Outcomes of Lower-Extremity Hemodialysis Vascular Access: A Systematic Review and Meta-Analysis.

BACKGROUND

Lower-extremity vascular access is used when conventional upper-extremity options for hemodialysis have failed or are anatomically unsuitable; however, its durability and complication profile remain uncertain. This systematic review and meta-analysis evaluated patency, graft survival, complications, mortality, and access-class differences after lower-extremity hemodialysis access creation.

METHODS

PubMed, Scopus, Web of Science, and MEDLINE were searched from inception to 30 April 2026. Studies of surgically created lower-extremity hemodialysis access in adults were included. Random-effects proportional meta-analyses were performed using logit transformation and inverse-variance weighting. Outcomes were stratified by follow-up duration and access class where feasible.

RESULTS

Forty-five studies, corresponding to 47 reports, were included. Pooled primary patency declined from 69% at 6 months (95% confidence interval [CI], 45%-86%; I2 = 85.5%) to 62% at 12 months (95% CI, 53%-70%; I2 = 85.0%) and 35% at 24 months (95% CI, 22%-43%; I2 = 86.1%). Secondary patency was higher, with pooled estimates of 80% at 6 months (95% CI, 63%-90%; I2 = 78.6%), 81% at 12 months (95% CI, 75%-87%; I2 = 82.5%), and 67% at 24 months (95% CI, 51%-80%; I2 = 90.0%). At 12 months, autogenous arteriovenous fistula/femoral vein transposition (AVF/FVT) had higher primary patency than prosthetic arteriovenous graft (AVG) access (79% vs 53%; subgroup p = 0.0016), supported by direct comparison (risk ratio [RR], 1.23; 95% confidence interval [CI], 1.08-1.39; p = 0.0011). Secondary patency was also higher with AVF/FVT (88% vs 77%; subgroup p = 0.0069; RR, 1.19; 95% CI, 1.13-1.27; p < 0.0001). Pooled thrombosis, infection, leg ischemia, arterial steal, and all-cause mortality rates were 22%, 16%, 10%, 7%, and 17%, respectively. Infection was higher with prosthetic AVG than AVF/FVT (19% vs 7%; p = 0.0054).

CONCLUSIONS

Lower-extremity hemodialysis access provides a viable salvage option, with preserved secondary patency despite declining intervention-free patency. Autogenous AVF/FVT may provide superior 12-month patency and lower infection risk, although heterogeneity and observational evidence require cautious interpretation.