Ten Years of Experience and Outcomes in Arteriovenous Fistula Creation: Should we be Performing Suture or Clip Anastomosis?
Samantha Terranella, M.D., Marie Fefferman, B.S., Yanyu Zhang, M.S., Edward Hollinger, M.D., Oyedolamu Olaitan, M.D., Martin Hertl, M.D., Stephen Jensik, M.D., Richard Keen, M.D., Edie Chan, M.D..
Rush University, Chicago, IL, USA.
Objective: Studies examining anastomotic techniques in arteriovenous fistula (AVF) creation have demonstrated either equivalent or improved patency rates and decreased operative time in clips compared to standard suturing technique. This study is a quality assessment to determine the one-year complication rate, difference in operative time and cost variability in patients undergoing upper extremity autologous AVF creation using clip vs. polypropylene suture technique over a ten-year period at a single institution.
Methods: 405 patients between 2009 and 2018 were retrospectively analyzed. Only patients undergoing autologous AVF creation in the upper extremity were included. Patients were stratified by age and sex. A systematic chart review was performed to determine surgical technique (U-clip, AnastoClip or polypropylene), OR time, and complications (aneurysm, stenosis and thrombosis) within one-year. A cost analysis was performed at the conclusion of the study.
Results: 405 patients underwent autologous upper extremity AVF creation (283 using continuous suturing and 122 using interrupted clips). 186 patients were female and 219 were male with a mean age of 56. Fisher’s exact test and logistic regression model with adjustments for age and gender were used to analyze primary outcomes (Table 1). Using suture technique, patients were more likely to experience aneurysm (OR: 1.54, 95%CI: 0.31-7.56), thrombosis (OR: 1.28, 95%CI: 0.67-2.45) and stenosis (OR: 1.28, 95%CI: 0.76-2.17); however, the difference was not statistically significant. Using a linear regression model to adjust for age, gender and surgeon, there was no statistical difference in mean OR time (suture: 112.9 mins vs. clip: 109.46 mins, p = 0.42). When evaluating the cost of each technique, the reimbursement rates were equivalent (all procedures billed by CPT code 36821); however, the cost to the hospital for the material was 7x more for the clips.
Table 1: Post-operative complication rates
| Variable | Levels | Total | Suture (N = 283, 69.88%) | Clip (N = 122, 30.12%) | Chi-Square Test p-value | |||||
| N | % | N | Col % | N | Col % | |||||
| Aneurysm | > .999 F | |||||||||
| Yes | 10 | 2.48 | 7 | 2.48 | 3 | 2.48 | ||||
| No | 393 | 97.52 | 275 | 97.52 | 118 | 97.52 | ||||
| Thrombosis | 0.3505 | |||||||||
| Yes | 60 | 14.93 | 45 | 16.01 | 15 | 12.40 | ||||
| No | 342 | 85.07 | 236 | 83.99 | 106 | 87.60 | ||||
| Stenosis | 0.9257 | |||||||||
| Yes | 102 | 25.31 | 72 | 25.44 | 30 | 25.00 | ||||
| No | 301 | 74.69 | 211 | 74.56 | 90 | 75.00 | ||||
Conclusion: Despite previous data to support improved patency and shorter OR time, the use of clips in AVF creation is equivalent to standard suturing technique at one-year with no significant difference in OR time at our institution. With increasing healthcare costs in the U.S., the extra cost of vascular clips may favor the standard polypropylene suture technique when creating an AVF.
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