Economic Evaluation of Suture Versus Clip Anastomosis in Arteriovenous Fistula Creation.

OBJECTIVE Techniques like the use of nonpenetrating vascular clips for arteriovenous fistula (AVF) anastomotic creation have been developed in an effort to reduce fistula-related complications. However, the outcome data for the use of clips remains equivocal, while cost evaluations to support their use have been largely theoretical. Therefore, this study aimed to determine both the clinical and cost outcomes of AVFs created with nonpenetrating vascular clips compared to continuous suture technique over a 10-year period at a single institution. METHODS All patients undergoing AVF creation in the upper extremity from 2009 through 2018 were retrospectively analyzed. Patient demographics and AVF outcomes were collected and compared by the surgical technique used. A cost analysis was performed on a subgroup of patients from the years 2013 to 2018. RESULTS During the 10-year study period, 916 AVFs were created (79% using continuous suture technique and 21% using nonpenetrating vascular clips). Patient demographics and comorbid conditions did not differ between the two groups, and there were no differences between maturation, primary patency, assisted primary patency or complication rates between groups at one year. The suture group had a shorter time to maturation (4.3 months vs. 5.5 months, p<0.01) and improved secondary patency compared to clips (77.13% vs. 69.59%, p = 0.03) Cost analysis of the procedures revealed a significant difference in direct cost (suture $1,389.26 vs. clip $1,716.51, p<0.01) and contribution margin (suture $1,770.19 vs. clip $1,128.36, p<0.01) for the two groups. CONCLUSIONS Both suture and clip techniques in AVF creation demonstrate equivalent rates of maturation, primary patency, assisted primary patency and complications at one-year with higher expense associated with the use of clips. Thus, in an effort to reduce the economic burden of healthcare in the U.S., the findings from this study support the preferential use of standard polypropylene suture technique when creating upper extremity AVFs.