Clip versus suture anastomosis for arteriovenous fistula: A systematic review and meta-analysis

Introduction: Anastomotic techniques play a crucial role in arteriovenous fistula (AVF) construction and influence longevity. Whilst traditional suturing has been the standard of care for vascular access anastomosis creation, alternative methods such as vascular clips have emerged as a potential technique to improve technical outcomes and influence AVF patency. This systematic review and meta-analysis aims to evaluate the comparative efficacy of suture versus clip-based anastomosis techniques in AV fistula creation. Methods: Studies comparing suture and clip techniques for AV fistula formation were included. The primary outcome was primary patency at 1 year. Secondary outcomes include 2-year primary patency, primary assisted patency, secondary patency, overall failure, mean time to thrombosis, mean operating time and maturation rate. Data were pooled using a random-effects model and statistical significance was assessed at a threshold of p < 0.05. Results: Nine studies were included. Data from 2964 patients were available for analysis. Clip anastomosis was associated with significantly higher 1-year primary patency compared to suture techniques (RR 1.13, 95% CI 1.03–1.23, p = 0.007). Two-year primary patency was also significantly improved in the clip group (RR 1.23, 95% CI 1.13–1.34, p = 0.00001). Mean time to thrombosis was significantly shorter in the suture group (MD 4.36, 95% CI 0.60–8.12, p = 0.02), indicating earlier failure relative to clips. Mean operating time was not statistically shorter in the clip group (RR −6.47, 95% CI −16.49 to 3.55, p = 0.21). Maturation rates were not statistically significant between the groups (RR 1.05, 95% CI 0.95–1.16, p = 0.31). Conclusion: This systematic review and meta-analysis demonstrates evidence that clip anastomosis may offer superior patency and longevity for AV fistula access when compared to standard of care. Studies were largely retrospective in nature and heterogeneity may influence results. Higher quality studies comparing clip and suture-based techniques are required to validate these outcomes.