Snuffbox Versus Cimino Arteriovenous Fistulas: A Single-Center Comparative Analysis

Background The distal-first principle prioritizes distal radio-cephalic sites for hemodialysis access. While snuffbox arteriovenous fistulas (SBAVFs) offer an additional option for future revisions, smaller vessel calibers may impair maturation compared to Cimino fistulas (RCAVFs). Aims We compared the outcomes of SBAVFs and RCAVFs to evaluate whether a SBAVF-first approach is justified. Methods One year outcomes of SBAVFs and RCAVFs (2021–2024) created for hemodialysis were analyzed retrospectively. Endpoints included maturation rates (functioning dialysis or ultrasound results for preemptive cases), reinterventions (specifically proximalizations), and ischemic complications. Access site selection was based on vessel diameter measurements during preoperative sonography (under anesthesia or prior vascular mapping by an angiologist). Results A total of 61 distal radio-cephalic fistulas were created (25 SBAVFs, 36 RCAVFs). Eight patients were lost to follow-up due to unrelated death or transfer to external care. In the SBAVF group (n=23), primary maturation was 52.2% (12/23) and secondary 73.9% (17/23). 14 reinterventions were required in 11 patients (47.8%), including 12 surgical revisions — eight of which were proximalizations (34.8%)—and two percutaneous transluminal angioplasties (PTA). Notably, two cases of steal syndrome (8.7 %) were identified. In the RCAVF group (n=30), primary and secondary maturation rates were 63.3% (19/30) and 83.3% (25/30) respectively. 19 reinterventions were needed in 14 patients (46.7%) including five proximalizations (16.7%) and 11 PTAs. No ischemic complications were observed. Conclusion Snuffbox fistulas have slightly lower maturation rates than Cimino fistulas and require twice as many proximalization procedures. Furthermore, steal syndrome was observed exclusively in the snuffbox fistula group. Consequently, a SBAVF-first approach may not be justified.