Similar failure and patency rates when comparing one- and two-stage basilic vein transposition

Abstract

Basilic vein transposition is recommended in patients who are not candidates for a radial or brachial artery to cephalic vein fistula for dialysis access. Both one-stage and two-stage procedures have their advantages and disadvantages. Which procedure results in improved outcomes remains unclear. A systematic review was conducted of the MEDLINE and EMBASE databases for studies that compared one-stage and two-stage brachial-basilic vein transpositions. Abstracts and full-text studies were screened independently by two reviewers with data abstraction done in duplicate. Random-effects meta-analysis was used to identify differences in primary failure rates and 1-year primary and secondary patency rates. Study quality was assessed by a previously described tool designed for observational studies reporting on dialysis access outcomes. Of 1662 abstracts screened, 97 were selected for full-text review. Of these, eight studies (one randomized trial, seven observational studies) involving 882 patients met the inclusion criteria. The pooled odds ratio estimate for primary failure was 1.21 (95% confidence interval [CI], 0.73-1.98; P = .46), suggesting no difference in failure rate between one-stage and two-stage transpositions. Similarly, the estimated odds ratio for 1-year primary patency rate of 1.39 (95% CI, 0.71-2.72; P = .33) and 1-year secondary patency rate of 1.02 (95% CI, 0.36-2.87; P = .98) indicated no difference between the two groups. Study quality was limited by unclear outcome definitions, minimal control for confounding, and variable selection criteria. The decision to pursue a one-stage vs a two-stage procedure was often based on size of the basilic vein, with a two-stage procedure reserved for patients with smaller veins. Meta-analysis of the existing literature comparing one-stage and two-stage basilic vein transposition suggests no difference in failure and patency rates, despite the two-stage procedure's being used in patients with smaller basilic veins. These findings are limited by the small size, observational design, and inconsistent quality of included studies. Reserving a two-stage procedure for patients with smaller basilic veins appears justified, although the strength of the evidence is limited.