Comparison of Nonpenetrating Titanium Clips versus Continuous Polypropylene Suture in Dialysis Access Creation

Abstract

Nonpenetrating titanium surgical clips (clips) offer a theoretical advantage of inducing less intimal hyperplasia at an anastomosis because of less endothelial injury. Whether this translates into improved outcomes when used in the creation of arteriovenous fistulas (AVFs) remains unclear. We sought to compare the maturation, patency, and failure rates of anastomoses created using traditional continuous polypropylene suture and clips. All primary AVF created at a single Veterans Administration Medical Center were reviewed over a 6-year period. Anastomoses were created with either clips or suture based on surgeon preference. Patient characteristics and surgical outcomes were collected. Comparisons were made between the 2 groups. Over a 6-year period, 334 fistulas were created (29% suture and 71% clips) in 326 patients. The mean age was 64.8 ± 11 years with 98% males. Comorbidities included diabetes (70%), hypertension (96.1%), and tobacco use (52.9% previous or current). Approximately half the patients were predialysis. Comparison of patient characteristics showed no differences between the suture and clip groups. There was no significant difference in maturation rate (suture 79% versus clips 72%, P = 0.25), median time to maturation (suture 62 ± 35 versus clips 71 ± 13 days, P = 0.07), 1 year primary patency rate (suture 37.4% versus clips 39.6, P = 0.72), 1 year assisted primary patency rate (suture 82.4% versus clips 76.3%, P = 0.31), or overall failure rates (suture 62% versus clips 58%, P = 0.56). Median time to initial failure or reintervention was not significantly different in the clip group (suture 615 [range, 239-991] versus clips 812 [range, 635-989] days, P = 0.72). Compared to traditional polypropylene suture creation of upper extremity AVFs, nonpenetrating clips had equivalent maturation, 1-year patency, and overall failure rates. Neither clips nor suture offers any clear advantage in the creation of AVF.