Sizing matters not: Technical standardization of small anastomoses in AVF surgery for complex patients

Introduction: Arteriovenous fistulas (AVFs) remain the preferred vascular access for hemodialysis, though failure to mature, juxta-anastomotic stenosis, and distal hypoperfusion ischemic syndrome (DHIS) continue to limit their effectiveness. We evaluated a standardized approach combining small-size anastomoses (SSA) and the piggyback Straight-Line Onlay Technique (pSLOT) to improve outcomes in complex AVF creation. Materials and methods: This single-center prospective study included all consecutive patients referred for AVF creation from January 2022 to December 2023. Anastomoses were created using a 3.6 mm punch, and pSLOT was used in all cases. Doppler ultrasound was performed intraoperatively, at discharge, and during follow-up. Primary outcomes included AVF maturation and patency; secondary outcomes included DHIS incidence. Results: A total of 78 AVFs were created (mean age 57 +/- 18 years). Primary patency rates at 1, 2, and >4 months were 98.2%, 96.5%, and 94.7%, respectively. Maturation was achieved in 98.2% of cases. No cases of DHIS, thrombosis, or late failure were observed. Mean AVF flow at 12 months was 1080 +/- 170 mL/min. Discussion and conclusions: This standardized technique proved safe and effective in a high-risk cohort. The results support its adoption in anatomically complex cases and highlight the value of surgical standardization in VA practice.