Schon D, Mishler R
Arizona Kidney Disease and Hypertension Center, Lifeline Outpatient Surgery Center, Phoenix, AZ, USA.
Am J Kidney Dis. 2000 Oct;36(4):804-10. doi: 10.1053/ajkd.2000.17671.
Well-functioning vascular access is essential to optimizing outcomes in hemodialysis patients. Initial placement of greater numbers of autologous arteriovenous fistulae (AVFs) is needed, as is more attention to salvage of such accesses when they become occluded. In this study, thrombolysis with small doses of thrombolytic agents in combination with balloon angioplasty was attempted in 15 patients with 16 autologous AVFs (7 forearm AVFs, 8 upper-arm AVFs). Either urokinase (UK; mean dose, 109,375 U) or tissue plasminogen activator (tPA; mean dose, 7.1 mg) was used for thrombolysis. The technical success rate was 94%, whereas long-term patency was achieved in 81% of the accesses. Failure to achieve long-term patency was caused by the inability to achieve adequate drainage in 2 patients. In 1 patient, technical inability to cannulate the access and penetrate the venous end of a basilic vein transposed fistula occurred. One patient was successfully declotted and angioplastied twice. Successful salvage of thrombosed AVFs can be safely performed with much lower doses of thrombolytic agents than previously reported. In addition, tPA is effective in this setting, in addition to UK. Salvage of occluded autologous AVFs should be attempted more frequently than is currently practiced and would result in improved hemodialysis patient outcomes.
功能良好的血管通路对于优化血液透析患者的治疗效果至关重要。需要增加自体动静脉内瘘（AVF）的初始植入数量，并且在这些通路发生闭塞时要更加重视对其进行挽救。在本研究中，对15例患者的16个自体AVF（7个前臂AVF，8个上臂AVF）尝试采用小剂量溶栓剂联合球囊血管成形术进行溶栓治疗。使用尿激酶（UK；平均剂量，109,375 U）或组织纤溶酶原激活剂（tPA；平均剂量，7.1 mg）进行溶栓。技术成功率为94%，而81%的通路实现了长期通畅。未能实现长期通畅是由于2例患者无法实现充分引流。在1例患者中，出现了技术上无法穿刺通路并穿透转位的贵要静脉内瘘的静脉端的情况。1例患者成功进行了两次血栓清除和血管成形术。与先前报道相比，使用低得多的溶栓剂剂量就可以安全地成功挽救血栓形成的AVF。此外，除了UK，tPA在这种情况下也有效。对于闭塞的自体AVF，应比目前更频繁地尝试进行挽救，这将改善血液透析患者的治疗效果。
