Anchor versus parachute suturing technique in arteriovenous fistula creation for hemodialysis

IntroductionChronic kidney disease (CKD) affects 13% of the global population and requires renal replacement therapy due to ESRD. Hemodialysis (HD) is the most common dialysis modality for ESRD patients, but establishing vascular access is challenging due to high morbidity and mortality rates. Arteriovenous fistulas (AVFs) are the gold standard for vascular access, but many fail due to anastomotic hemodynamics, vein diameter, and anastomatic suture technique. A prospective study was conducted to evaluate the impact of two continuous suturing techniques, the anchor technique and the parachute technique, on AVFs' initial outcomes.MethodsThis randomized, controlled study involved adult patients who presented for AVF creation at our center. We divided the patients into two groups: anchors and parachutes. Four skilled vascular access surgeons performed the procedures. The primary goal was functional maturation of the AVF, defined as an AVF fistula ready to be cannulated with a cannulating vein length of at least 10 cm, a diameter of more than 6 mm, a depth of less than 6 mm, and a flow rate of 600 mL/min. Secondary goals included patency and complications such as bleeding, infection, steal syndrome, and aneurysmal dilatation at the anastomosis site. AVFs were evaluated immediately after surgery and during follow-up visits at the outpatient clinic. A duplex scan was performed to measure flow at various intervals. All patients provided appropriate written consent.ResultThe study involved 186 patients, with 86 excluded. 100 were randomized, with 5 cases losing follow-up and 3 deaths within 12 months. The follow-up continued until January 2024, with a mean of 8.6 months. The Parachute technique shows higher technical success (p value = 0.046) and primary patency at 30 days (p value = 0.014) compared to Anchor, but there is no statistical significance between both groups regarding functional maturation at 6 weeks (p value = 0.352). The parachute technique has a higher hematoma rate than the anchor technique (p value = 0.025), while other complications like intra-operative bleeding, postoperative bleeding, pseudoaneurysm formation, thrombosis, steal syndrome, and seroma formation show no significant differences. Nine patients, five of whom were diabetic and underwent conservative management, exhibited mild to moderate steal syndrome. This suggests an increased risk of steal syndrome among diabetic patients.ConclusionThe parachute technique for AVF creation offers better technical success and short-term primary patency outcomes, while both parachute and anchor techniques are equally effective for long-term functional maturation and overall complication rates.