Distal vein ligation in radiocephalic arteriovenous fistula creation: A randomized trial of hemodynamic impact and early maturation

Background: The optimal anastomotic configuration for distal radiocephalic arteriovenous fistula (AVF) creation remains debated, particularly regarding the role of distal venous outflow preservation. This randomized controlled trial compared latero-lateral AVF without distal vein ligation (LL-AVF) versus latero-lateral AVF with distal vein ligation (LLT-AVF) to assess early maturation and hemodynamic performance. Methods: We conducted a prospective randomized study including 60 patients with end-stage kidney disease undergoing first distal radiocephalic AVF. Patients were randomized 1:1 to LL-AVF or LLT-AVF. Preoperative duplex ultrasound mapping and standardized surgical technique were used in all cases. The primary endpoint was functional AVF maturation at 30 days, defined as brachial artery flow ⩾500 mL/min and venous diameter ⩾5 mm. Secondary endpoints included brachial artery flow, venous diameter, and resistance index (RI). Results: Baseline demographic, clinical, and vascular characteristics were comparable between groups. Overall 30-day maturation rate was 75%, with no significant difference between LL-AVF and LLT-AVF (71% vs 77%, p = 0.639). Mean brachial artery flow was 967.1 ± 421.8 mL/min in the LL group and 1028.5 ± 444.2 mL/min in the LLT group ( p = 0.303). Venous diameter was similar between groups (5.2 ± 0.85 mm vs 5.4 ± 0.89 mm; p = 0.148). One case of venous congestion occurred and was successfully managed with distal vein ligation. Conclusions: Latero-lateral radiocephalic AVF with or without distal vein ligation results in comparable early maturation rates and similar hemodynamic outcomes at 30 days. Although distal vein ligation is associated with a lower early resistance index, this does not translate into improved functional maturation. Preservation of distal venous outflow appears to be a safe and effective alternative strategy in distal AVF creation.