Comparison of side-to-end vs. side-to-side proximal arteriovenous fistula anastomosis in chronic renal failure patients

Abstract

Introduction Anastomotic creation of autogenous arteriovenous fistulas can be performed in different ways, side-to-end or side-to-side. However, there is a paucity of evidence to recommend them. The aim of this study is to compare both anastomosis types in elbow arteriovenous fistulas. Material and methods A prospective observational national multicenter study (ISRCTN62033470) was designed, including patients receiving a native arteriovenous fistula in the elbow using side-to-end or side-to-side anastomosis, between September, 2016 and September, 2017, with six-month postoperative follow-up period. Patient characteristics, surgical details, and follow-up data (primary, assisted primary and secondary patency, maturation, functionality, complications) were recorded and compared between both anastomosis groups using Kaplan–Meier curves estimations, at one and six-month follow-up, and finally a multivariate analysis with Cox regression was performed. Results Three centers participated in the study, including 133 cases (96 side-to-end, 37 side-to-side). The cephalic vein was more often used for side-to-end (58.3%) and basilic for side-to-side (78.4%; P < 0.001). Side-to-end anastomoses were faster to create (65.1–75.1 min; P = 0.009). During follow-up, 23 cases were lost (transplanted, dead, ligated, or lost), with no differences at one month. At six months, primary patency was better for the side-to-end group (78.5 − 55.9%; P = 0.038), but it was not confirmed as an independent predictor in the multivariate analysis. Furthermore, no significant differences in assisted primary or secondary patency, maturation or functionality were seen. Patients with side-to-side anastomosis more often required vein superficialization (2.1–16.2%; P = 0.002) and presented more frequent puncture hematomas (4.9–30.0%; P = 0.015). Conclusions Anastomosis type was not significantly related to different outcomes in the follow-up. Even though side-to-end anastomosis showed better primary patency at six months with lower need of vein superficialization and fewer puncture hematomas during follow-up, it was not confirmed as an independent predictor in the multivariate analysis, and similar assisted primary and secondary patency, maturation, and functionality rates have been seen after arteriovenous fistula creation.

Comparison of end-to-side versus side-to-side anastomosis in upper limb arteriovenous fistula in hemodialysis patients: A systematic review and meta-analysis

“…Thus, it can be concluded that the better patency noted with STS at 12 months in the combined meta-analysis of all studies was influenced by distal vein ligation. These results are similar to another recent meta-analysis of Weigang et al (21) which too noted better patency rates with STS and distal vein ligation but with just seven studies in the review.…”

“…All studies were thoroughly screened to identify 23 articles related to the review topic. Seven studies were excluded and 16 studies were analyzed in our systematic review and meta-analysis (8)(9)(10)(11)(12)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26).…”

“…On the other hand, the STS method is the easier method with the highest fistula flow (28). Nevertheless, STS has a high risk of venous hypertension, AVF-induced ischemia, and greater complexity with vein approximation and mobilization (21). An old study by Wedgwood et al (6) with 71 patients had shown that ETS and STS techniques had a 9-month patency rate of 79.2% and 78.6% respectively.…”

“…Important to note is that the STS technique can be modified with ligation of the distal end of the vein to reduce the incidence of venous hypertension. The nomenclature is still STS in most studies but it has also been named functional ETS by others (21). Single arm studies have reported good outcomes with the STS technique accompanied with distal vein ligation.…”

“…The better patency rates with STS and distal vein ligation could be due to two reasons (21). Firstly, when using this technique repeated turnover of the vessels is avoided as the artery and vein are relatively parallel and stationary.…”