Distal vein ligation in radiocephalic arteriovenous fistula creation: A randomized trial of hemodynamic impact and early maturation.

BACKGROUND

The optimal anastomotic configuration for distal radiocephalic arteriovenous fistula (AVF) creation remains debated, particularly regarding the role of distal venous outflow preservation. This randomized controlled trial compared latero-lateral AVF without distal vein ligation (LL-AVF) versus latero-lateral AVF with distal vein ligation (LLT-AVF) to assess early maturation and hemodynamic performance.

METHODS

We conducted a prospective randomized study including 60 patients with end-stage kidney disease undergoing first distal radiocephalic AVF. Patients were randomized 1:1 to LL-AVF or LLT-AVF. Preoperative duplex ultrasound mapping and standardized surgical technique were used in all cases. The primary endpoint was functional AVF maturation at 30 days, defined as brachial artery flow ⩾500 mL/min and venous diameter ⩾5 mm. Secondary endpoints included brachial artery flow, venous diameter, and resistance index (RI).

RESULTS

Baseline demographic, clinical, and vascular characteristics were comparable between groups. Overall 30-day maturation rate was 75%, with no significant difference between LL-AVF and LLT-AVF (71% vs 77%, p = 0.639). Mean brachial artery flow was 967.1 ± 421.8 mL/min in the LL group and 1028.5 ± 444.2 mL/min in the LLT group (p = 0.303). Venous diameter was similar between groups (5.2 ± 0.85 mm vs 5.4 ± 0.89 mm; p = 0.148). One case of venous congestion occurred and was successfully managed with distal vein ligation.

CONCLUSIONS

Latero-lateral radiocephalic AVF with or without distal vein ligation results in comparable early maturation rates and similar hemodynamic outcomes at 30 days. Although distal vein ligation is associated with a lower early resistance index, this does not translate into improved functional maturation. Preservation of distal venous outflow appears to be a safe and effective alternative strategy in distal AVF creation.