Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 130-136

Comparative study of the effects of two suturing techniques of End-to-side arteriovenous anastomosis on early outcomes of radio-cephalic fistulas

Padmashree Dr. D. Y. Patil Hospital and Research Centre, Navi Mumbai, Maharashtra, India

Date of Submission23-May-2021
Date of Acceptance06-Jun-2021
Date of Web Publication20-Jan-2022

Correspondence Address:
Sameer Vilas Vyahalkar
Padmashree Dr. D. Y. Patil Hospital and Research Centre, Navi Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_58_21

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Introduction: Radiocephalic arteriovenous fistulas (AVFs) for dialysis have significantly high maturation failure rate. Many surgical technique-related factors are known to impact the outcomes of AVF surgery; anastomotic suturing technique is one such factor for which the published data is sparse. Patients and Methods: We retrospectively analyzed the data of patients who underwent end-to-side radio-cephalic AVF surgery during a 2-year period and grouped it according to the two techniques of anastomotic suturing: Anchor technique and parachute technique. Comparative analysis was done to study the effect of the technique on well-defined outcomes within the first 6 months of surgery. Results: A total of 119 AVFs (anchor technique = 65, parachute technique = 54) were included in the study. The aggregated primary patency at 6 weeks and 6 months was 85.7% and 78.1% respectively and successful use of fistula was seen in 62.2%. The parachute technique was associated with lower immediate access thrombosis (3.7% vs. 15.4%, P = 0.019) and primary failure (31.5% vs. 43%, P = 0.033) than the anchor technique. The groups did not differ statistically in outcomes like early access failure (P = 0.376), maturation failure (P = 0.105), primary patency at 6 weeks (P = 0.07) and at 6 months (P = 0.083) and successful use of fistula at 6 months (P = 0.196). Conclusion: In this retrospective single-center study, the parachute technique of anastomotic suturing was associated with lower incidence of immediate access failure of radio-cephalic AVF as compared to the anchor technique, although other early outcomes were similar with both techniques. The effects of different suturing techniques on surgical outcomes of AVF should be studied in large randomized trials.

Keywords: Early outcomes, end-to-side anastomosis, radiocephalic arteriovenous fistula

How to cite this article:
Vyahalkar SV, Chaudhari AE, Binnani PG, Kulkarni AV, Nagarik AP, Jawade KK, Chandrashekhar SS. Comparative study of the effects of two suturing techniques of End-to-side arteriovenous anastomosis on early outcomes of radio-cephalic fistulas. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:130-6

How to cite this URL:
Vyahalkar SV, Chaudhari AE, Binnani PG, Kulkarni AV, Nagarik AP, Jawade KK, Chandrashekhar SS. Comparative study of the effects of two suturing techniques of End-to-side arteriovenous anastomosis on early outcomes of radio-cephalic fistulas. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 May 25];8, Suppl S2:130-6. Available from:

  Introduction Top

The radio-cephalic arteriovenous fistula (RCAVF) for chronic hemodialysis (HD), first described by Brescia, Cimino, and co-workers in 1965, continues to be the most preferable vascular access (VA) having better technique-survival, lower infection rate and mortality, and lower cost of therapy while preserving proximal sites for access creation in future, as compared to other types of VA.[1] A major factor that precludes a wider use of RCAVFs is maturation failure, with various studies reporting non-maturation rates ranging from 30% to 70%,[2],[3],[4],[5],[6],[7],[8] and this may be an important reason why surgeons are increasingly opting for upper arm arteriovenous (AV) fistula as the primary autologous access.[6],[8],[9],[10] Many factors are implicated in the pathogenesis of nonmaturation of RCAVF, like inadequate vessel diameter, poor inflow, surgical trauma from venous mobilization,[11] and hemodynamic factors in the juxta-anastomotic area like disturbed flow (which, unlike laminar flow leads to maladaptive vascular remodeling) and low and oscillating wall shear stress (WSS),[12] which lead to neointimal hyperplasia, juxta-anastomotic stenosis and thrombosis. Nevertheless, the surgical technique remains the crucial factor deciding the “success” of RCAVF surgery.[13],[14] Quite pertinent to the end-to-side AV anastomosis, which is the most commonly used method of RCAVF creation,[15] are the biomechanical factors that contribute to the phenomenon of disturbed flow and low WSS, like anastomotic compliance, torsional stress on the vein resulting from three-dimensional movement during mobilization[16] and the anastomotic angulation.[16],[17],[18]

The continuous suturing method for AV anastomosis has been criticized to contribute to abnormal hemodynamics in the anastomotic area as it may lead to unequal tension on suture line and a purse-string effect, resulting in anastomotic narrowing and sub-optimum anastomotic compliance.[19] Therefore we carried out a retrospective study of RCAVFs done with two different techniques of continuous suturing, namely the anchor technique and the parachute technique, to compare between the effects of these two techniques on early outcomes of RCAVFs.

  Patients and Methods Top

Data of patients who underwent AV fistula (AVF) surgery by a nephrologist at our institute between September 1, 2018, and August 31, 2020, was analyzed for preoperative demographic characteristics, co-morbidities, intra-operative findings, complications, and immediate patency. Immediate patency, primary (unassisted) patency, functional patency, complications, and AVF fistula maturation parameters on follow-up at 2, 6, 12, and 36 weeks were recorded. Dialysis records of patients whose RCAVFs were used as accesses for HD were analyzed. [Table 1] provides definitions for the study end-points which are adapted from the recommendations of the 'Committee of Reporting Standards for Arteriovenous Access' of the Society for Vascular Surgery and American Association for Vascular Surgery.[20] Exclusion criteria for the study were: Age ≤12 years, secondary AVF constructed utilizing the arterialized outflow vein of a thrombosed AVF, loss of follow-up, AVF in anatomical location other than radio-cephalic AVF and death during the study period with a patent access on last follow up. Patients who had anatomically patent preemptively created AVF but did not undergo dialysis at the end of 6 months of surgery were considered to have indeterminate outcome and were excluded from the study. The study was approved by the Institutional Ethical Committee. Observations were recorded in Microsoft Excel™ spreadsheet and multivariate analysis was entered in contingency tables. Chi-squared test was used to study association between variables from categorical data and t-test was used to analyze paired data; P < 0.05 was considered statistically significant.
Table 1: Definitions of study end-points[20],[21]

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Preparation and operative procedure

Those patients of chronic kidney disease who were recommended for AVF surgery by nephrologists were assessed clinically, with a particular focus on arterial and venous system of the upper extremities. Duplex Doppler ultrasound (DDU) was selectively done in patients who had diabetes mellitus (DM), history of previous failed AVF, or abnormal clinical findings. A diameter of ≥1.8 mm for radial artery and cephalic vein was considered as adequate for RCAVF creation if supported by clinical examination.[24],[25],[26] The RCAVF surgery was done under local anesthesia without loupe magnification after obtaining consent. End-to-side AV anastomosis was created in all RCAVFs. After initial exploration, cephalic vein was marked for orientation, dissected, and freed for a length of approximately 3–5 cm; it was transected after ligating distally with 3-0 silk and then spatulated on posteromedial aspect. Radial artery was exposed for 3–4 cm before clamping, and depending on the venous diameter, 6–10 mm arteriotomy was made on its anterior aspect. Double arm 7-0 or 8-0 polypropylene was used for anastomotic suturing. In the anchor technique [Figure 1], the suture was secured first at the heel region after entering the artery and the vein in an inside-out fashion, and a surgical knot was tied, after which the suture was run continuously across the lateral margins of anastomosis, entering the vein outside-in and the artery inside-out, from heel (proximal end of arteriotomy) to toe (distal end). Then the suture was run to complete suturing the medial margins from heel to toe, entering the artery outside-in and the vein inside-out, and final knots were taken. In the parachute technique [Figure 2], suture was first secured at 11 o'clock position entering both vessels in an inside-out fashion, then continuous suturing was commenced towards 5 o'clock position across the heel, entering the vein outside-in and the artery inside-out, without approximating the vessels. Then, gentle traction was applied on the sutures to allow even distribution of tension along the suture-line and 'parachuting' or approximation of vessel walls together. The suture was then run in a continuous fashion across the proximal margin (toward surgeon) and across the toe region, and finally, surgical knots were applied at midway on the distal margin. Standard surgical practices like maintenance of proper orientation, avoidance of tension on the anastomosis, and ensuring suture line eversion and direct intima to intima contact were followed. Skin closure was done with 3-0 Ethilon mattress sutures. The fistula was examined for the presence of thrill and bruit immediately after surgery and once again after 24 h.
Figure 1: In the anchor technique, the suturing commenced after securing a knot at the heel region or the proximal corner, then completing the posterior wall suturing first (a), and finally the anterior wall suturing (b) before tying knots at the distal corner. (RA: Radial artery, CV: Cephalic vein)

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Figure 2: In the parachute technique, (a) sutures commenced from 11 o'clock position of arteriotomy, entering the artery from inside-out and the vein from outside-in fashion and proceeded to 5 o'clock position across the heel region without approximation of the vessels, and (b) after approximation of vessels, continuous suturing was completed in anticlockwise fashion before finally tying the knots along the posterior wall. (RA: Radial artery, CV: Cephalic vein)

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  Results Top

Baseline characteristics of AVFs done in the study are summarized in [Figure 3]. Out of the 119 RCAVFs that were included, 65 RCAVFs in 64 patients were done with anchor technique (Anchor group), and 54 RCAVFs in 54 patients were done with parachute technique (Parachute group). The age range was 13–75 years (mean 48 ± 15 years). Dominant upper extremity was selected for RCAVF in 10 patients (15.3%) of anchor group and 9 patients (16.6%) of parachute group. The patient population in both groups was comparable in age and gender distribution as well as co-morbidities and location of RCAVF in forearm [Table 2].
Figure 3: Summary of arteriovenous fistula surgeries done during the study period

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Table 2: Comparative distribution of baseline characteristics of study group

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[Table 3] depicts the comparative data of the procedure-associated complications. The incidence of immediate access thrombosis was significantly higher in the anchor group than the parachute group; 10 patients (15.4%) in anchor group and 2 patients (3.7%) in parachute group developed immediate access thrombosis (P = 0.019). Intra-operative hemorrhage from anastomosis requiring additional interrupted suture placement was more common in the parachute group although the difference was not statistically significant (P = 0.770); typically, the hemorrhage occurred at the heel region of anastomosis and possibly resulted from technical error. The incidence of other complications was similar in both groups (P = 0.241).
Table 3: Procedure-related complications

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[Table 4] provides comparative data of the early clinical outcomes. After including patients with immediate thrombosis, the primary patency rate at 6 weeks was 81.5% and 90.7% (P = 0.07), and primary patency at 6 months was 73.8% and 83.3% (P = 0.083) in anchor and parachute groups respectively. Successful use of fistula for HD was seen in 57% and 68.5% of patients in anchor and parachute groups respectively (P = 0.196). In anchor group, there was a significantly higher incidence of immediate access failure due to immediate thrombosis (P = 0.019) and primary failure (P = 0.033) than the parachute group, whereas both groups had similar early access failure and maturation failure.
Table 4: Early clinical outcomes of arteriovenous fistula surgery

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[Table 5] depicts the subgroup analysis of various factors implicated in primary failure of RCAVFs in the study. Primary failure was significantly associated with the presence of DM in anchor group, whereas it was significantly associated with the presence of DM and calcification of radial arteries in parachute group.
Table 5: Association between the risk factors for primary failure of arteriovenous fistula and the anastomotic technique

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  Discussion Top

Clinical studies with different surgical modifications of the end-to-side AV anastomosis are evolving continuously with the aim to improve the geometrical configuration, optimize flow hemodynamics and reduce the inciting events that lead to non-maturation.[16],[19],[27],[28] Various technical modifications of the suturing technique for end-to-side AV anastomosis exist, for example, 4-quadrant technique, anchor technique, parachute technique, and the “back-wall first” or Tellis technique.[19],[29],[30] The variability in surgical techniques, skills and a lack of standardization for anastomosis can significantly affect outcomes of AVF,[31] especially when there is lack of substantial comparative data in literature regarding the outcomes associated with various anastomotic suturing techniques. Our study compares early outcomes with two commonly used techniques of anastomosis and is one of the few studies in this regard.

Immediate access failure on the day of surgery is generally regarded as a 'technical' failure of surgery but may also be due to intrinsic vessel properties.[22],[24] The finding of similar primary patency rates at 6 months and similar rates of successful use of fistula for HD in both groups of suturing techniques despite a significantly lower incidence of immediate failure in parachute group in our study suggests that although parachute technique was technically better in preserving immediate anatomical patency of AVF, the intrinsic vessel properties might have negatively impacted the outcomes of RCAVFs. Conversely, it may also suggest that, with proper vessel selection, the improved immediate access patency with parachute technique may transform into a better primary patency rate. The parachute technique of end-to-side AV anastomosis may be advantageous with respect to equal distribution of tension over the suture line especially in the “heel” region, better visualization of arterial intima throughout the procedure, and ease of doing an anteroposterior AV anastomosis (thus reducing the torsion of the vein).[16]

The maturation outcomes of our study fare comparably with studies by Huijbregts et al.[7] and Schinstock et al.[8] in which primary failure rate was 40% and 37%, and primary patency rate at 6 months was 57% and 50%, respectively. Maturation rates of AVF in our study were also comparable with the study by Kordzadeh et al.,[15] in which 335 patients underwent RCAVFs by parachute technique, with a primary functional maturation rate of 66%. Studies from India have reported primary failure rates in RCAVFs of 15%–22%;[32],[33] however these studies have not included nonmaturation rates in defining primary failure rates.

Factors like elderly age group, female gender, presence of DM, obesity, smoking, peripheral vascular disease, predialysis hypotension, and small vessel sizes are known to have an adverse impact on AVF patency rates.[34],[35] In the present study, DM was significantly associated with higher primary failure in both study groups, whereas radial artery calcification was significantly associated with primary failure in parachute group but not in anchor group. We believe this resulted due to differences in the extent of vascular calcification between the groups, rather than a technique-related factor.

Limitations of our study include the following: First, it is a single-center, single-surgeon, retrospective study. Second, it is possible that primary failures in some of the patients occurred due to improper vessel selection based on physical examination alone since DDU was done selectively in our study. Our policy of selective preoperative DDU study was in accordance with the guidelines by Kidney Disease Outcomes Quality Initiative[36] and the evidence provided by earlier studies that DDU is not mandatory when adequate vessels are defined by clinical examination.[26] Of note, although routine preoperative vascular mapping with DDU is shown to be associated with lower immediate AVF failure,[37] the incidence of primary failure and nonmaturation of RCAVF continues to remain significantly high (30%–70%) despite proper vessel selection.[5],[34] Vessel diameters of both artery and vein of more than 2 mm in forearm are considered desirable for AVF, however, smaller diameters do not preclude a creation of successful AVF;[24],[25],[26] the ideal cut-off values for arterial and venous diameters to predict RCAVF maturation are not known, probably because other factors like presence of arterial inflow insufficiency and endothelial dysfunction may play a role and venous properties like distensibility and the effect of physiological conditions on venous diameter may confound the utility of venous diameter solely for decision making.[26]

  Conclusion Top

The parachute technique of end-to-side AV anastomosis resulted in better immediate anatomical patency than the anchor technique in the present study, although early outcomes of radio-cephalic AVFs at 6 months were similar with both the techniques. Larger randomized studies should be carried out to observe the impact of various anastomotic techniques on outcomes of AVFs.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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