The effect of blood flow training restriction on endothelial function and arterial stiffness: a systematic review and meta-analysis

Background Blood flow restriction training (BFRT) is used to enhance low-load exercise, but vascular effects remain uncertain. We compared BFRT with matched non-BFRT exercise on endothelial function, arterial stiffness, and vascular structure.Methods This PRISMA 2020 review was preregistered (PROSPERO CRD420251118357). PubMed, Web of Science, Cochrane Library, and Chinese National Knowledge Infrastructure were searched on October 2, 2025, with systematic snowballing. Randomized parallel-group, crossover, or within-subject controlled trials were pooled using random-effects models (three-level or conventional) to estimate Hedges’ g; subgroup/meta-regression examined moderators; RoB2, PEDro, and GRADE assessed study quality.Results Thirty-five trials (n = 764) were included. Overall, BFRT showed no advantage for flow-mediated dilation (FMD; k = 30; g = −0.10) or pulse wave velocity (PWV; k = 32; g = −0.04); pooled effects were also non-significant for blood flow, AIx, CAVI, arterial diameter, and ankle–brachial index. Effects depended on protocol: resistance BFRT improved FMD (g = 0.56), whereas handgrip (g = −0.85) and some interval/aerobic BFRT reduced FMD; interventions <4 weeks decreased FMD (g = −0.69). Low-load BFRT reduced PWV versus high-load resistance training (g = −0.76). Age positively moderated FMD responses; certainty ranged from very low to moderate.Conclusions Evidence does not support a generalized vascular benefit of BFRT. Low-load resistance BFR may be most favorable, while small-muscle and moderate-to-high-intensity protocols warrant caution. Larger trials, especially in women and clinical populations, are needed.