Comparison of drug-coated balloon angioplasty versus common balloon angioplasty in hemodialysis patients with arteriovenous fistula stenosis: A meta-analysis of randomised controlled trials

doi:10.21203/rs.3.rs-2442104/v1

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Comparison of drug-coated balloon angioplasty versus common balloon angioplasty in hemodialysis patients with arteriovenous fistula stenosis: A meta-analysis of randomised controlled trials

https://doi.org/10.21203/rs.3.rs-2442104/v1

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Drug-coated balloons (DCBs) have been used in dialysis patients with arteriovenous fistula (AVF) stenosis, but whether they have advantages over ordinary balloons is still controversial. A meta-analysis was designed to investigate the safety and efficacy of DCBs and common balloons (CBs) in the treatment of AVF stenosis, with a registration in INPLASY (INPLASY202280112). A total of 15 randomized controlled trials (RCTs) were included in this meta-analysis. The results showed that the DCB group had a higher first-stage patency rate of the target lesion 6 months and 12 months after surgery, and the difference was statistically significant. There was no statistically significant difference in all-cause mortality between the two groups at 6 months and 12 months.

Drug-coated balloon

Common balloon angioplasty

Arteriovenous fistula

Stenosis

End-stage renal disease

All-cause mortality

Meta-analysis.

Worldwide, approximately 2 million people receive dialysis for end-stage renal disease¹, and end-stage renal disease is usually treated with haemodialysis². Autogenous arteriovenous fistula (AVF) is the preferred vascular access of haemodialysis in patients³; however, with the gradual prolongation of the application time of AVF, the incidence of vascular access-related complications such as AVF stenosis or even occlusion increases significantly. Several studies have shown that the AVF patency rate is usually only 60–65% at 1 year after operation⁴. The effective solution to AVF stenosis is to adopt a second operation to re-establish the internal fistula, but this will reduce the vascular resources of dialysis patients and eventually lead to the depletion of vascular resources. With the development of medicine, percutaneous transluminal angioplasty (PTA) has gradually become one of the main methods for the treatment of AVF stenosis⁵. However, some studies have suggested that PTA is related to a high restenosis rate of AVF, and intimal hyperplasia is the main pathophysiological mechanism of vascular restenosis after PTA⁶. A better solution was needed for the treatment of AVF and a drug-coated balloon (DCB) approach was developed.

DCB was initially used for interventional therapy in coronary and lower extremity arteries. The balloon surface is attached with anti-proliferative drugs, and the most commonly used drug is paclitaxel. The lipophilicity of paclitaxel increases the tissue drug absorption rate so that it can effectively inhibit cell migration and proliferation at low concentrations⁷. When paclitaxel-coated balloons are used to dilate stenotic blood vessels, the balloon can rapidly release drugs, make drugs enter the vessel wall quickly, inhibit the proliferation of smooth muscle, and prevent restenosis⁸.

In recent years, there have been a few studies on the use of DCBs in the treatment of AVF stenosis. However, the sample size of these studies was small, which may lead to bias in interpreting the results^{9, 10}. In addition, some randomized controlled trial (RCT) findings are controversial. Therefore, we collected the literature comparing the safety and efficacy of DCBs and common balloons (CBs) in the treatment of AVF stenosis and conducted a meta-analysis to provide a reference for clinical decision-making.

Study protocol

This article was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines¹¹ and registered in INPLASY (DOI: 10.37766/inplasy2022.8.0112).

Search strategy

Two researchers (Yong Zhang and Xiang-Yang Hu) independently searched the PubMed, Embase, Web of Science, the Cochrane Library and China National Knowledge Internet (CNKI) databases from inception to 11 Aug 2022 by using medical subject headings (MeSH), Emtree, and text words with no language limitations.

The following keywords were used for the search strategy: “Drug-coated balloon”, “DCB”, “Paclitaxel-coated balloon”, “Haemodialysis access”, “Vascular access”, “Arteriovenous fistula”, “AVF”, “dialysis”, “haemodialysis”, “Angioplasty” and “stenosis”. Reference lists from the identified studies were also searched for potentially eligible articles. Preliminary publications were imported into EndNote X9.1 (Clarivate Analytics, Philadelphia, USA), duplicate records and irrelevant literature were removed, and appropriate studies with detailed classification were compiled (Supplementary Table S1).

Eligibility criteria

Two authors (Yong Zhang and Xiang-Yang Hu) independently carried out the primary review to search for trials that met the inclusion criteria (Supplementary Table S2). Any discrepancy was resolved by discussion and consensus (Supplementary Figure S1). The following criteria were used: (1) Adults participants (≥ 18 y) on dialysis for at least 6 months, irrespective of age, gender, and race. (2) haemodialysis patients with stenotic AVF or arteriovenous graft (AVG), comparison between DCB angioplasty and CB angioplasty at 6 months or 12 months. (3) One of the following outcomes must have been included: primary patency and all-cause mortality at 6 months or 12 months. (4) Only RCTs were included in the meta-analysis. The main characteristics of the included studies are listed in Table 1.

Data extraction

Two reviewers (Xiang-Yang Hu and Yong Zhang) independently extracted data from the same set of publications. The following information was extracted: author, year, country, sample size, average age, paclitaxel dose, follow-up, and main results.

Summary of effect size

Odds ratios (ORs) with 95% confidence intervals (CIs) were used as the effect size measures of dichotomous data. The weight of enrolled studies was accounted for by taking into account the size of the treatment group, control group, and total sample size. A Z-test was calculated, and therapeutic efficacy was deemed significant with a P < 0.05 cut-off¹².

Risk of bias

The quality of all trials was independently evaluated by two authors (Xiang-Yang Hu and Yong Zhang) according to the Cochrane quality criteria (Supplementary Figure S2). Any disagreement between the authors was settled by discussion with a third author (Zhen-Wu Zou). We used weighted kappa scores to assess inter-rater agreements. If a kappa score below 0.2 was considered a “none” agreement, 0.21–0.39 as “minimal” agreement, 0.40–0.59 as “weak” agreement, 0.60–0.79 as “good” agreement, 0.80–0.90 as “strong” agreement, above 0.90 as “almost perfect” agreement¹³.

GRADE Quality Assessment

The overall quality of evidence was evaluated by two authors (Xiang-Yang Hu and Qi-Bing Wang) according to The Grading of Recommendations Assessment, Development and Evaluation (GRADE), judging the evidence on^{14, 15}: i) study limitations, ii) inconsistency, iii) imprecision, iv) indirectness, and v) publication bias. Any disagreement between the two authors was first solved by discussion and then by counselling the third author (Zhen-Wu Zou) or the senior author (Yong Zhang). The results and the overall quality of evidence are presented in Supplementary Table S3.

Statistical Analysis

STATA 16.0 (Stata Corp LP, College Station, TX, USA) was used to perform statistical analyses. Labbe plots and meta-regression were used for intuitive judgement of heterogeneity. For the remaining circumstances, a random effect model was used to pool the effect size to calculate statistical heterogeneity. Heterogeneity was analysed by I² and χ² statistics. If there was significant heterogeneity, a L'Abbe plot and Galbraith plot were conducted to evaluate the consistency and quality of the results. Sensitivity analysis, subgroup analysis and meta-regression were performed to determine sources of heterogeneity. Publication bias was evaluated using Begg's and Egger's tests and funnel plots.

Study Selection

A total of 484 studies were identified during the initial search after excluding duplicate records (n = 35). Eighty-five articles were retained after title/abstract curation (excluding 433 records). Thereafter, we read the full text and analysed 15 RCTs^{9, 10, 16–28} involving a total of 1525 patients for quantitative synthesis (Supplementary Figure S1). The main characteristics of the included RCTs (country, design, sample size, age, intervention, follow-up and main results) are described in Table 1. The kappa’s score for inter-rater agreement of study selection was 0.857 (95% CI: 0.356, 1.358), which demonstrated “strong” inter-rater agreement. Inter-rater reliability for risk of bias assessment were provided in Supplementary Table S4.

Primary patency rate of the target lesion

Pooled analysis of 14 studies^{9, 10, 17–28} (n = 1489) demonstrated that the forest plot of the 6-month primary patency rate in the DCB group (n = 750) was higher than that in the CB group (n = 739) at 6 months after balloon expansion (OR = 2.31, 95% CI: 1.69, 3.15, P < 0.01, Supplementary Figure S3). No significant heterogeneity was observed (I² = 32.90%). The L’Abbe plot showed that 13 of the 14 included studies fell to the upper left of the diagonal line, indicating a higher primary patency rate in the DCB group (Supplementary Figure S4). The choropleth map reveals regional differences in the 6-month primary patency rate between Belgium, the Netherlands, Sweden, the United Kingdom and the United States of America (Figure. 1). Overall, subgroup analysis showed that in Asia and Oceania, DCBs had a higher primary patency rate at 6 months after balloon expansion, but in Europe and North America there was no significant difference between DCBs and CBs (Supplementary Figure S5). The meta-regression by bubble plot revealed no significant heterogeneity in the study size (P = 0.557, Supplementary Figure S6) or publication year (P = 0.816, Supplementary Figure S7). Sensitivity analysis (Supplementary Figure S8) and Galbraith plots (Supplementary Figure S9) were performed to evaluate the stability of our results. The analysis results suggested that no individual studies significantly affected the pooled OR, indicating that the results were statistically robust. No significant publication bias was found in the results of Begg’s plots (P = 0.228, Supplementary Figure S10), Egger’s test (P = 0.271, Supplementary Figure S11) or the funnel plots (Supplementary Figure S12).

Pooled analysis of 13 studies^{9, 10, 16–18, 20–24, 26–28} (n = 910) demonstrated that the forest plot of the primary patency rate at 12 months after balloon expansion in the DCB group (n = 457) was higher than that in the CB group (n = 453) (OR = 2.09, 95% CI: 1.50, 2.91, P < 0.01, Supplementary Figure S13). No significant heterogeneity was observed (I² = 9.28%). The L’Abbe plot showed that all 13 included studies fell to the upper left of the diagonal line, also indicating a higher primary patency rate at 12 months in the DCB group (Supplementary Figure S14). The choropleth map reveals regional differences in the 12-month primary patency rate in Australia, Belgium, the Netherlands, Sweden, Singapore, Spain, and the United Kingdom (Figure. 2). Overall, subgroup analysis showed that in Asia and Europe, DCBs had a higher primary patency rate at 12 months after balloon expansion, but in Oceania, there was no significant difference between DCBs and CBs (Supplementary Figure S15). The meta-regression by bubble plot analysis revealed no significant heterogeneity in the study size (P = 0.067, Supplementary Figure S16) or publication year (P = 0.597, Supplementary Figure S17). Sensitivity analysis (Supplementary Figure S18) and Galbraith plots (Supplementary Figure S19) were performed to evaluate the stability of our results. The analysis results suggested that no individual studies significantly affected the pooled OR, indicating that the results were statistically robust. Moreover, no significant publication bias was found in the results of Begg’s plots (P = 0.161, Supplementary Figure S20), Egger’s test (P = 0.942, Supplementary Figure S21) or the funnel plot (Supplementary Figure S22).

All-cause mortality

Five studies^{9, 16, 19, 25, 26} assessed the incidence of all-cause mortality at 6 months after balloon expansion between the two groups in a total of 757 patients, with 382 assigned to DCB groups and 375 assigned to CB groups (OR = 0.85, 95% CI: 0.47, 1.52, P = 0.58, Figure. 3). No significant heterogeneity was observed (I² = 11.64%). The meta-regression by bubble plot revealed no significant heterogeneity of the sample size (P = 0.090, Supplementary Figure S23) or publication year (P = 0.476, Supplementary Figure S24). Sensitivity analysis (Supplementary Figure S25) and Galbraith plots (Supplementary Figure S26) were performed to evaluate the stability of our results and we found that no individual studies significantly affected the pooled OR, confirming that the results were statistically robust. No significant publication bias was found in the results of Begg’s plots (P = 0.327, Supplementary Figure S27), Egger’s test (P = 0.318, Supplementary Figure S28) or the funnel plot (Supplementary Figure S29).

Seven studies^{9, 16, 19–21, 26, 27} assessed the incidence of all-cause mortality at 12 months after balloon expansion between the two groups in a total of 774 patients, with 382 assigned to DCB groups and 392 assigned to CB groups (OR = 0.99, 95% CI: 0.60, 1.64, P = 0.97, Figure. 4). No significant heterogeneity was observed (I² = 0%). The meta-regression by bubble plot revealed no significant heterogeneity of the sample size (P = 0.241, Supplementary Figure S30) or publication year (P = 0.912, Supplementary Figure S31). Sensitivity analysis (Supplementary Figure S32) and Galbraith plots (Supplementary Figure S33) were performed to evaluate the stability of our results. The analysis results suggested that no individual studies significantly affected the pooled OR, indicating that the results were statistically robust. No significant publication bias was found in the results of Begg’s plots (P = 0.453, Supplementary Figure S34), Egger’s test (P = 0.793, Supplementary Figure S35) or the funnel plot (Supplementary Figure S36).

Main Findings

Contrary to previous studies²⁹, our meta-analysis demonstrated that DCBs had a significantly higher primary patency rate of target lesions than CBs at 6 and 12 months after angioplasty. Meanwhile, we observed that there were some regional differences in the above conclusions. Overall, DCB has a higher primary patency rate at 6 months after balloon expansion in Asia and Oceania, but in Europe and North America, there is no significant difference between DCB and CB treatment. DCB has a higher primary patency rate at 12 months after balloon expansion in Asia and Europe, but in Oceania, there is no significant difference between the two groups. There was no statistically significant difference in all-cause mortality between the two groups at 6 months and 12 months.

Interpretation

Most patients with end-stage renal disease require long-term haemodialysis treatment, and vascular access is essential for effective haemodialysis. At present, long-term haemodialysis treatment mainly relies on AVF and AVG. Among them, AVF has become the first choice for dialysis access due to its advantages of long application time and fewer intervention times³⁰. However, with the gradual prolongation of the application time of AVF, the incidence of vascular access-related complications such as AVF stenosis or even occlusion has increased significantly. Several studies have shown that the AVF patency rate after 1 year is usually only 60–65%⁴. A large number of studies have shown that the main mechanism of AVF stenosis is that under the proinflammatory state of chronic kidney disease, haemodynamic changes caused by different anatomical morphologies of dialysis access and repeated puncture promote the proliferation of vascular intima tissue, make the vascular lumen smaller, and eventually lead to the failure of dialysis access³¹. An effective solution to AVF stenosis is to use secondary surgery to re-establish the internal fistula, but this will reduce the vascular resources of dialysis patients and eventually lead to the depletion of vascular resources.

With the advancement of medicine, PTA has gradually become one of the main methods for the treatment of AVF stenosis. In recent years, high-pressure balloons, cutting balloons and other instruments have been gradually used in clinical practice, but there is still a high incidence of restenosis, as high as 55%-75% within one year²⁷. It has been suggested that PTA is associated with a high restenosis rate of AVF, and intimal hyperplasia is the main pathophysiological mechanism of restenosis after PTA⁶. A better solution was needed, so a drug-coated balloon (DCB) approach was developed.

DCB was originally used in coronary and lower extremity arterial interventional therapy, with drugs that inhibit cell proliferation attached to the surface of balloons. At present, paclitaxel is the most commonly used drug for DCB. The lipophilicity of paclitaxel can increase the tissue drug absorption rate so that it can effectively inhibit cell migration and proliferation at low concentrations⁷. When paclitaxel-coated balloons are used to dilate stenotic blood vessels, the balloon can rapidly release drugs, make drugs enter the vessel wall quickly, inhibit the proliferation of smooth muscle, and prevent restenosis⁸.

In recent years, there have been a few studies on the use of DCBs in the treatment of AVF stenosis. However, the sample size of these studies was small, which may lead to bias in the results¹⁰. In addition, some RCT findings are also controversial. This meta-analysis showed that compared with CB angioplasty, DCB angioplasty had a higher primary patency rate of target lesions at 6 and 12 months after the operation, and the difference was statistically significant (P < 0.05). This confirmed that DCB could delay the occurrence of restenosis of AVF, improve the primary patency rate of target lesions, and thus prolong the vascular access time of patients with end-stage renal disease.

In addition, studies have shown that the use of paclitaxel DCB can increase the risk of death in patients with peripheral artery disease, which has aroused widespread concern about the safety of paclitaxel-related endovascular devices³². However, some scholars questioned whether the above analysis results were affected by selection bias³³. Recently, a large number of studies have shown that paclitaxel DCB is safe, and there is no significant correlation between the use of paclitaxel and the death of patients^{34, 35}. In terms of the safety of paclitaxel DCB in AVF stenosis, the results of this study showed that there was no significant difference in all-cause mortality between the DCB group and the POBA group at 6 and 12 months after the operation (P > 0.05). Therefore, we believe that there is currently no evidence that paclitaxel DCB increases mortality in patients with AVF.

However, it is worth noting that although DCBs can prolong the primary patency rate of target lesion pairs without increasing the mortality rate of patients, the wide application of DCBs in the treatment of AVF stenosis is limited due to the large difference in price between DCBs and CB, their high initial treatment cost, and unclear potential economic benefits.

Strengths And Limitations

First, our meta-analysis was performed by strict quality control evaluated by Cohen’s kappa coefficient (κ = 0.823, 95% CI: 0.642–0.937), which showed a high degree of agreement. Second, contrary to previous studies²⁹, our study included more higher quality RCTs (n = 15), and we attempted to be as inclusive and transparent in this manuscript in terms of our methods, including all origins of software and websites. Third, we refined our analyses strictly in accordance with the PICOS principle. We performed rigorous statistical analysis. For instance, the L'Abbe plot and Galbraith plot were used to evaluate the consistency and quality of the results. Sensitivity analysis, meta-regression and subgroup analysis with a choropleth map were performed to determine sources of heterogeneity. Publication bias was evaluated using Begg's and Egger's tests and a funnel plot. Specifically, we conducted 4 subgroup analyses according to different countries and continents to make our findings more comprehensive and rigorous.

However, several limitations of our meta-analysis should be considered. First, the true event rates of participants lost to follow-up are unpredictable and unlikely to be at either extreme of our assumptions. Second, the paclitaxel doses were variable in studies analyzed, which could have affected our conclusions. Third, the concomitant diseases of patients included in various institutes were different, which may lead to a risk of bias. Fourth, this meta-analysis did not include a particularly large number of RCTs and could have affected our conclusions.

In conclusion, compared with CB, DCB as a new endovascular treatment for AVF stenosis has a higher primary patency rate of target lesions and can delay the occurrence of restenosis. At present, there is no evidence that DCB can increase the mortality of patients, but further clinical studies are needed to determine its mid- and long-term efficacy and safety in the treatment of AVF stenosis.

Ethical Approval

All the data used in this meta-analysis has been published, ethical approval is not available.

Competing interests

The authors have no conflicts of interest to disclose.

Authors' contributions

Conceptualization: Xiang-Yang Hu, Zhen-Wu Zou and Yong Zhang

Data curation: Xiang-Yang Hu, Zhen-Wu Zou and Yong Zhang

Formal analysis: Xiang-Yang Hu, Zhen-Wu Zou and Yong Zhang

Investigation: Xiang-Yang Hu, Zhen-Wu Zou and Yong Zhang

Methodology: Xiang-Yang Hu and Zhen-Wu Zou

Project administration: Qi-Bing Wang

Resources: Zhen-Wu Zou and Yong Zhang

Software: Xiang-Yang Hu and Zhen-Wu Zou

Supervision: Qi-Bing Wang and Zhen-Wu Zou

Validation: Xiang-Yang Hu, Zhen-Wu Zou and Yong Zhang

Visualization: Xiang-Yang Hu, Zhen-Wu Zou and Yong Zhang

Roles/Writing - original draft: Xiang-Yang Hu, Zhen-Wu Zou and Yong Zhang

Writing - review & editing: Xiang-Yang Hu, Zhen-Wu Zou and Yong Zhang

Funding

None.

Availability of data and materials

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding authors.

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Table 1

Main characteristics of the included studies.
Study	Country	Sample		DCB vs. CB*		Average age		Dose^#	Follow-up	Result
Study	Country	DCB	CB	6 months	12 months	DCB	CB	(ug/mm2)	(months)
Bjorkman2019	Finland	18	18	--	16/4	67	67.4	3.5	12	①②④
Fransson2022	Sweden	22	20	10/8	4/2	68	62	--	12	②③④
Guo2022	China	20	22	17/12	14/10	63.3 ± 10.7	59.9 ± 11.7	--		①②
Irani2018	Singapore	59	60	48/37	30/20	59.0 ± 11.5	59.4 ± 8.80	3.0	12	③④
Kitrou2015	United Kingdom	20	20	15/0	10/0	64.3 ± 14.5	57 ± 14.2	3.0	12	③④
Kitrou2017	United Kingdom	20	20	8/4	2/1	56.7	57	2	6	①②③④
Lai2014	China Taiwan	10	10	7/0	2/0	67.2 ± 9.4		--	12	③④
Liao2019	China Taiwan	22	22	9/2	8/2	70.4 ± 10.6	65.9 ± 15.9	--	12	③④
Lookstein2020	New Zealand	170	160	125/88	--	65.8 ± 13.1	65.5 ± 13.4	3.5	6	①③
Maleux2018	Belgium	33	31	22/20	14/12	66.9 ± 17.0	69.3 ± 14.85	--	12	①②③④
Moreno2019	Spain	71	69	57/45	41/37	71 ± 11.31	69 ± 12.99	--	12	②③④
Roosen2017	Netherlands	16	18	2/8	1/2	80	83		24	③④
Swinne2019	Australia	68	60	52/28	25/14	65.2 ± 13.6	64.5 ± 13.9	3	12	③④
Trerotola2018	America	141	144	100/91	--	64 ± 15	61 ± 13	2	6	③④
Yin2021	China	78	83	51/31	57/47	56 ± 13	54 ± 13	3	12	②③
①: All-cause mortality at 6 months. ②: All-cause mortality at 12 months. ③: Primary patency rate of target lesion at 6 months after operation.
④: Primary patency rate of target lesion at 121 months after operation. *Target Lesion Primary Patency. ^#Paclitaxel dose.

No competing interests reported.

Supplementaryfigures.doc
Fig S1. PRISMA 2009 flow diagram. Fig S2. Risk of bias assessments for included studies. Fig S3. Forest plot of 6-month primary patency of target lesion. Fig S4. L'Abbe plot of the 6-month primary patency rate. Fig S5. Subgroup analysis of the 6-month primary patency rate. Fig S6. Meta-regression of sample size of 6-month primary patency rate. Fig S7. Meta-regression of publication year of 6-month primary patency rate. Fig S8. Sensitivity analysis of the 6-month primary patency rate. Fig S9. Galbraith plot of the 6-month primary patency rate. Fig S10. Begg' s plots of the 6-month primary patency rate. Fig S11. Egger's plots of the 6-month primary patency rate. Fig S12. Funnel plot of the 6-month primary patency rate. Fig S13. Forest plot of 12-month primary patency of target lesion. Fig S14. L'Abbe plot of the 12-month primary patency rate. Fig S15. Subgroup analysis of the 6-month primary patency rate. Fig S16. Meta-regression of study size of 12-month primary patency rate. Fig S17. Meta-regression of publication year of 12-month primary patency rate. Fig S18. Sensitivity analysis of the 12-month primary patency rate. Fig S19. Galbraith plot of the 12-month primary patency rate. Fig S20. Begg' s plots of the 12-month primary patency rate. Fig S21. Egger' s plots of the 12-month primary patency rate. Fig S22. Funnel plot of 12-month primary patency of target lesion. Fig S23. Meta-regression of sample size of all-cause mortality at 6 months. Fig S24. Meta-regression of publication year of all-cause mortality at 6 months. Fig S25. Sensitivity analysis of all-cause mortality at 6 months. Fig S26. Galbraith plot of all-cause mortality at 6 months. Fig S27. Begg's plots of all-cause mortality at 6 months. Fig S28. Egger's plots of all-cause mortality at 6 months. Fig S29. Funnel plot of all-cause mortality at 6 months. Fig S30. Meta-regression of sample size of all-cause mortality at 12-months. Fig S31. Meta-regression of publication year of all-cause mortality at 12-months. Fig S32. Sensitivity analysis of all-cause mortality at 12 months. Fig S33. Galbraith plot of all-cause mortality at 12 months. Fig S34. Begg's plots of all-cause mortality at 12 months. Fig S35. Egger's plots of all-cause mortality at 12 months. Fig S36. Funnel plot of all-cause mortality at 12 months.
SupplementaryTable.doc
Table S1 Inter-rater agreement for study selection and risk of bias. Table S2. GRADE quality assessment.
Table S3. Search strategy. Table S4. Inclusion or exclusion Criteria.

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Comparison of drug-coated balloon angioplasty versus common balloon angioplasty in hemodialysis patients with arteriovenous fistula stenosis: A meta-analysis of randomised controlled trials

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Abstract

Figures

Introduction

Methods

Study protocol

Search strategy

Eligibility criteria

Data extraction

Summary of effect size

Risk of bias

GRADE Quality Assessment

Statistical Analysis

Results

Study Selection

Primary patency rate of the target lesion

All-cause mortality

Discussion

Main Findings

Interpretation

Strengths And Limitations

Conclusions

Declarations

References

Tables

Additional Declarations

Supplementary Files

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