Drug-Coated Balloon Versus Plain Balloon Angioplasty for the Treatment of Dysfunctional Dialysis Access: A Systematic Review and Meta-analysis.

Background: The optimal treatment for dysfunctional dialysis access between drug-coated balloon angioplasty (DCBA) and plain balloon angioplasty (PBA), including standard balloon angioplasty (SBA) and high-pressure balloon angioplasty (HPBA), remains unclear. This study aims to compare the efficacy and safety of DCBA and PBA.

Materials and methods: A systematic review was conducted to identify randomized controlled trials (RCTs) comparing DCBA and PBA. Outcomes included target lesion primary patency (TLPP), access circuit primary patency (ACPP), target lesion revascularization (TLR), technical success, and all-cause mortality. A meta-analysis with a priori subgroup analysis (ie, DCBA vs HPBA and DCBA vs SBA) was performed using a random-effects model to calculate risk ratios (RRs) and 95% confidence intervals (CIs).

Results: Twenty-five RCTs with a total of 2838 patients were included. DCBA showed higher TLPP at 6 months (RR: 1.27, 95% CI: 1.12-1.43, p<0.001) and 12 months (RR: 1.28, 95% CI: 1.13-1.45, p<0.001) than PBA. ACPP was also superior with DCBA at 6 months (RR: 1.25, 95% CI: 1.04-1.40, p=0.002) and 12 months (RR: 1.42, 95% CI: 1.23-1.65, p<0.001). However, no significant difference was found between DCBA and HPBA for TLPP (RR: 1.49, 95% CI: 0.83-2.67, p=0.181) and ACPP (RR: 1.30, 95% CI: 0.92-1.84, p=0.133) at 12 months. TLR was lower with DCBA at 6 months (RR: 0.60, 95% CI: 0.35-0.80, p=0.003) and 12 months (RR: 0.79, 95% CI: 0.68-0.93, p=0.005). No significant difference in the technical success rate and all-cause mortality was observed.

Conclusions: DCBA improves TLPP and ACPP and reduces the TLR rate compared to PBA. However, it shows no significant advantage over HPBA in terms of TLPP and ACPP at 12 months. The technical success rate and all-cause mortality were similar between the 2 approaches.Clinical ImpactThis meta-analysis highlights the differential effectiveness of drug-coated balloon angioplasty (DCBA) compared with standard balloon angioplasty (SBA) and high-pressure balloon angioplasty (HPBA) in dysfunctional dialysis access. DCBA significantly improves primary patency and reduces revascularization rates compared to SBA, supporting its clinical utility. However, no clear advantage was found over HPBA at 12 months. These results suggest that while DCBA offers benefits over SBA, its added value over HPBA remains uncertain. Clinicians should consider individual patient factors and access characteristics when selecting the optimal angioplasty strategy.