Murphy G J, White S A, Nicholson M L
University Department of Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
Br J Surg. 2000 Oct;87(10):1300-15. doi: 10.1046/j.1365-2168.2000.01579.x.
The recent expansion of renal replacement therapy programmes has been associated with an increase in the number and complexity of patients requiring permanent vascular access. The introduction of strategies designed to maximize secondary access patency is, therefore, increasingly important as a means of prolonging patient survival on dialysis, reducing morbidity and reducing the escalating cost of such programmes.
A review of the current literature on the planning of vascular access, access surveillance methods and treatment of the most common complications was performed.
Multidisciplinary vascular access planning, increased use of preoperative imaging and the preferential use of autogeneous vein are essential to obtain the best long-term results. While vascular access surveillance, in particular protocols involving direct measurement of access flow, enables the prospective detection and treatment of venous stenosis, the precise indications for treating venous stenosis remain unclear. Surgical revision remains the gold standard for the treatment of failing arteriovenous fistulas, but recent advances in interventional radiological techniques along with the suitability of arteriovenous fistulas for percutaneous intervention may offer an effective alternative. The effect of both these interventions on access patency requires comparison in a randomized trial.
The introduction of strategies to improve access patency rates will change vascular access surgical practice away from the construction of new fistulas towards an increase in outpatient percutaneous intervention and surgical revisional procedures. The role of surgical interventions requires clearer definition.
近期肾脏替代治疗项目的扩展与需要永久性血管通路的患者数量增加及病情复杂性上升相关。因此，采用旨在最大程度提高次级通路通畅率的策略，作为延长透析患者生存期、降低发病率以及降低此类项目不断攀升的成本的一种手段，变得越发重要。
对当前有关血管通路规划、通路监测方法以及最常见并发症治疗的文献进行了综述。
多学科血管通路规划、增加术前影像学检查的应用以及优先使用自体静脉对于获得最佳长期效果至关重要。虽然血管通路监测，特别是涉及直接测量通路血流量的方案，能够前瞻性地检测和治疗静脉狭窄，但治疗静脉狭窄的确切指征仍不明确。手术修复仍然是治疗失败的动静脉内瘘的金标准，但介入放射技术的最新进展以及动静脉内瘘对经皮介入的适用性可能提供一种有效的替代方法。这两种干预措施对通路通畅性的影响需要在一项随机试验中进行比较。
引入提高通路通畅率的策略将改变血管通路手术实践，从构建新的内瘘转向增加门诊经皮介入和手术修复程序。手术干预的作用需要更明确的界定。
