Systematic review confirms clip anastomosis improves one and two year primary patency rates for arteriovenous fistula creation compared to suture methods

This systematic review and meta-analysis evaluated the efficacy of clip anastomosis versus suture anastomosis in patients undergoing arteriovenous fistula (AVF) creation. The pooled data, derived from 2,964 patients across multiple studies, provides a robust comparison of these two surgical techniques. The primary focus was on primary patency at one year, with secondary analyses extending to two years and assessing assisted patency, secondary patency, overall failure, time to thrombosis, operating duration, and maturation rates. The findings hold significant implications for vascular surgeons seeking to optimize access longevity.

The analysis revealed that the clip group demonstrated significantly higher primary patency at one year compared to the suture group. The relative risk was 1.13 with a 95% confidence interval of 1.03 to 1.23 and a p-value of 0.007. This favorable outcome suggests that using clips to secure the anastomosis reduces the likelihood of early thrombosis. Furthermore, at the two-year mark, the advantage persisted with a relative risk of 1.23 and a p-value of 0.00001, indicating a sustained benefit for the clip technique over the standard suture method.

Despite the clear patency benefits, the study noted that the mean time to thrombosis was significantly shorter in the suture group. The mean difference was 4.36 days, with a p-value of 0.02, suggesting that suture techniques may lead to earlier failure events. However, the confidence interval for this mean difference ranged from 0.60 to 8.12 days, indicating some variability in the timing of these events across different clinical settings. This earlier failure in the suture group aligns with the lower patency rates observed in the long-term analysis.

Operational metrics showed no statistically significant difference between the two groups regarding mean operating time. The relative risk was -6.47 minutes, with a p-value of 0.21 and a confidence interval spanning from -16.49 to 3.55 minutes. This indicates that the adoption of clip anastomosis does not impose a time penalty on the surgical procedure. Similarly, maturation rates were not statistically significant between the groups, with a relative risk of 1.05 and a p-value of 0.31. The confidence interval for maturation rates ranged from 0.95 to 1.16, suggesting comparable rates of vessel readiness for use.

Safety data were not explicitly reported in the included studies, and no serious adverse events or discontinuations were noted in the available literature. The absence of reported adverse events suggests a comparable safety profile between the two techniques. However, the limitations of the included studies, which were largely retrospective in nature, warrant caution when interpreting these safety findings. Heterogeneity among the studies may also influence the overall results, necessitating further investigation with higher quality prospective trials.

In conclusion, clip anastomosis may offer superior patency and longevity for AV fistula access when compared to the standard of care suture technique. The evidence supports the use of clips to improve long-term outcomes without increasing operative time or compromising maturation. Future research should focus on higher quality studies comparing clip and suture-based techniques to validate these outcomes and address existing limitations. Clinicians should consider these findings when selecting anastomosis methods for their patients.