End-To-Side versus Side-To-Side Anastomosis in Upper Limb Arteriovenous Fistula for Dialysis Access: A Systematic Review and a Meta-Analysis

Background: An arteriovenous fistula (AVF) is the best modality for hemodialysis access. The end-to-side (ETS) technique has been suggested in the literature to produce superior results to the side-to-side (STS) approach; however, in the absence of a systematic review, this practice remains debatable. Methods: Online search for randomized controlled trials and observational studies that compared the ETS versus the STS anastomosis techniques in creating an upper limb AVF. Aims were to systematically assess the difference between both procedures in terms of access maturation, patency, and postoperative complications. Results: Seven studies were included with 463 patients in the ETS group and 523 in the STS group. The difference between the 2 techniques was not significant in relation to patency rates at 3, 6, 12, and 24 months (P values: 0.28, 0.82, 0.54, and 0.21, respectively). There were fewer cases of postoperative hematoma in the ETS group; however, the difference was not significant (P = 0.09). Arterial steal syndrome was found to be significantly associated with the STS configuration in pooled analysis (pooled risk ratio = 0.11 [ 0.01-0.88], 95% CI, P = 0.04). Conclusions: Similar maturation rates between ETS and STS fistula configuration, however, arterial steal syndrome was significantly associated with the STS technique. ETS will likely remain as the preferred AVF configuration as it is less technically demanding.