Revisiting the arterial anastomosis: A beveled approach to prosthetic grafts in challenging vascular anatomy

BACKGROUND: The configuration of the arterial anastomosis in prosthetic arteriovenous grafts (AVGs) significantly affects hemodynamics, thrombogenicity, and long-term patency. While tapered grafts have been developed to optimize inflow, their use is limited by cost, availability, and reduced adaptability. We evaluated a surgeon-modified beveled end-to-side anastomosis using standard grafts as a simple, cost-neutral alternative for upper-limb AVG creation, including in high-risk and urgent settings. METHODS: We conducted a retrospective single-center study of 46 patients who received AVGs with a beveled anastomosis tailored to ~60°, based on a standardized cutting protocol. Data were collected prospectively. Outcomes included technical and clinical success, thrombosis, patency, and complications. Hemodynamic implications were contextualized using existing computational and clinical models. RESULTS: Technical success was achieved in 100% of cases; clinical success in 93.5%. Early thrombosis occurred in 4.3% and was managed with thrombectomy. Late thrombosis (15.2%) was mainly due to venous outflow stenosis; inflow-related stenosis was rare (4.3%). No cases of hand ischemia, pseudoaneurysm, or suture-related complications were observed. Intraoperative imaging and follow-up ultrasound confirmed stable graft geometry. The technique was feasible across graft types, with trilaminar grafts requiring reduced angles (~45°). In selected cases, it served as a temporary bridge to native AVF maturation. CONCLUSIONS: This beveled anastomosis is a safe, reproducible technique for prosthetic AVG creation, with favorable hemodynamic characteristics and broad adaptability. It may offer specific advantages in complex or urgent cases.