BACKGROUND: Dysfunctional vascular access is a major cause of morbidity and mortality in patients undergoing hemodialysis, affecting both arteriovenous fistulas and grafts. The most optimal strategy to restore long-term patency has not been established. This meta-analysis compares drug-coated balloon (DCB) versus uncoated balloon (UCB) angioplasty for dysfunctional vascular access. METHODS: We performed a systematic literature search across multiple databases from inception to June 2024. Randomized-controlled trials (RCTs) comparing DCB and UCB in dialysis patients with dysfunctional vascular access were included. Risk ratios were pooled using a random-effects model. RESULTS: Twenty-seven RCTs (2645 patients) were included. Target lesion patency (TLP) at 6 months was significantly superior in the DCB group (RR 1.22, 95% CI 1.07-1.39, p = 0.003). The two regimens were comparable for TLP at 3 months (RR 1.14, p = 0.24) and 12 months (RR 1.14, p = 0.10). The two regimens were comparable in terms of circuit patency rate, target-lesion revascularization, and all-cause mortality. CONCLUSION: DCB has significantly superior TLP and a comparable risk of mortality to UCB. Further research is warranted to identify factors affecting outcomes following DCB angioplasty for dysfunctional dialysis access.