title: A multicenter study of permanent hemodialysis access patency: beneficial effect of clipped vascular anastomotic technique.
abstract: OBJECTIVE
  There is an urgent and compelling need to reduce the morbidity and expense of maintaining hemodialysis vascular access patency. This large, long-term, retrospective, multicenter study, which compared access patency of autogenous arteriovenous fistulas (AVF) and synthetic bridge grafts (AVG) created with conventional sutures or nonpenetrating clips, was undertaken to resolve conflicting results from previous smaller studies.
  
  
  METHODS
  Patency data for 1385 vascular access anastomoses (clipped or sutured) was obtained from 17 hospitals and dialysis centers (Appendix). Five hundred eighteen AVF (242 clip, 276 suture) and 827 AVG (440 clip, 384 suture) were analyzed. Statistical comparisons were made with Kaplan-Meier survival analysis, log-rank test, two-sample t test, and X(2) test. The Cox proportional hazards model was used to confirm Kaplan-Meier analysis.
  
  
  RESULTS
  Access patency (primary, secondary, overall, and intention to treat) was significantly improved in access anastomoses constructed with clips. In the intention-to-treat group, primary patency at 24 months was 0.54 for clipped AVF and 0.34 for sutured AVF, and was 0.36 for clipped AVG and 0.17 for sutured AVG. At 24 months, primary patency rate for AVF successfully used for dialysis was 0.67 for clips and 0.48 for sutures, and for AVG was 0.39 for clips and 0.19 for sutured constructs. Interventions necessary to maintain patency were significantly fewer in clipped anastomoses.
  
  
  CONCLUSIONS
  Replacing conventional suture with clips significantly reduces morbidity associated with maintaining permanent hemodialysis vascular access. This beneficial effect may be due to the biologic superiority of interrupted, nonpenetrating vascular anastomoses.
authors.affiliation: Washington University School of medicine, One Barnes Hospital Plaza, Suite 6107 Queeny Tower, St Louis, MO 63110, USA. ShenoySu@msnotes.wustl.edu
authors.forename: Surendra
authors.initials: S
authors.lastname: Shenoy
authors.forename: Arnold
authors.initials: A
authors.lastname: Miller
authors.forename: Floyd
authors.initials: F
authors.lastname: Petersen
authors.forename: Wolff M
authors.initials: WM
authors.lastname: Kirsch
authors.forename: Taylor
authors.initials: T
authors.lastname: Konkin
authors.forename: Peter
authors.initials: P
authors.lastname: Kim
authors.forename: Cindy
authors.initials: C
authors.lastname: Dickson
authors.forename: A Frederick
authors.initials: AF
authors.lastname: Schild
authors.forename: Leslie
authors.initials: L
authors.lastname: Stewart
authors.forename: Martha
authors.initials: M
authors.lastname: Reyes
authors.forename: Lennart
authors.initials: L
authors.lastname: Anton
authors.forename: Robert S
authors.initials: RS
authors.lastname: Woodward
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000379:methods*; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000379:methods*; D012189:Retrospective Studies; D013536:Suture Techniques; D014654:Vascular Patency