Abstract
Surgical arteriovenous fistula (AVF) or graft (AVG) is preferred to a central venous catheter for dialysis access. Surgical access may suffer thrombosis early after placement and systemic anticoagulation during surgical access formation may increase patency rates but would be expected to increase bleeding-related complications. A systematic review and meta-analysis of randomised controlled trials was conducted to examine the impact of systemic anticoagulation on access surgery perioperative bleeding and patency rates. We included randomised controlled trials testing systemic anticoagulation during access formation versus a control group without systemic anticoagulation reporting bleeding complications and access patency. Medline, Embase, CENTRAL and CINAHL were searched up to March 2015. Risk of bias was assessed using the Cochrane risk of bias tool and the Jadad score. Meta-analysis was performed using Cochrane Revman® software. Searches identified 445 reports of which four randomised studies involving 411 participants were included. Three studies pertained to AVF only and one included both AVF and AVG. Systemic anticoagulation led to increased bleeding events in all access [four trials; risk ratio (RR) 7.18; confidence interval (CI), 2.41 to 21.38; p<0.001]. Patency was not improved for all access (four trials; RR, 0.64; CI, 0.37 to 1.09; p = 0.10) but was improved when AVF analysed alone (three trials; RR, 0.57; CI, 0.33 to 0.97; p = 0.04). The use of intraoperative systemic anticoagulation during access formation is associated with a highly significant increased risk of bleeding-related complications. A significant improvement in AVF patency was seen, though not when AVF and AVG were analysed together.
Highlights
The use of autologous arteriovenous fistulae for the purpose of haemodialysis was first described in 1966 by Brescia et al(1) and the arteriovenous fistula (AVF) is recognised as the gold standard for maintenance haemodialysis due to superior long term patency, reduced rates of complications and superior cost effectiveness in comparison to grafts or central lines(2)
Surgical access formation results in a number of failures due to thrombosis and many strategies have been researched in an attempt to minimise the loss of access and the lifesaving dialysis they provide (4, 5)
The use of systemic anticoagulation during access formation surgery has been suggested as one such strategy to improve patency rates(6), there is the potential of an increased risk of peri-operative bleeding and/or haematoma formation
Summary
The use of autologous arteriovenous fistulae for the purpose of haemodialysis was first described in 1966 by Brescia et al(1) and the arteriovenous fistula (AVF) is recognised as the gold standard for maintenance haemodialysis due to superior long term patency, reduced rates of complications and superior cost effectiveness in comparison to grafts or central lines(2). The use of systemic anticoagulation during access formation surgery has been suggested as one such strategy to improve patency rates(6), there is the potential of an increased risk of peri-operative bleeding and/or haematoma formation. The aim of this report is to review the evidence regarding outcomes of access surgery with and without use of systemic anticoagulation with specific reference to rates of bleeding related complications and access patency
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