Economic evaluation of suture versus clip anastomosis in arteriovenous fistula creation

J Vasc Surg. 2021 Jun;73(6):2098-2104. doi: 10.1016/j.jvs.2020.10.076. Epub 2020 Nov 27.


Objective: Techniques such as the use of nonpenetrating vascular clips for arteriovenous fistula (AVF) anastomotic creation have been developed in an effort to reduce fistula-related complications. However, the outcomes data for the use of clips have remained equivocal, and the cost evaluations to support their use have been largely theoretical. Therefore, the present study aimed to determine both the clinical and the cost outcomes of AVFs created with nonpenetrating vascular clips compared with the continuous suture technique during a 10-year period at a single institution.

Methods: All patients undergoing AVF creation in the upper extremity from 2009 through 2018 were retrospectively analyzed. The patient demographics and AVF outcomes were collected and compared stratified by the surgical technique used. A cost analysis was performed of a subgroup of patients from 2013 to 2018.

Results: During the 10-year study period, 916 AVFs were created (79% using the continuous suture technique and 21% using nonpenetrating vascular clips). Patient demographics and comorbid conditions did not differ between the two groups, and no differences were present in maturation, primary patency, assisted primary patency, or complication rates between the two groups at 1 year. The suture group had a shorter time to maturation (4.3 months vs 5.5 months; P < .01) and improved secondary patency compared with the clip group (77.13% vs 69.59%; P = .03) The cost analysis of the procedures revealed a significant difference in direct costs (suture, $1389.26 vs clip, $1716.51; P < .01) and contribution margin (suture, $1770.19 vs clip, $1128.36; P < .01) for the two groups.

Conclusions: Both suture and clip techniques in AVF creation demonstrated equivalent rates of maturation, primary patency, assisted primary patency, and complications at 1 year with higher expense associated with the use of clips. Thus, in an effort to reduce the economic burden of healthcare in the United States, the findings from the present study support the preferential use of the standard polypropylene suture technique when creating upper extremity AVFs.

Keywords: Arteriovenous fistula; Autogenous fistula; Clinical outcomes; Cost effectiveness; Dialysis access; Vascular clips.

Publication types

  • Comparative Study
  • Observational Study

MeSH terms

  • Adult
  • Aged
  • Arteriovenous Shunt, Surgical / adverse effects
  • Arteriovenous Shunt, Surgical / economics*
  • Arteriovenous Shunt, Surgical / instrumentation*
  • Cost Savings
  • Cost-Benefit Analysis
  • Female
  • Health Care Costs*
  • Humans
  • Male
  • Middle Aged
  • Postoperative Complications / economics
  • Postoperative Complications / therapy
  • Renal Dialysis / economics
  • Retrospective Studies
  • Surgical Instruments / economics*
  • Suture Techniques / adverse effects
  • Suture Techniques / economics*
  • Time Factors
  • Treatment Outcome
  • Vascular Patency