Dougherty M J, Calligaro K D, Schindler N, Raviola C A, Ntoso A
Section of Vascular Surgery, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, USA.
J Vasc Surg. 1999 Dec;30(6):1016-23. doi: 10.1016/s0741-5214(99)70039-x.
The objective of this study was to compare clinical outcome and costs for two widely used treatment strategies for hemodialysis graft thrombosis.
During a 4-year period, 80 patients with thrombosed dialysis grafts were randomly assigned to surgical thrombectomy with or without graft revision (SURG) or thrombolytic therapy with urokinase with the pulse-spray technique (ENDO), with adjunctive percutaneous transluminal angioplasty as indicated. All the procedures were performed in an endovascular operating suite with fistulography. The clinical and cost data were tabulated, and the outcome was analyzed with the life-table method.
Fifty-six women and 24 men ranged in age from 33 to 90 years (mean, 63.7 years). The patients had undergone a mean of 2.8 prior access procedures in the ipsilateral extremity. All the grafts were upper extremity expanded polytetrafluoroethylene grafts. Lesions that were presumed to be the primary cause of graft thrombosis were identified in 73 of 80 grafts, and 60 of these were at the venous anastomosis. The procedure time averaged 99 minutes for the patients in the SURG group and 113 minutes for the patients in the ENDO group (P =.12). Eleven patients in the ENDO group crossed over to surgical revision as compared with two patients in the SURG group who required adjunctive percutaneous transluminal angioplasty (P =.005). The mean cost of treatment (including room and supply costs but not professional fees) was significantly higher for the ENDO group than for the SURG group ($2945 vs $1512; P <.001). There were no procedure-related complications in either group. At a median follow-up time of 24 months, there was no difference in primary or assisted primary patency between groups, which averaged 6 and 7 months, respectively.
Although thrombolytic therapy combined with endovascular treatment can extend the life of dialysis grafts with results similar to surgical revision, there is a high rate of technical failure necessitating surgery and a substantially higher cost for thrombolysis.
本研究的目的是比较两种广泛应用的治疗血液透析移植物血栓形成的策略的临床结局和成本。
在4年期间，80例血栓形成的透析移植物患者被随机分配接受有或无移植物修复的手术取栓（SURG）或采用脉冲喷射技术的尿激酶溶栓治疗（ENDO），并根据需要进行辅助经皮腔内血管成形术。所有手术均在配备血管造影术的血管内手术室进行。将临床和成本数据制成表格，并采用寿命表法分析结局。
56例女性和24例男性，年龄范围为33至90岁（平均63.7岁）。患者同侧肢体先前平均接受过2.8次血管通路手术。所有移植物均为上肢膨体聚四氟乙烯移植物。在80例移植物中的73例中确定了被认为是移植物血栓形成主要原因的病变，其中60例位于静脉吻合口处。SURG组患者的手术时间平均为99分钟，ENDO组患者为113分钟（P = 0.12）。ENDO组有11例患者转为手术修复，而SURG组有2例患者需要辅助经皮腔内血管成形术（P = 0.005）。ENDO组的平均治疗成本（包括病房和耗材成本，但不包括专业费用）显著高于SURG组（2945美元对1512美元；P < 0.001）。两组均无手术相关并发症。在中位随访时间24个月时，两组之间的初次或辅助初次通畅率无差异，分别平均为6个月和7个月。
尽管溶栓治疗联合血管内治疗可以延长透析移植物的使用寿命，结果与手术修复相似，但技术失败率高，需要进行手术，且溶栓成本显著更高。
