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Comparison Of Different Types Of Balloon Angioplasty For Arteriovenous Fistula Stenosis
Fachreza A. Damara, MD1, Yasser Jamil, MD2, Kassem Farhat, MD2, Diaa Hakim, MD3, Lee Kirksey, MD1.
1Cleveland Clinic, Cleveland, OH, USA, 2Yale University, New Haven, CT, USA, 3Brigham & Women’s Hospital/Harvard Medical School, Boston, MA, USA.

OBJECTIVES: There is a growing number of studies comparing different types of balloon angioplasty in preserving the patency of the dysfunctional arteriovenous fistula (AVF). While studies are mostly comparing active interventions against plain balloon angioplasty (PBA), concerns have been raised about the relative effectiveness of competing types of balloons. Network meta-analysis has emerged with the ability to compare multiple interventions based on both direct and indirect comparisons of the competing interventions. This study aims to characterize the impact of different types of balloon angioplasty on patency and technical success in patients with AVF stenosis.
METHODS: Multiple databases were reviewed systematically to identify published randomized controlled trials (RCTs) studies on comparing balloon angioplasty in patients with dysfunctional AVF up to August 2023. The following types of balloons were compared: drug-coated balloon (DCB), cutting balloon (CtB), high-pressure balloon (HPB), and PBA. Indirect comparisons of all balloon types were compared using random-effect network meta-analysis (NMA). The primary outcomes were primary patency rates of the AVF at 3, 6, 9, and 12 months. The P-score (estimate of the probability of being the best treatment) was used to rank the types of balloons for each outcome. RESULTS: Twenty-three RCTs involving 2,951 patients were included. Direct meta-analyses showed, compared to PBA, higher primary patency rates at 3 months in CtB (OR=1.23, 95%CI[1.05-1.44]) group, at 6 months in CtB (OR=1.52, 95%CI[1.05-2.20]) and DCB (OR=1.19, 95%CI[1.02-1.38]) groups, at 9 months in DCB group (OR=1.41, 95%CI[1.15-1.73]), and at 12 months in DCB group (OR=1.38, 95%CI[1.04-1.82]). NMA showed that DCB was ranked as the best option based on P-score on 9-, and 12-month patency rates (Table 1). HPB was ranked the highest in terms of technical success. Direct meta-analysis showed significantly higher technical success in HPB compared to PBA (OR=1.23, 95%CI[1.08-1.41]). A comparison of all-cause mortality between DCB and PBA indicated no statistical difference (OR=0.89, 95%CI[0.66-1.20]). CONCLUSIONS: Based on evidence from 23 trials, DCB is superior to PBA in preserving primary patency in patients with AVF stenoses. HPB serves a greater technical success compared to PBA.

Ranking of balloon types for primary patency and technical success outcomes
Target Lesion and Circuit Patency
3 monthsCtB, P = 0.95HPB, P = 0.57DCB, P = 0.43PBA, P = 0.03
6 monthsCtB, P = 0.94DCB, P = 0.61HPB, P = 0.36PBA, P = 0.08
9 monthsDCB, P = 0.90CtB, P = 0.73PBA, P = 0.29HPB, P = 0.07
12 monthsDCB, P = 0.85CtB, P = 0.62PBA, P = 0.28HPB, P = 0.25
Technical success
HPB, P = 0.87CtB, P = 0.74DCB, P = 0.21PBA, P = 0.18

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