arteriovenous fistula (BB-AVF) can provide access for haemodialysis in patients who are not eligible for a more superficial fistula. However, it is unclear whether one or two stage BB-AVF is the best option for patients. Aim: To systematically assess the difference between both procedures in terms of access maturation, patency and postoperative complications. Methods: Online search for randomised controlled trials (RCTs) and observational studies that compared the one-stage versus the twostage technique for creating a BB-AVF. Results: Eight studies were included (849 patients with 859 fistulas), 366 created using a one stage technique, while 493 in a two stage approach. There was no statistically significant difference between the two groups in the rate of successful maturation (pooled risk ratio = 0.95 [0.82, 1.11], P = 0.53). Similarly, the incidence of postoperative haematoma (pooled risk ratio = 0.73 [0.34, 1.58], P = 0.43), wound infection (pooled risk ratio = 0.77 [0.35, 1.68], P = 0.51) and steal syndrome (pooled risk ratio = 0.65 [0.27, 1.53], P = 0.32) were statistically comparable. Conclusion: Although more studies seem to favour the 2-stage BVT approach, evidence in the literature is not sufficient to draw a final conclusion as the difference between the 1-stage and the 2-stage approaches for creation of a BB-AVF is not statistically significant in terms of the overall maturation rate and postoperative complications. Patency rates (primary, assisted primary and secondary) were comparable in the majority of studies. Large randomised properly conducted trials with superior methodology and adequate sub-group analysis are needed before making a final recommendation