Side-to-side anastomosis, distal vein ligation, and the importance of venous configuration in AV fistula surgery
A recent publication by Marco Taurisano and colleagues in the Journal of Vascular Access caught my attention.
The authors investigated whether ligation of the distal venous segment influences early maturation of radiocephalic arteriovenous fistulas (AVFs) created with a side-to-side anastomosis. In this randomized study of 60 patients, no statistically significant difference in early maturation was observed between fistulas with and without distal vein ligation.
The question itself is not new. Earlier randomized work, for example on ligation of the dorsal branch of the cephalic vein, also found no significant difference in patency. And yet the debate continues in daily practice.
Reading the paper made me think about a somewhat different question:
What are the advantages of side-to-side anastomosis itself?
Why side-to-side?
Side-to-side has long been my preferred configuration for radiocephalic AVF creation.
The reason is not simply that the technique is familiar or technically convenient. One of its potential advantages lies in the geometry of the venous outflow.
In a conventional end-to-side anastomosis, the vein must be divided, mobilized and brought toward the artery. Depending on the anatomical relationship between the two vessels, this may require considerable rotation or displacement of the vein. Such manipulation can create an unfavorable configuration in the juxta-anastomotic segment, including torsion, angulation or kinking.
With a side-to-side anastomosis, the vein generally requires less displacement and rotation. Some mobilization is still necessary, but the technique may allow a more favorable venous configuration.
This was also an important aspect of the surgical approach advocated by my clinical teacher, mentor and friend, Klaus Konner, who consistently emphasized the importance of meticulous anastomotic technique.
Of course, side-to-side anastomosis is not always anatomically feasible. When the vein and artery lie too far apart, a tension-free and geometrically favorable anastomosis may be difficult to achieve.
The juxta-anastomotic segment: why geometry matters
Juxta-anastomotic stenosis remains one of the most frequent causes of AVF maturation failure and subsequent dysfunction.
Its development is multifactorial: changes in wall shear stress, vascular remodeling, neointimal hyperplasia and local mechanical conditions all play a role. However, the geometry of the outflow vein deserves particular attention.
The transition between the anastomosis and the more proximal venous segment is especially important. Excessive rotation, angulation or tension may influence local hemodynamics and potentially contribute to unfavorable remodeling.
This concern is reflected in the development of alternative surgical configurations, such as the piggyback Straight-Line Onlay Technique (pSLOT) described by Bharat, Jaenicke and Shenoy. The concept behind pSLOT is to achieve a straighter venous outflow and to reduce torsional stress in the juxta-anastomotic segment.
Although pSLOT differs from a conventional side-to-side anastomosis, both approaches raise the same fundamental question:
Could optimizing venous geometry be as important as the anastomotic technique itself?
What about distal vein ligation?
Returning to the study by Taurisano and colleagues: early maturation was comparable whether the distal venous segment was ligated or preserved.
From my personal surgical perspective, I still prefer distal vein ligation after a side-to-side anastomosis. My main reason is straightforward: to avoid unnecessary retrograde venous flow toward the hand and to direct the outflow through the intended proximal venous segment.
In effect, this creates a functional end-to-side configuration: the geometry of a side-to-side anastomosis combined with the flow direction of an end-to-side anastomosis.
This is a technical preference rather than a claim of proven superiority.
The study suggests that preserving distal venous outflow does not necessarily compromise early maturation. At the same time, its small sample size and short follow-up cannot answer questions about long-term function, venous hypertension or access durability. The choice should therefore remain guided by individual vascular anatomy and intraoperative findings.
Surgical technique is more than an anastomosis
One of the lessons I learned from Klaus Konner was that successful vascular access surgery depends on much more than simply connecting an artery and a vein.
Vessel selection, careful preparation, anastomotic geometry, avoidance of unnecessary tension and preservation of a suitable venous outflow all contribute to the final result.
A technically patent AVF is not necessarily a functional one. Our objective remains a fistula that matures reliably, can be cannulated repeatedly and provides durable haemodialysis access.
And sometimes, seemingly small details of surgical technique make a substantial difference.
Conclusion
The study by Taurisano et al. adds valuable data on distal vein ligation. For me, it is also a reminder that the geometry of the anastomosis and its venous outflow may matter as much as the question of ligation. Whether these biomechanical advantages translate into better long-term outcomes remains to be shown.
Perhaps anastomotic geometry deserves more attention.
How do you construct your radiocephalic fistulas: end-to-side, side-to-side or functional end-to-side? I look forward to your feedback via the contact form or on LinkedIn.
References
1. Taurisano M, et al. Distal vein ligation in radiocephalic arteriovenous fistula creation: a randomized trial of hemodynamic impact and early maturation. J Vasc Access. 2026. doi:10.1177/11297298261477791
2. Zhang H, Zhu G, Yan L, Lu Y, Shao F. Does ligation of the dorsal branch of the cephalic vein affect the patency of a distal forearm arteriovenous fistula? A randomised study. BMC Nephrol. 2020;21. doi:10.1186/s12882-020-01823-8
3. Konner K. The anastomosis of the arteriovenous fistula – common errors and their avoidance. Nephrol Dial Transplant. 2002;17:376–379. doi:10.1093/ndt/17.3.376
4. Konner K. The initial creation of native arteriovenous fistulas: surgical aspects and their impact on the practice of nephrology. Semin Dial. 2003;16:291–298. doi:10.1046/j.1525-139X.2003.16064.x
5. 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;55:274–280. doi:10.1016/j.jvs.2011.07.090
Dr. Vladimir Matoussevitch | VascularAccessTalk
Conflicts of interest: The author declares no conflicts of interest.-