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Terranella S, Fefferman M, Zhang Y, Wright K, Hollinger E, Olaitan O, Hertl M, Jensik S, Keen R, Chan E. Economic evaluation of suture versus clip anastomosis in arteriovenous fistula creation. J Vasc Surg 2020; 73:2098-2104. [PMID: 33249206 DOI: 10.1016/j.jvs.2020.10.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Techniques such as 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 outcomes data for the use of clips have remained equivocal, and the cost evaluations to support their use have been largely theoretical. Therefore, the present study aimed to determine both the clinical and the cost outcomes of AVFs created with nonpenetrating vascular clips compared with the continuous suture technique during 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. The patient demographics and AVF outcomes were collected and compared stratified by the surgical technique used. A cost analysis was performed of a subgroup of patients from 2013 to 2018. RESULTS During the 10-year study period, 916 AVFs were created (79% using the continuous suture technique and 21% using nonpenetrating vascular clips). Patient demographics and comorbid conditions did not differ between the two groups, and no differences were present in maturation, primary patency, assisted primary patency, or complication rates between the two groups at 1 year. The suture group had a shorter time to maturation (4.3 months vs 5.5 months; P < .01) and improved secondary patency compared with the clip group (77.13% vs 69.59%; P = .03) The cost analysis of the procedures revealed a significant difference in direct costs (suture, $1389.26 vs clip, $1716.51; P < .01) and contribution margin (suture, $1770.19 vs clip, $1128.36; P < .01) for the two groups. CONCLUSIONS Both suture and clip techniques in AVF creation demonstrated equivalent rates of maturation, primary patency, assisted primary patency, and complications at 1 year with higher expense associated with the use of clips. Thus, in an effort to reduce the economic burden of healthcare in the United States, the findings from the present study support the preferential use of the standard polypropylene suture technique when creating upper extremity AVFs.
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Affiliation(s)
- Samantha Terranella
- Division of Surgery, Department of Surgery, Rush University Medical Center, Chicago, Ill.
| | - Marie Fefferman
- Division of Surgery, Department of Surgery, Rush University Medical Center, Chicago, Ill
| | - Yanyu Zhang
- Bioinformatics and Biostatistics Core, Rush University Medical Center, Chicago, Ill
| | - Kathleen Wright
- Financial Planning and Decision Support, Rush University Medical Center, Chicago, Ill
| | - Edward Hollinger
- Division of Surgery, Department of Surgery, Rush University Medical Center, Chicago, Ill
| | - Oyedolamu Olaitan
- Division of Surgery, Department of Surgery, Rush University Medical Center, Chicago, Ill
| | - Martin Hertl
- Division of Surgery, Department of Surgery, Rush University Medical Center, Chicago, Ill
| | - Stephen Jensik
- Division of Surgery, Department of Surgery, Rush University Medical Center, Chicago, Ill
| | - Richard Keen
- Department of Surgery, John H. Stroger Hospital of Cook County, Chicago, Ill
| | - Edie Chan
- Division of Surgery, Department of Surgery, Rush University Medical Center, Chicago, Ill
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Ross JR. Creation of Native Arteriovenous Fistulas with Interrupted Anastomoses Using a Self-Closing Clip Device - One Clinic's Experience. J Vasc Access 2018; 3:140-6. [PMID: 17639476 DOI: 10.1177/112972980200300402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The nitinol U-CLIP™ Anastomotic Device (Coalescent Surgical, Inc., Sunnyvale, CA) is a self-closing penetrating vascular clip that reduces suture management and eliminates knot tying, thus enabling rapid and precise interrupted suture placement and facilitating creation of an optimal vascular anastomosis. This report describes the use of U-CLIP devices in the surgical creation of native arteriovenous fistulas in 68 chronic hemodialysis patients. Overall, 61 of the 65 fistulas created matured successfully within 8–9 weeks. Radial cephalic fistulas: 93% were mature at 8 weeks. Brachiocephalic fistulas: 69% were mature at 8 weeks. One-stage basilic vein transposition: 100% were mature at 9 weeks. Two-stage basilic vein transposition: 100% were mature at 8 weeks after second stage. The results in this report show the excellent performance of U-CLIP vascular clips in the creation of several types of native arteriovenous fistulas in chronic hemodialysis patients. The fistulas created using the U-CLIP devices had a high maturation rate within a relatively short time period, and provided uniformly high flow rates. The patients in this study were a challenging population, with a high incidence of diabetes mellitus (81% of the patients) and vein sizes that were smaller than typically used for fistula creation. The U-CLIP™ Anastomotic Device offers the opportunity to create superior interrupted anastomoses for AV fistulas, even in patients who would otherwise be considered poor candidates for fistula creation.
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Affiliation(s)
- J R Ross
- General Surgery, Bamberg County Hospital, Bamberg, South Carolina - USA
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3
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Thomas M, Nesbitt C, Ghouri M, Hansrani M. Maintenance of Hemodialysis Vascular Access and Prevention of Access Dysfunction: A Review. Ann Vasc Surg 2017; 43:318-327. [DOI: 10.1016/j.avsg.2017.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 02/28/2017] [Indexed: 01/24/2023]
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4
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Comparison of Nonpenetrating Titanium Clips versus Continuous Polypropylene Suture in Dialysis Access Creation. Ann Vasc Surg 2016; 32:15-9. [DOI: 10.1016/j.avsg.2015.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 11/18/2015] [Accepted: 11/24/2015] [Indexed: 11/17/2022]
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5
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A Nitinol “U-Clip” versus Sutured Arteriovenous Anastomosis: Local Tissue Response and Intimal Hyperplasia Development in a Sheep Model. Eur J Vasc Endovasc Surg 2015; 49:344-52. [DOI: 10.1016/j.ejvs.2014.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 12/17/2014] [Indexed: 11/17/2022]
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6
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Growing Cava Vein Anastomosis: Comparison of Cross-Clamping and Suture Times Using VCS Metallic Clips, Interrupted Nonabsorbable, or Continuous Absorbable Suturing Techniques. Ann Vasc Surg 2013; 27:947-53. [DOI: 10.1016/j.avsg.2013.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 03/19/2013] [Indexed: 11/23/2022]
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7
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Vascular anastomotic clips revisited. Eur J Vasc Endovasc Surg 2011; 43:232. [PMID: 22182352 DOI: 10.1016/j.ejvs.2011.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 11/26/2011] [Indexed: 11/22/2022]
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8
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Calles-Vázquez MC, Viguera FJ, Crisóstomo V, Usón-Gargallo J. Vascular Closure Stapler Clip Anastomosis Decreases Aortic Cross-Clamping Time Compared to Interrupted Nonabsorbable and Running Absorbable Sutures in Growing Pigs. Ann Vasc Surg 2006; 20:35-41. [PMID: 16378146 DOI: 10.1007/s10016-005-9321-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The latest generation in titanium clip application systems, the vascular closure staples (VCS) system avoids intimal lesions and therefore minimizes the subsequent hyperplastic reaction, while at the same time enhancing distensibility and vascular growth. Moreover, VCS clips allow the surgeon to perform vascular anastomosis easily and faster than conventional suture. This system may become the option of choice for vascular reconstruction in pediatric surgery where, as in the case of aortic and transplant surgery, decreasing vascular occlusion times may influence the outcomes. The aim of this study was to determine whether VCS metallic clips would allow shorter anastomosis times than conventional interrupted polypropylene or running Dexon suturing in end-to-end anastomosis performed in the abdominal aorta of young pigs. Twenty-four domestic swine, 45 days old, were used for this study. All animals were subjected to an end-to-end anastomosis in the abdominal aorta using VCS clips, interrupted polypropylene, or running Dexon suture. Aortic cross-clamping time was significantly shorter in the VCS clips group (4.02 +/- 0.72 min), compared to interrupted polypropylene (21.89 +/- 1.93 min) or running Dexon (9.82 +/- 3.97 min) suture. VCS clips are easy to use, and therefore may aid surgeons to significantly decrease the time needed for performing an end-to-end anastomosis in the abdominal aorta, thus decreasing cross-clamping time when compared to interrupted polypropylene or running Dexon sutures.
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Zeebregts CJ. Non-penetrating Clips for Vascular Anastomosis. Eur J Vasc Endovasc Surg 2005; 30:288-90. [PMID: 15893485 DOI: 10.1016/j.ejvs.2005.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Accepted: 04/06/2005] [Indexed: 11/17/2022]
Affiliation(s)
- C J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands.
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Abstract
Use of arteriovenous fistulas, grafts and central venous catheters for haemodialysis access varies considerably, because of perceived patient variables and preferences of surgeons, nephrologists and dialysis staff. Evidence clearly indicates that the arteriovenous fistula is superior to other methods of access in terms of patient survival, flow rates, patency, infection rates, expense and ease of maintenance. Strategies to increase the use and longevity of fistulas for definitive haemodialysis access include vein preservation, early referral for fistula surgery, preoperative clinical and ultrasound assessment of the venous and arterial systems, access surveillance, good cannulation technique, and aggressive conservatism in surgical and/or radiological correction of fistula problems.
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Affiliation(s)
- David Ma Francis
- Royal Melbourne Hospital, St Vincent's Hospital and Royal Children's Hospital, Melbourne, Victoria, Australia.
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Zeebregts CJ, van den Dungen JJAM, van Det RJ, Verhoeven ELG, Geelkerken RH, van Schilfgaarde R. Randomized clinical trial of continuous sutures or non-penetrating clips for radiocephalic arteriovenous fistula. Br J Surg 2004; 91:1438-42. [PMID: 15386322 DOI: 10.1002/bjs.4719] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Despite several modifications to the original design, patency rates of radiocephalic arteriovenous fistulas have changed little since the first report in 1966. The use of non-penetrating clips for vascular anastomosis on the outcome of such fistulas was studied.
Methods
Between January 2000 and August 2003, 107 primary radiocephalic fistulas were constructed in 98 patients. The vascular anastomoses were performed at random with either sutures (n = 56) or clips (n = 51).
Results
Although there were trends for better primary and primary assisted patency of clipped fistulas, the differences were not statistically significant. The 6-month primary patency rate was 61 per cent with sutures and 69 per cent with clips (P = 0·393). The mean(s.d.) primary patency was 315(306) and 285(285) days for clipped and sutured fistulas respectively. With regard to secondary patency, clipped fistulas were better (P = 0·009). The mean(s.d.) secondary patency was 435(376) and 344(316) days for clipped and sutured fistulas, respectively. There were no significant differences in flow characteristics, number of revisions or other morbidity.
Conclusion
This randomized clinical trial provided further evidence that the use of vascular clips may improve the patency rate of radiocephalic arteriovenous fistulas for haemodialysis.
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Affiliation(s)
- C J Zeebregts
- Department of Surgery, University Hospital Groningen, Groningen, The Netherlands.
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Zeebregts CJ, Kirsch WM, van den Dungen JJ, Zhu YH, van Schilfgaarde R. Five years' world experience with nonpenetrating clips for vascular anastomoses. Am J Surg 2004; 187:751-60. [PMID: 15191871 DOI: 10.1016/j.amjsurg.2003.08.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2003] [Revised: 08/11/2003] [Indexed: 11/22/2022]
Abstract
BACKGROUND A new sutureless technique has been introduced clinically to facilitate the process of vascular reconstruction and improve patency. The Vessel Closure System (VCS) is nonpenetrating, creates an elastomeric everted anastomosis, and is easily and reproducibly applied. The objective of this report is to review the published world experience that has accrued regarding these clips with attention to the assets, liabilities, and pitfalls associated with the new technology. DATA SOURCES Medline search and manual cross-referencing were performed, after which 61 original articles were identified on the use of VCS clips for vascular anastomoses. RESULTS Advantages of the clips compared with sutures include the technical ease of application, the reduced anastomotic time, the superior hemodynamics, and the improved healing pattern of the anastomosis. Disadvantages include the potential problems in atherosclerotic vessels, lack of prospective randomized long-term follow-up, and initial costs. The best clinical results have been achieved in microvascular repair, as well as with vascular access and transplantation surgery. CONCLUSIONS The VCS clip technology has become an accepted vascular anastomosing technique, which in future could lead to the use of clips as a standard approach and the use of sutures only in case of severe atherosclerosis and other circumstances in which vessel edges are difficult to evert.
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Affiliation(s)
- Clark J Zeebregts
- Department of Surgery, University Hospital Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands.
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Shenoy S, Miller A, Petersen F, Kirsch WM, Konkin T, Kim P, Dickson C, Schild AF, Stewart L, Reyes M, Anton L, Woodward RS. A multicenter study of permanent hemodialysis access patency: beneficial effect of clipped vascular anastomotic technique. J Vasc Surg 2003; 38:229-35. [PMID: 12891102 DOI: 10.1016/s0741-5214(03)00412-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE There is an urgent and compelling need to reduce the morbidity and expense of maintaining hemodialysis vascular access patency. This large, long-term, retrospective, multicenter study, which compared access patency of autogenous arteriovenous fistulas (AVF) and synthetic bridge grafts (AVG) created with conventional sutures or nonpenetrating clips, was undertaken to resolve conflicting results from previous smaller studies. DESIGN Patency data for 1385 vascular access anastomoses (clipped or sutured) was obtained from 17 hospitals and dialysis centers (Appendix). Five hundred eighteen AVF (242 clip, 276 suture) and 827 AVG (440 clip, 384 suture) were analyzed. Statistical comparisons were made with Kaplan-Meier survival analysis, log-rank test, two-sample t test, and X(2) test. The Cox proportional hazards model was used to confirm Kaplan-Meier analysis. RESULTS Access patency (primary, secondary, overall, and intention to treat) was significantly improved in access anastomoses constructed with clips. In the intention-to-treat group, primary patency at 24 months was 0.54 for clipped AVF and 0.34 for sutured AVF, and was 0.36 for clipped AVG and 0.17 for sutured AVG. At 24 months, primary patency rate for AVF successfully used for dialysis was 0.67 for clips and 0.48 for sutures, and for AVG was 0.39 for clips and 0.19 for sutured constructs. Interventions necessary to maintain patency were significantly fewer in clipped anastomoses. CONCLUSION Replacing conventional suture with clips significantly reduces morbidity associated with maintaining permanent hemodialysis vascular access. This beneficial effect may be due to the biologic superiority of interrupted, nonpenetrating vascular anastomoses.
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Affiliation(s)
- Surendra Shenoy
- Washington University School of medicine, One Barnes Hospital Plaza, Suite 6107 Queeny Tower, St Louis, MO 63110, USA.
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Tiwari A, Cheng KS, Salacinski H, Hamilton G, Seifalian AM. Improving the patency of vascular bypass grafts: the role of suture materials and surgical techniques on reducing anastomotic compliance mismatch. Eur J Vasc Endovasc Surg 2003; 25:287-95. [PMID: 12651165 DOI: 10.1053/ejvs.2002.1810] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND compliance mismatch is an important factor in the development of myointimal hyperplasia in both coronary and vascular anastomoses. This mismatch may be reduced by the use of newer suture materials and techniques. This review discusses the current techniques and materials used to date in generating anastomoses in both coronary and vascular applications and to correlate these with the degree of inherent compliance achieved. METHODS PubMed, ISIS, CAS and PAS database searches were performed. Other articles were cross-referenced. RESULTS AND CONCLUSION continuous suture is still the most used technique in both cardiac and vascular surgery for the generation of anastomoses due to the reduced time and improved haemostasis. However, continuous suture results in a greater compliance mismatch than the interrupted technique. Vein cuffs and patches improve compliance and transmission of pulsatile blood flow and offer improvement of graft patency. Alternative to sutures are biological glue, clips and laser generated solders all of which have shown promising results, but further work is required before they become applicable for routine use.
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Affiliation(s)
- A Tiwari
- Tissue Engineering Centre, University Department of Surgery, Royal Free and University College Medical School, University College London and The Royal Free Hospital, London, UK
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Clips metálicos VCS: una técnica de sutura más rápida y fácil de utilizar que la sutura convencional en reconstrucciones de vasos en crecimiento. ANGIOLOGIA 2003. [DOI: 10.1016/s0003-3170(03)74831-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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