• Uzair Ahmad Combined Military Hospital Peshawar
  • Nauman Imtiaz Combined Military Hospital Rawalpindi
  • Muhammad Irfan Combined Military Hospital Peshawar
  • Qurat ul Ain Khyber Girls Medical College, Peshawar
  • Farid Ullah Khan Combined Military Hospital Peshawar
  • Rizwan Khan Combined Military Hospital Rawalpindi



Keywords: Chronic kidney disease, Arteriotomy, arterio-Venous fistula, intimal dissection


Background: This study was carried out to introduce a new technique of excision arteriotomy and to compare it with standard excision arteriotomy in terms of achieving desired size, shape and margins with minimal technical problems.  Methods: This was a comparative study carried out at the Vascular Surgery Unit of Combined Military Hospital Peshawar between January and September 2022. A total of 150 patients of chronic renal failure undergoing Arteriovenous access fulfilling the inclusion criteria were enrolled in our study. The patients were randomized into two groups, 75 in each group: Group A consisted of patients who underwent Conventional excision arteriotomy and Group B underwent Double Stab excision Arteriotomy. The endpoint of the study was to achieve an appropriate arteriotomy of the desired size and shape by having regular margins without intimal dissection during its formation or otherwise inappropriate arteriotomy if any of the criteria is not met. Results: Among the total 150 patients included in our study, Ages ranged between 30–60 years and a mean age of 52.5 years. There were 82 (54.66%) males and 68 (45.33%) females with a male-to-female ratio of 1.2:1. In group A (Conventional Excision arteriotomy) there were 30 (40%) inappropriate arteriotomies and 45 (60%) appropriate arteriotomies. Among the total 30(40%) inappropriate arteriotomies in group A, larger than desired size arteriotomies were 10 cases (33.33%) followed by smaller than desired size arteriotomies; 6 (20%), irregular margins 9 (30%), intimal dissection 3(10%) & lateral tear 2 (6.66%) respectively. In group B of double stab excision arteriotomies, appropriate arteriotomies were achieved in 69 (92%) while the rest had inappropriate arteriotomies in 6 (8%). Among the total 6 (8%) inappropriate arteriotomies in group B, larger than desired size arteriotomies were 2 (33.33%), smaller than desired size arteriotomy; 1 (16.66%), irregular margins 1 (16.66%), intimal dissection; 2 (33.33%) & no lateral tear respectively. Conclusion: This study concluded that the Double stab excision arteriotomy technique is superior to the conventional excision arteriotomy technique. The advantages of our technique are; its reliability with a short learning curve and can be performed precisely and safely.


Suresh DA, Gupta DA, Kumar DV. Distally based V-flap on the artery in an end-to-side anastomosis for Arteriovenous Fistula creation – A Randomised Controlled Pilot Study. J Plast Reconstr Aesthet Surg 2022;75(9):3174–81.

Bhuiyan I, Misskey JD, Hsiang YN. The arteriovenous fistula and the history of a forgotten pioneer. J Vasc Surg Cases Innov Tech 2022;8(4):688–92.

Ooi ASH, Butz DR, Fisher SM, Collier ZJ, Gottlieb LJ. Geometric Three-Dimensional End-to-Side Microvascular Anastomosis: A Simple and Reproducible Technique. J Reconstr Microsurg 2018;34(4):258–63.

Saoodi MQ, Arajy ZY. Evaluation of Longitudinal Slit Arteriotomy for End to Side Anastomosis in Free Tissue Transfer. Iraqi Postgrad Med J 2021;20(3):277–84.

El Rifaï S, Boudard J, Haïun M, Obert L, Pauchot J. Tips and tricks for end-to-side anastomosis arteriotomies. Hand Surg Rehabil 2016;35(2):85–94.

Chung JH, Sohn SM, You HJ, Yoon ES, Lee B Il, Park SH, et al. Use of a biopsy punch for end-to-side anastomosis in free-tissue transfer. J Plast Surg Hand Surg 2020;54(4):215–9.

Storrie A, McGeachie J, Samuels R, Hunneybun B, Bartlett N. Transverse or longitudinal arteriotomies in end‐to‐side microvascular anastomoses for small vessels (1–2 mm). Microsurgery 1990;11(2):108–13.

Pafitanis G, Nicolaides M, Kyprianou K, O’Sullivan J, Sitpahul N, Kiranantawat K, et al. The “crater” Arteriotomy: A Technique Aiding Precise Intimal Apposition in End-to-side Microvascular Anastomosis. Plast Reconstr Surg Glob Open 2020;8(10):e3014.

Hallock GG, Rice DC. Use of a micropunch for arteriotomy in end-to-side anastomosis. J Reconstr Microsurg 1996;12(1):59–62.

Lynch JB, Hussey AJ, O’Sullivan ST. Using a punch biopsy to fashion an arteriotomy for end-to-side anastomosis. J Reconstr Microsurg 2011;27(2):139–40.

Shimbo K, Okuhara Y, Yokota K. Usability of a biopsy punch to form an elliptical arteriotomy for end-to-side anastomosis. Microsurgery 2020;40(4):514–5.

Pederson WC, Barwick WJ. Use of the vascular punch microsurgery. J Reconstr Microsurg 1989;5(2):115–8.

Ikuta Y, Watari S, Kawamura K, Shima R, Matsuishi Y. Free flap transfers by end-to-side arterial anastomosis. Br J Plast Surg 1975;28(1):1–7.

Godina M . Preferential use of end-to-side arterial anastomoses in free flap transfers. Plast Reconstr Surg 1979;64(5):673–82 .

Legagneux J, Gilbert A. Apprentissage de la microchirurgie vasculaire. EMC. EMC –Techniques Chir – Chir Plast Reconstr Etesthétique 2007;2007:44480–6.

Tan BK, Wong CH, ChewW Hong SW. Use of slit arte riotomy for end-to-side arterial anastomosis in free-tissue transfers to the extremities. J Plast Reconstr Aesthet Surg 2009;62(11):1519–23.

Hall EJ . End-to-side anastomoses: a model and a technique with clinical application. J Microsurg 1980;2(02):106–12.

Zhang L, Moskovitz M, Piscatelli S, Longaker MT, Siebert JW. Hemodynamic study of different angled end-to-side anasto moses. Microsurgery 1995;16(02):114–17.

Sen C, AgirH Iscen D. Simple and reliable procedure for end-to–side microvascular anastomosis: the diamond technique. Microsurgery 2006;26(03):160–4.

Onoda S , Kimata Y , Goto A . The drop-down technique as an op timal technique for back-wall end-to-side anastomosis. J Craniofac Surg 2014;25(04):1435–7.

Gu H, Chua A, Tan BK, Chew Hung K. Nonlinear finite element simulation to elucidate the efficacy of slit arteriotomy for end-to-side arterial anastomosis in microsurgery. J Biomech 2006;39(3)435–43.

Zoubos AB, Seaber AV, Urbaniak JR. Hemodynamic and histological differences in end-to-side anastomoses. Microsurgery 1992;13(4)200–3.

Dash H, Kononov A, Maloney 3rd J, Browne E. A simple arteriotomy method for microsurgical end-to-side anastomoses: technical aspects ofuse in training and laboratory applications. J Reconstr Microsurg1993;9(5)381–4.

Storrie A, McGeachie J, Samuels R, Hunneybun B, Bartlett N. Transverseor longitudinal arteriotomies in end-to-side microvascular anastomosesfor small vessels (1–2 mm). Microsurgery 1990;11(2)108–13.

Korber KE, Kraemer BA, Li Z. Angled side wall microarteriotomy scissors: a new end-to-side microvascular anastomosis instrument. Microsurgery 1990;11(3)217–9.

Additional Files