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Archivos Espanoles de Urologia Aug 2022Minimally invasive techniques for the treatment and diagnosis of kidney disease seek to preserve the greatest amount of parenchyma. Bleeding after these practices is...
UNLABELLED
Minimally invasive techniques for the treatment and diagnosis of kidney disease seek to preserve the greatest amount of parenchyma. Bleeding after these practices is rare, but must be treated quickly given its severity. Iatrogenic renal vascular injuries (IRVI) resulting from these procedures include active bleeding, arterial pseudoaneurysms, and arteriovenous fistulas. Renal artery embolization (RAE) is the main pillar in the treatment of this type of complications.
OBJECTIVE
To assess the results of RAE for the treatment of IRVI and its impact on the renal function of patients.
METHOD
Retrospective analysis of all patients who presented vascular complications after renal procedures and who were referred for management by RAE, between August 2012 and December 2020.
RESULTS
18 patients were included. 4 patients presented with pseudoaneurysm, 10 patients with active bleeding, and 1 patient with arteriovenous fistula; 2 patients had a combination of different IRVI; 1 patient did not present any findings at the time of renal angiography in dissonance with her computed tomography angiography. Technical and clinical success was achieved in all patients. One renal artery dissection was the only complication. No differences were found in serum creatinine ( = 0.51), urea ( = 0.37), hemoglobin ( = 0.26) and hematocrit ( = 0.24) after embolization.
CONCLUSION
EAR is a safe and effective method for the treatment of IRVI, achieving a very high technical and clinical success rate with a low incidence of complications and without significant repercussions on the renal function of patients.
Topics: Aneurysm, False; Arteriovenous Fistula; Creatinine; Embolization, Therapeutic; Endovascular Procedures; Female; Hemorrhage; Humans; Iatrogenic Disease; Kidney Diseases; Retrospective Studies; Treatment Outcome; Urea; Vascular System Injuries
PubMed: 36138501
DOI: 10.37554/es-j.arch.esp.urol-20210515-3507-27 -
Clinical Neuroradiology Sep 2022Endovascular treatment represents the first-line therapy for cavernous sinus dural arteriovenous fistulas (CS-dAVF); however, different approaches and embolic agents as... (Meta-Analysis)
Meta-Analysis
PURPOSE
Endovascular treatment represents the first-line therapy for cavernous sinus dural arteriovenous fistulas (CS-dAVF); however, different approaches and embolic agents as well as occlusion rates, complications and clinical outcomes are reported among the published series. In this study we performed a comprehensive meta-analysis to investigate clinical and radiological outcomes after endovascular treatment of CS-dAVFs.
METHODS
PubMed, Ovid Medline, Ovid EMBASE, Scopus, and Web of Science were screened for a comprehensive literature review from 1990 to 2020 regarding series of patients treated for CS-dAVF with endovascular approaches. We performed a proportion meta-analysis estimating the pooled rates of each outcome also including data of patients treated in our center.
RESULTS
A total of 22 studies reporting 1043 patients and 1066 procedures were included. Chemosis was reported in 559 out of 1043 patients (45.9%), proptosis in 498 (41.5%), and ophthalmoplegia in 344 (23.5%). A transvenous embolization was preferred in 753 cases (63.2%) and coils were used in 712 out of 1066 procedures (57.8%). Overall, 85% (95% confidence interval, CI 69.5-96.1%) of patients had a complete resolution of symptoms, while complications occurred in 7.75% (95% CI 3.82-12.7%) with minimal permanent deficits (0.15%). The mortality rate was 1 out of 1043 patients (< 0.001).
CONCLUSION
A transvenous coiling is the most common endovascular approach for CS-dAVF, achieving a high percentage of radiological and clinical resolution and low complication rates. Transvenous approaches show less complications than transarterial ones, and coils appear safer than liquid embolic agents.
Topics: Cavernous Sinus; Central Nervous System Vascular Malformations; Embolization, Therapeutic; Endovascular Procedures; Exophthalmos; Humans; Radiography; Retrospective Studies; Treatment Outcome
PubMed: 34910224
DOI: 10.1007/s00062-021-01107-0 -
European Journal of Vascular and... May 2016Peripheral arterial bypass is an effective procedure for the management of patients with critical limb ischaemia. However, it is commonly associated with high rates of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Peripheral arterial bypass is an effective procedure for the management of patients with critical limb ischaemia. However, it is commonly associated with high rates of graft occlusion and subsequent limb loss. This is particularly apparent when the distal anastomosis is to the below-knee arterial segment. A number of studies have suggested that an arteriovenous fistula (AVF) sited at the distal anastomosis may reduce afterload, improve graft patency, and boost subsequent limb salvage. The aim of this study was to assess the effects of adjuvant AVF on the outcomes of peripheral arterial bypass.
METHODS
The following databases were searched up to May 2015: Medline through Pubmed; the Cochrane Library; EMBASE; and reference lists of articles.
STUDY ELIGIBILITY
All randomised controlled and observational studies that assessed the role of AVF as an adjunct to peripheral arterial bypass were included. Studies were required to include at least one pre-defined outcome. Data were extracted and assessed by two reviewers with any disagreements adjudicated on by the senior author. Pooled risk ratios were calculated using a random effects model. Additional subgroup analyses were performed.
RESULTS
Two randomised controlled trials and seven retrospective cohort studies comprising 966 participants were included. Pooled standardized data showed no difference in primary graft patency (pooled RR = 1.25, 95% CI 0.73-2.16), secondary patency (pooled RR = 1.16, 95% CI 0.82-1.66), or limb salvage at 12-months (pooled RR = 1.13, 95% CI 0.80-1.60) for the peripheral bypass with AVF group compared with peripheral bypass alone. Subgroup analysis indicated a reduction in reintervention rates associated with AVF when performed in conjunction with a synthetic graft (pooled RR = 0.55, 95% CI 0.30-0.98).
CONCLUSION
Although adjuvant AVF is not associated with additional operative complication there is little evidence to support its use. The evidence assessing its merits is weakened by small, retrospective studies with heterogeneous cohorts.
Topics: Arteriovenous Shunt, Surgical; Humans; Peripheral Vascular Diseases; Treatment Outcome; Vascular Grafting
PubMed: 27067191
DOI: 10.1016/j.ejvs.2016.01.014 -
Journal of Vascular Surgery Mar 2020Owing to the lack of comparative evidence between the endovascular technologies for arteriovenous fistula (AVF) stenosis treatments, we sought to summarize the reported... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Owing to the lack of comparative evidence between the endovascular technologies for arteriovenous fistula (AVF) stenosis treatments, we sought to summarize the reported data comparing the effectiveness of different endovascular approaches for the treatment of AVF stenoses at the juxta-anastomotic site.
METHODS
We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 12, 2018 for observational and randomized studies that had examined the effectiveness of AVF stenosis treatment using plain percutaneous balloon angioplasty (PTA), cutting balloon angioplasty, drug-eluting balloon (DEB) angioplasty, high-pressure balloon angioplasty, and stenting. Bias was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Collaboration tool for randomized studies. Article screening, full-text review, assessment of bias, and data collection were conducted in duplicate, with a third reviewer to reconcile any discrepancies. We conducted a qualitative synthesis of the available evidence and a quantitative meta-analysis for the primary assisted patency outcome. The meta-analysis was conducted using Review Manager, version 5.3, using random effects models, with the I statistic used to assess heterogeneity. Statistical significance was set at P < .05.
RESULTS
Our search yielded 3683 reports. Of these, three randomized trials and three observational studies were included. Three studies with 342 patients had described the effectiveness of high-pressure balloon angioplasty, conventional PTA, and stenting and had analyzed the data qualitatively. Three studies with 141 patients had investigated native AVF patency after DEB angioplasty and conventional PTA and were included in the meta-analysis. DEB angioplasty showed significantly greater primary assisted patency rates at 12 months after treatment compared with PTA (odds ratio, 3.66; 95% confidence interval, 1.32-10.14; I = 49%). No statistically significant differences were found in 6-month primary assisted patency among the treatment groups (odds ratio, 2.03; 95% confidence interval, 0.64-6.45; I = 50%). A total of 58 of 72 AVFs remained patent 6 months after DEB angioplasty compared with 45 of 69 at 6 months after PTA. At 12 months after treatment, 48 of 72 AVFs remained patent after DEB angioplasty compared with 23 of 69 AVFs after PTA.
CONCLUSIONS
Our findings suggest DEB angioplasty is a more effective treatment option for AVF stenosis at the juxta-anastomotic site compared with PTA. Although DEB angioplasty might provide longer term patency than other endovascular treatments, further high-quality data are needed to confirm this finding.
Topics: Angioplasty, Balloon; Arteriovenous Shunt, Surgical; Constriction, Pathologic; Drug-Eluting Stents; Graft Occlusion, Vascular; Humans; Vascular Patency
PubMed: 32089200
DOI: 10.1016/j.jvs.2019.07.075 -
The Cochrane Database of Systematic... Oct 2017Adequate haemodialysis (HD) in people with end-stage kidney disease (ESKD) is reliant upon establishment of vascular access, which may consist of arteriovenous fistula,... (Review)
Review
BACKGROUND
Adequate haemodialysis (HD) in people with end-stage kidney disease (ESKD) is reliant upon establishment of vascular access, which may consist of arteriovenous fistula, arteriovenous graft, or central venous catheters (CVC). Although discouraged due to high rates of infectious and thrombotic complications as well as technical issues that limit their life span, CVC have the significant advantage of being immediately usable and are the only means of vascular access in a significant number of patients. Previous studies have established the role of thrombolytic agents (TLA) in the prevention of catheter malfunction. Systematic review of different thrombolytic agents has also identified their utility in restoration of catheter patency following catheter malfunction. To date the use and efficacy of fibrin sheath stripping and catheter exchange have not been evaluated against thrombolytic agents.
OBJECTIVES
This review aimed to evaluate the benefits and harms of TLA, preparations, doses and administration as well as fibrin-sheath stripping, over-the-wire catheter exchange or any other intervention proposed for management of tunnelled CVC malfunction in patients with ESKD on HD.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Specialised Register up to 17 August 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.
SELECTION CRITERIA
We included all studies conducted in people with ESKD who rely on tunnelled CVC for either initiation or maintenance of HD access and who require restoration of catheter patency following late-onset catheter malfunction and evaluated the role of TLA, fibrin sheath stripping or over-the-wire catheter exchange to restore catheter function. The primary outcome was be restoration of line patency defined as ≥ 300 mL/min or adequate to complete a HD session or as defined by the study authors. Secondary outcomes included dialysis adequacy and adverse outcomes.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed retrieved studies to determine which studies satisfy the inclusion criteria and carried out data extraction. Included studies were assessed for risk of bias. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using GRADE.
MAIN RESULTS
Our search strategy identified 8 studies (580 participants) as eligible for inclusion in this review. Interventions included: thrombolytic therapy versus placebo (1 study); low versus high dose thrombolytic therapy (1); alteplase versus urokinase (1); short versus long thrombolytic dwell (1); thrombolytic therapy versus percutaneous fibrin sheath stripping (1); fibrin sheath stripping versus over-the-wire catheter exchange (1); and over-the-wire catheter exchange versus exchange with and without angioplasty sheath disruption (1). No two studies compared the same interventions. Most studies had a high risk of bias due to poor study design, broad inclusion criteria, low patient numbers and industry involvement.Based on low certainty evidence, thrombolytic therapy may restore catheter function when compared to placebo (149 participants: RR 4.05, 95% CI 1.42 to 11.56) but there is no data available to suggest an optimal dose or administration method. The certainty of this evidence is reduced due to the fact that it is based on only a single study with wide confidence limits, high risk of bias and imprecision in the estimates of adverse events (149 participants: RR 2.03, 95% CI 0.38 to 10.73).Based on the available evidence, physical disruption of a fibrin sheath using interventional radiology techniques appears to be equally efficacious as the use of a pharmaceutical thrombolytic agent for the immediate management of dysfunctional catheters (57 participants: RR 0.92, 95% CI 0.80 to 1.07).Catheter patency is poor following use of thrombolytic agents with studies reporting median catheter survival rates of 14 to 42 days and was reported to improve significantly by fibrin sheath stripping or catheter exchange (37 participants: MD -27.70 days, 95% CI -51.00 to -4.40). Catheter exchange was reported to be superior to sheath disruption with respect to catheter survival (30 participants: MD 213.00 days, 95% CI 205.70 to 220.30).There is insufficient evidence to suggest any specific intervention is superior in terms of ensuring either dialysis adequacy or reduced risk of adverse events.
AUTHORS' CONCLUSIONS
Thrombolysis, fibrin sheath disruption and over-the-wire catheter exchange are effective and appropriate therapies for immediately restoring catheter patency in dysfunctional cuffed and tunnelled HD catheters. On current data there is no evidence to support physical intervention over the use of pharmaceutical agents in the acute setting. Pharmacological interventions appear to have a bridging role and long-term catheter survival may be improved by fibrin sheath disruption and is probably superior following catheter exchange. There is no evidence favouring any of these approaches with respect to dialysis adequacy or risk of adverse events.The current review is limited by the small number of available studies with limited numbers of patients enrolled. Most of the studies included in this review were judged to have a high risk of bias and were potentially influenced by pharmaceutical industry involvement.Further research is required to adequately address the question of the most efficacious and clinically appropriate technique for HD catheter dysfunction.
PubMed: 29106711
DOI: 10.1002/14651858.CD011953.pub2 -
Journal of Vascular Surgery Jun 2020Penetrating vertebral artery injuries (VAIs) are rare. Because of their rarity, complex anatomy, and difficult surgical exposures, few surgeons and trauma centers have...
BACKGROUND
Penetrating vertebral artery injuries (VAIs) are rare. Because of their rarity, complex anatomy, and difficult surgical exposures, few surgeons and trauma centers have developed significant experience with their management. The objectives of this study were to review their incidence, clinical presentation, radiologic identification, management, complications, and outcomes and to provide a review of anatomic exposures and surgical techniques for their management.
METHODS
A literature search on MEDLINE Complete-PubMed, Cochrane, Ovid, and Embase for the period of 1893 to 2018 was conducted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used. Our literature search yielded a total of 181 potentially eligible articles with 71 confirmed articles, consisting of 21 penetrating neck injury series, 13 VAI-specific series, and 37 case reports. Operative procedures and outcomes were recorded along with methods of angiographic imaging and operative management. All articles were reviewed by at least two independent authors, and data were analyzed collectively.
RESULTS
There were a total of 462 patients with penetrating VAIs. The incidence of VAI in the civilian population was 3.1% vs 0.3% in the military population. More complete data were available from 13 collected VAI-specific series and 37 case reports for a total of 362 patients. Mechanism of injury data were available for 341 patients (94.2%). There were gunshot wounds (178 patients [49.2%]), stab wounds (131 [73.6%]), and miscellaneous mechanisms of injury (32 [8.8%]). Anatomic site of injury data were available for 177 (49%) patients: 92 (25.4%) left, 84 (23.2%) right, and 1 (0.3%) bilateral. Anatomic segment of injury data were available for 204 patients (56.4%): 28 (7.7%) V1, 125 (34.5%) V2, and 51 (14.1%) V3. Treatment data were available for 212 patients. Computed tomography angiography was the most common imaging modality (163 patients [77%]). Injuries were addressed by operative management (94 [44.3%]), angiography and angioembolization (72 [34%]), combined approaches (11 [5.2%]), and observation (58 [27.4%]). Stenting and repair were less frequently employed (10 [4.7%]). The incidence of aneurysms or pseudoaneurysms was 18.5% (67); the incidence of arteriovenous fistula was 16.9% (61). The calculated mortality in VAI-specific series was 15.1%; in the individual case report group, it was 10.5%.
CONCLUSIONS
The majority of VAIs present without neurologic symptoms, although some may present with exsanguinating hemorrhage. Computed tomography angiography should be considered first line to establish diagnosis. Gunshot wounds account for most injuries. The most frequently injured segment is V2. Surgical ligation is the most common intervention, followed by angioembolization, both of which constitute important management approaches.
Topics: Endovascular Procedures; Humans; Incidence; Risk Factors; Time Factors; Treatment Outcome; Vascular Surgical Procedures; Vascular System Injuries; Vertebral Artery; Wounds, Penetrating
PubMed: 31902594
DOI: 10.1016/j.jvs.2019.10.084 -
BMC Anesthesiology Aug 2020Arteriovenous fistulae (AVF) are the hemodialysis access modality of choice for patients with end-stage renal disease. However, they have a high early failure rate. Good... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Arteriovenous fistulae (AVF) are the hemodialysis access modality of choice for patients with end-stage renal disease. However, they have a high early failure rate. Good vascular access is essential to manage long-term hemodialytic treatment, but some anesthesia techniques directly affect venous diameter as well as intra- and post-operative blood flow. The main purpose of this meta-analysis was to compare the results of regional and local anesthesia (RA and LA) for arteriovenous fistula creation in end-stage renal disease.
METHODS
We conducted a systematic review and meta-analysis to synthesize evidence from 7 randomized controlled trials (565 patients) and 1 observational study (408 patients) with the aim of evaluating the safety and efficacy of RA versus LA in surgical construction of AVF.
RESULTS
Pooled data showed that RA was associated with higher primary patency rates than LA (odds ratio [OR], 1.88; 95% confidence interval [CI]: 1.24-2.84; P = 0.003; I = 31%). Additionally, brachial artery diameter was significantly increased in the RA versus LA group (mean difference [MD], 0.83; 95% CI: 0.75-0.92; P < 0.001; I = 97%) and the need for intra- as well as post-operative pain killers was significantly less (RA, P = 0.0363; LA, P = 0.0318). Moreover, operation duration was significantly reduced using RA versus LA (MD, - 29.63; 95% CI: - 32.78 - -26.48; P < 0.001; I = 100%).
CONCLUSIONS
This meta-analysis suggests that RA is preferable to LA in patients with end-stage renal disease in guaranteeing AVF patency and increasing brachial artery diameter.
Topics: Anesthesia, Conduction; Anesthesia, Local; Arteriovenous Shunt, Surgical; Humans; Kidney Failure, Chronic; Randomized Controlled Trials as Topic; Retrospective Studies; Treatment Outcome
PubMed: 32867692
DOI: 10.1186/s12871-020-01136-1 -
Acta Medica Indonesiana Jan 2023Arteriovenous fistula (FAV) is the most widely used vascular access for end-stage renal disease (ESRD) patients undergoing routine hemodialysis in Indonesia. However,...
BACKGROUND
Arteriovenous fistula (FAV) is the most widely used vascular access for end-stage renal disease (ESRD) patients undergoing routine hemodialysis in Indonesia. However, FAV can become dysfunctional before it is used for the initiation of hemodialysis, a condition known as primary failure. Clopidogrel is an anti-platelet aggregation that has been reported to reduce the incidence of primary failure in FAV compared to other anti-platelet aggregation agents. Through this systematic review, we aimed to assess the role of clopidogrel to the incidence of primary FAV failure and the risk of bleeding in ESRD patients.
METHODS
A literature search was carried out to obtain randomized Control Trial studies conducted since 1987 from Medline / Pubmed, EbscoHost, Embase, Proquest, Scopus, and Cochrane Central without language restrictions. Risk of bias assessment was performed with the Cochrane Risk of Bias 2 application.
RESULTS
All of the three studies involved indicated the benefit of clopidogrel for the prevention of AVF primary failure. However, all of the studies have substantial differences. Abacilar's study included only participants with diabetes mellitus. This study also administered a combination of clopidogrel 75 mg and prostacyclin 200 mg/day, while Dember's study gave an initial dose of clopidogrel 300 mg followed by daily dose 75 mg and Ghorbani's study only gave clopidogrel 75 mg/day. Ghorbani and Abacilar started the intervention 7-10 days before AVF creation, while Dember started 1 day after VAF creation. Dember gave treatment for 6 weeks with an assessment of primary failure at the end of week 6, Ghorbani's treatment lasted for 6 weeks with an assessment at week 8, while Abacilar gave treatment for one year with an assessment at weeks 4 after AVF creation. In addition, the prevalence of bleeding did not differ between the treatment and control groups.
CONCLUSION
Clopidogrel can reduce the incidence of primary FAV failure without significant increase of bleeding events.
Topics: Humans; Clopidogrel; Arteriovenous Shunt, Surgical; Kidney Failure, Chronic; Renal Dialysis; Hemorrhage; Arteriovenous Fistula; Randomized Controlled Trials as Topic
PubMed: 36999257
DOI: No ID Found -
Brain Sciences Jan 2024Surgical treatment of neurovascular lesions like intracranial aneurysms, arteriovenous malformations and arteriovenous dural fistulas is still associated with high... (Review)
Review
Surgical treatment of neurovascular lesions like intracranial aneurysms, arteriovenous malformations and arteriovenous dural fistulas is still associated with high morbidity. Several recent studies are providing increasing insights into reliable tools to improve surgery and reduce complications. Inadvertent vessel compromise and incomplete occlusion of the lesion represent the most possible complications in neurovascular surgery. It is clear that direct visual examination alone does not allow to identify all instances of vessel compromise. Various modalities, including angiography, microvascular Doppler and neurophysiological studies, have been utilized for hemodynamics of flow vessels in proper clipping of the aneurysm or complete obliteration of the lesion. We intended to review the current knowledge about the intraoperative microvascular Doppler (iMDS) employment in the most updated literature, and explore the most recent implications not only in intracranial aneurysms but also in neurovascular lesions like arteriovenous malformations (AVMs) and arteriovenous dural fistulas (AVDFs). According to the PRISMA guidelines, systematic research in the most updated platform was performed in order to provide a complete overview about iMDS employment in neurovascular surgery. Twelve articles were included in the present paper and analyzed according to specific research areas. iMDS employment could represent a crucial tool to improve surgery in neurovascular lesions. The safety and effectiveness of the surgical treatment of neurovascular lesions like intracranial aneurysm and other neurovascular lesions like AVMs and AVDFs requires careful and accurate consideration regarding the assessment of anatomy and blood flow. Prognosis may depend on suboptimal or incomplete exclusion of the lesion.
PubMed: 38248271
DOI: 10.3390/brainsci14010056 -
The Cochrane Database of Systematic... Oct 2022The failure of arteriovenous fistulas (AVF) to mature is a major problem in patients with kidney failure who require haemodialysis (HD). Preoperative planning is an... (Review)
Review
BACKGROUND
The failure of arteriovenous fistulas (AVF) to mature is a major problem in patients with kidney failure who require haemodialysis (HD). Preoperative planning is an important factor in increasing functional AVF. Upper limb exercise has been recommended to gain AVF maturation. Studies of pre- and post-operative upper limb exercises in patients with kidney failure patients have been reported; however, the optimal program for this population is unknown due to inconsistent results among these programs.
OBJECTIVES
We aimed to determine if upper limb exercise would be beneficial for AVF maturation (prior to and post AVF creation) in patients with kidney failure and to improve AVF outcomes. This review also aimed to identify adverse events related to upper limb exercise.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Register of Studies up to 15 March 2022 through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov, and other resources (e.g. reference list, contacting relevant individuals, and grey literature).
SELECTION CRITERIA
We included randomised controlled trials (RCTs) and quasi-RCTs, comparing upper limb exercise training programs with no intervention or other control programs before or after AVF creation in patients with kidney failure. Outcome measures included time to mature, ultrasound and clinical maturation, venous diameter, blood flow in the inflow artery, dialysis efficacy indicator, vascular access function (functional AVF), vascular access complications, and adverse events.
DATA COLLECTION AND ANALYSIS
Study selection and data extraction were taken by four independent authors. Bias assessment and quality assessment were undertaken independently by two authors. The effect estimate was analysed using risk ratio (RR) with 95% confidence intervals (CI) for dichotomous data, or mean difference (MD) or standardised mean difference (SMD) for continuous data. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
MAIN RESULTS
Nine studies (579 participants) were included, and seven studies (519 participants) conducting post-operative exercise training could be meta-analysed. Three comparisons were undertaken: (i) isotonic exercise training versus no intervention; (ii) isometric versus isotonic exercise training; and (iii) isotonic (high volume) versus isotonic exercise training (low volume). Due to insufficient data, we could not analyse pre-operative exercise training. Overall, the risk of bias was low for selection and reporting bias, high for performance and attrition bias, and unclear for detection bias. Compared to no intervention, isotonic exercise training may make little or no difference to ultrasound maturation (2 studies, 263 participants: RR 1.09, 95% CI 0.94 to 1.25; I² = 0%; low certainty evidence), but may improve clinical maturation (2 studies, 263 participants: RR 1.14, 95% CI 1.02 to 1.27; I² = 0%; low certainty evidence). Compared to isotonic exercise training, isometric exercise training may improve both ultrasound maturation (3 studies, 160 participants: RR 1.56, 95% CI 1.21 to 2.00; I² = 22%; low certainty evidence) and clinical maturation (3 studies, 160 participants: RR 1.80, 95% CI 1.18 to 2.76; I² = 53%; low certainty evidence). Venous diameter (3 studies, 160 participants: MD 0.84 mm, 95% CI 0.45 to 1.23; I² = 0%; low certainty evidence) and blood flow in the inflow artery (3 studies, 160 participants: MD 140.62 mL/min, 95% CI 38.72 to 242.52; I² = 0%; low certainty evidence) may be greater with isometric exercise training. It is uncertain whether isometric exercise training reduces vascular access complications (2 studies, 110 participants: RR 2.54, 95% CI 0.38 to 17.08; I² = 47%; very low certainty evidence). It is uncertain whether high volume isotonic exercise training improves venous diameter (2 studies, 93 participants: MD 0.19 mm, 95% CI -0.75 to 1.13; I² = 34%; very low certainty evidence) or blood flow in the inflow artery (1 study, 15 participants: MD -287.70 mL/min, 95% CI -625.99 to 60.59; very low certainty evidence) compared to low volume isotonic exercise training. None of the included studies reported time to mature, dialysis efficacy indicator, vascular access function, or adverse events.
AUTHORS' CONCLUSIONS
Our findings suggest that the current research evidence examining upper limb exercise programs is of low quality, attributable to variability in the type of interventions used and the overall low number of studies and participants.
Topics: Arteriovenous Fistula; Exercise; Humans; Renal Dialysis; Renal Insufficiency; Upper Extremity
PubMed: 36184076
DOI: 10.1002/14651858.CD013327.pub2