Modified technique of end to side distal radio-cephalic shunt to overcome juxta-anastomotic stenosis


  • Haitham Atif Department of Surgery, Faculty of Medicine, Menoufia University, Egypt
  • Nehad Abdou Zaid Department of Surgery, Faculty of Medicine, Menoufia University, Egypt
  • Abd El-Mieniem Fareed Mohamed Department of Surgery, Faculty of Medicine, Menoufia University, Egypt
  • Yehia Mohamed Alkhateep Department of Surgery, Faculty of Medicine, Menoufia University, Egypt



Dialysis, JAS, Modified technique, Patency rate, Radiocephalic fistula


Background: Juxta-anastomotic stenosis (JAS) is one of the predominant causes of arteriovenous fistula (AVF) failure, with the reported incidence of 65%, so that technical modification to alter the outflow vein configuration using the modified technique has been applied to prevent JAS and improve AVF maturation. The aim of the study to evaluate the modified technique of end-to-side distal radiocephalic A-V fistula regarding maturation, patency rate and the resultant juxta-anastomotic stenosis.

Methods: This prospective study was carried out on 80 patients with end stage renal disease (ESRD) at vascular surgery unit in general surgery department, Menoufia university hospital that prepared for dialysis. 40 patients "intervention group" underwent the modified technique to establish a functioning radiocephalic fistula; the other group (40 patients, control group) had the conventional technique of end to side radiocephalic fistula. Follow up of patients was over 6 months regarding function, patency rate and development of juxta-anastomotic stenosis.

Results: There was statistically significant difference between 2 groups regarding primary failure, patency and JAS. Primary failure was detected in 2 patients in group A and in 5 patients in group B (p-value is 0.04). Considering patency rate, after 3 months the ratio between group A and group B was 37:34 with significant P value of 0.02, and after 6 months the ratio was 35:33 with P value of 0.03. Regarding JAS, by the end of follow up period, 4 patients diagnosed with JAS in group A, while group B had 8 patients, with p value of 0.01.

Conclusions: Modified technique of end to side anastomosis for primary radio-cephalic fistula creation has better patency rate and low incidence of JAS than conventional method.


Saran R, Robinson B, Abbott KC, Agodoa LY, Albertus P, Ayanian J, et al. US renal data system 2016 annual data report: epidemiology of kidney disease in the United States. Am J kidney Dis. 2017;69(3):7-8.

Weiss MD, Wasdell MB, Bomben MM, Rea KJ, Freeman RD. Sleep hygiene and melatonin treatment for children and adolescents with ADHD and initial insomnia. J Am Aca Child Adolescent Psy. 2006;45(5):512-9.

Konner K, Keller F, Cetto C, Langer S, Hepp W, Thon P, et al. Dialyseshuntchirurgie. Dialyseshunts. Heidelberg: Steinkopff; 2009:119-276.

Wang Y, Krishnamoorthy M, Banerjee R, Zhang J, Rudich S, Holland C, et al. Venous stenosis in a pig arteriovenous fistula model-anatomy, mechanisms and cellular phenotypes. Nephrol Dialysis Transplantation. 2007;23(2):525-33.

Wong CY, de Vries MR, Wang Y, van der Vorst JR, Vahrmeijer AL, van Zonneveld AJ, et al. A novel murine model of arteriovenous fistula failure: the surgical procedure in detail. J Vis Exp. 2016;(108):e53294..

Bharat A, Jaenicke M, Shenoy S. A novel technique of vascular anastomosis to prevent juxta-anastomotic stenosis following arteriovenous fistula creation. J Vasc Surg. 2012;55(1):274-80.

Michael A, Michelle LR. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int. 2002;62(4):1109-24.

Dember LM, Beck GJ, Allon M, Delmez JA, Dixon BS, Greenberg A, et al. Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized controlled trial. JAMA. 2008;299(18):2164-71.

Al-Benna S, Deardon D, Hamilton D, El-Enin H. Long-term outcome of upper limb autogenous arteriovenous fistulas for hemodialysis access. Saudi J Kidney Dis Transplant. 2013;24(1):109.

Murphy GJ, Nicholson ML. Autogeneous elbow fistulas: the effect of diabetes mellitus on maturation, patency, and complication rates. Eur J Vasc Endovasc Surg. 2002;23(5):452-7.

Ali S, Shahzad I, Baloch MU. Arterio venous fistula experience at a tertiary care hospital in Pakistan. Pakistan J Med Sci. 2013;29(1):161-5.

Schinstock CA, Albright RC, Williams AW, Dillon JJ, Bergstralh EJ, Jenson BM, et al. Outcomes of Arteriovenous Fistula Creation after the Fistula First Initiative. Clin J Am Soc Nephrol. 2011;6(8):1996-2002.

Huijbregts HJT, Bots ML, Wittens CHA, Schrama YC, Moll FL, Blankestijn PJ. Hemodialysis Arteriovenous Fistula Patency Revisited: Results of a Prospective, Multicenter Initiative. Clin J Am Soc Nephrol. 2008;3(3):714-9.

Sadaghianloo N, Declemy S, Jean-Baptiste E, Haudebourg P, Robino C, Islam MS, et al. Radial artery deviation and reimplantation inhibits venous juxta-anastomotic stenosis and increases primary patency of radial-cephalic fistulas for hemodialysis. J Vasc Surg. 2016;64(3):698-706.e1.

Sidawy AN, Spergel LM, Besarab A, Allon M, Jennings WC, Padberg Jr FT, et al. The Society for Vascular Surgery: clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access. J Vasc Surg. 2008;48(5):2-25.

Radojica S. Most Important Chronic Complications of Arteriovenous Fistulas for Hemodialysis. Med Princ Pract. 2013;22(3):220-8.

Woo K, Cook PR, Garg J, Hye RJ, Canty TG. Midterm results of a novel technique to salvage autogenous dialysis access in aneurysmal arteriovenous fistulas. J Vasc Surg. 2010;51(4):921-5.






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