Preserving perianastomotic venous collaterals in arteriovenous grafts: A paradigm shift in outflow management

Surgical management of perianastomotic venous collaterals during the creation of vascular access remains a critical yet often overlooked step. Traditionally, these branches are ligated to optimize hemodynamics and direct the entire flow into the primary venous outflow tract. However, pathophysiological analysis suggests that this practice may limit the overall resilience of the access. Perianastomotic collaterals serve a functional role as essential compensatory outflow pathways; in the presence of stenosis or obstruction of the primary venous segment, their patency maintains blood flow, reduces resistance, and prevents stagnation. Systematically preserving these branches, rather than ligating them, can significantly delay the onset of thrombotic events and ensure the functional survival of the access even if the main outflow fails. This "conservative" hemodynamic approach proposes a paradigm shift in surgical strategy, prioritizing vascular redundancy to improve long-term patency and minimize the need for complex salvage interventions.