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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Lower-extremity arteriovenous access for haemodialysis: a systematic review

GA Antoniou, MK Lazarides, GS Georgiadis, GS Sfyroeras, ES Nikolopoulos, and AD Giannoukas.

Review published: 2009.

Link to full article: [Journal publisher]

CRD summary

The review found that lower-extremity vascular access for haemodialysis had acceptable patency rates; femoral vein transposition had better rates than femoral grafts. Autologous access was associated with fewer infective but more ischaemic complications compared with prosthetic access. All the included studies were observational and no quality assessment was made, so the reliability of the findings is uncertain.

Authors' objectives

To synthesise the evidence on the efficacy and safety of different types of lower-extremity vascular access for haemodialysis.


MEDLINE and Scopus (1980 to January 2009) were searched; search terms were listed in the review. A manual search of reference lists of identified articles was performed. Only studies published in English were eligible for inclusion.

Study selection

Studies of at least 10 autologous or prosthetic arteriovenous haemodialysis accesses with both outflow and inflow vessels in the lower extremity that reported on patency and access-related complications were eligible for inclusion.

In the included studies, the most common access configuration was upper thigh prosthetic; other configurations were mid-thigh prosthetic and femoral vein transposition. Where reported, mean age ranged from 48 to 62 years, 13% to 60% of the participants were male and 0% to 60% had diabetes.

Two reviewers independently performed the study selection; the authors did not state how discrepancies were resolved.

Assessment of study quality

The authors did not state that they assessed validity.

Data extraction

Data were abstracted from the text, tables or graphs of included studies. Patency rates and the severity of access complications were determined according to the standards of Committee of Reporting Standards for Arteriovenous Haemodialysis Accesses. Primary and secondary patency rates were calculated for 12 and 24 months following access construction if there were at least two studies that reported data for the period.

Two reviewers independently performed the data extraction; the authors did not state how discrepancies were resolved.

Methods of synthesis

Weighted mean primary and secondary patency rates were calculated; the number of arteriovenous accesses created was used to weight each study. Complication rates were summarised using odds ratios (ORs) and 95% confidence intervals (CI). The authors did not state how the ORs were pooled. Event rates between different types of arteriovenous accesses were compared using a Χ2 test.

Results of the review

The review included 15 studies: two prospective, 10 retrospective and three of unstated design). No randomised controlled trials (RCTs) were identified. Studies included at least 656 patients with 782 accesses; 660 were upper-thigh grafts, 60 were mid-thigh grafts and 62 were femoral vein transposition arteriovenous fistulae.

Overall weighted mean primary patency rates were 53% at 12 months and 37% at 24 months; secondary patency rates were 71% at 12 months and 60% at 24 months. The 12-month patency rates of femoral vein transposition arteriovenous fistulae (83%) were better than those of upper-thigh (48%) and mid-thigh (43%) grafts.

Complication rates were similar for upper and mid-thigh arteriovenous access. Infection rates were significantly lower in femoral vein transposition than either mid-thigh (OR 0.073, 95% CI 0.009 to 0.585) or upper thigh (OR 0.073, 95% CI 0.010 to 0.531) accesses. Steal rates were higher: OR 2.388 (95% CI 0.842 to 6.767) compared to mid-thigh and OR 3.543 (95% CI 1.738 to 7.222) compared to upper thigh.

Grade 2 infection was significantly less frequent in autologous compared to prosthetic grafts (OR 0.073, 95% CI 0.010 to 0.530) and steal was more frequent (OR 3.427, 95% CI 1.707 to 6.881).

The amputation rate following arteriovenous access creation ranged from 0% and 7% (seven studies).

Authors' conclusions

Lower-extremity vascular access had acceptable patency rates. Femoral vein transposition had better rates than femoral grafts. Autologous access was associated with fewer infective but more ischaemic complications compared with prosthetic access. Because of the lack of RCTs, the results should be treated with caution.

CRD commentary

The review addressed a clear question. Intervention and outcome inclusion criteria were clearly stated. The search strategy was unlikely to have been comprehensive: only studies published in English and listed in one of two databases were eligible for inclusion, so the results could have been affected by language bias. The authors did not report any attempt to consider publication bias.

Study selection and data extraction were performed in duplicate to minimise errors. It appeared that no attempt was made to assess the quality of the included studies. It appeared that the authors used appropriate methods for pooling the patency rates, but it was unclear how the odds ratios for complication rates were pooled. Heterogeneity between studies was not assessed. Comparisons between the different types of accesses were made indirectly.

The authors conclusions were suitably cautious given the lack of direct comparisons and use of data based on largely retrospective studies of unknown quality.

Implications of the review for practice and research

Practice: The authors stated that the type of lower-extremity vascular access chosen should take into account the patients' comorbidities.

Research: The authors stated that RCTs were required to confirm the observational data. Larger studies with longer follow-up were required.


No funding received.

Bibliographic details

Antoniou GA, Lazarides MK, Georgiadis GS, Sfyroeras GS, Nikolopoulos ES, Giannoukas AD. Lower-extremity arteriovenous access for haemodialysis: a systematic review. European Journal of Vascular and Endovascular Surgery 2009; 38(3): 365-372. [PubMed: 19596598]

Indexing Status

Subject indexing assigned by NLM


Arteriovenous Shunt, Surgical /adverse effects; Blood Vessel Prosthesis Implantation /adverse effects; Female; Femoral Artery /surgery; Femoral Vein /surgery; Humans; Ischemia /etiology; Kidney Failure, Chronic /therapy; Male; Prosthesis-Related Infections /etiology; Renal Dialysis; Saphenous Vein /surgery; Surgical Wound Infection /etiology; Thigh /blood supply; Time Factors; Treatment Outcome; Vascular Patency



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19596598