Patel Sheela T, Hughes John, Mills Joseph L
Vascular Surgery, University of Arizona Health Sciences Center, Tucson, AZ 85718, USA.
J Vasc Surg. 2003 Sep;38(3):439-45; discussion 445. doi: 10.1016/s0741-5214(03)00732-8.
The Dialysis Outcome Quality Initiative (DOQI) guidelines recommend that arteriovenous fistulas (AVF) be constructed in at least 50% of hemodialysis access procedures. Preoperative duplex ultrasound (US) scanning and venography may increase options for AVF with identification of veins that are not clinically evident. However, maturation of autogenous fistulas created on the basis of findings at duplex US scanning and venography has not been carefully examined.
From January 1999 to July 2002, 256 new hemodialysis access procedures were performed in 202 patients in an academic tertiary care center. If physical examination failed to disclose adequate vessels for hemodialysis access, patients underwent duplex US scanning mapping. Venography was performed when no usable vein or only a basilic vein was identified at duplex US scanning. Functional maturation rate and mean maturation time (time from fistula creation to initiation of hemodialysis) were determined. This experience was compared with that in a group of 128 patients in whom 148 hemodialysis access fistulas were created before we implemented liberal use of preoperative duplex US scanning and venography (January 1997-December 1998).
From January 1999 to July 2002, preoperative duplex US scanning was performed in 68% of patients, and venography in 32% of patients. Autogenous fistula creation rate increased from 61% to 73% in all patients with hemodialysis access fistulas (P =.15) and from 66% to 83% in patients undergoing a first access procedure (P <.05). The use of basilic vein transposition also increased, from 3% in the earlier period to 13% in the later period (P <.05). Mean maturation time for arteriovenous fistulas was 70 days. Functional maturation rate decreased from 73% to 57% (P <.05) after implementation of preoperative imaging and more aggressive vein use.
Implementation of preoperative duplex US scanning and venography as a component of a more aggressive protocol to create native fistulas was pivotal in exceeding DOQI guidelines for hemodialysis access. However, this approach resulted in the unintended sequela of decreased fistula maturation rate. Our experience suggests that improved selection criteria based on findings at preoperative imaging are needed to further refine and optimize arteriovenous access surgery.
透析结果质量改进计划（DOQI）指南建议，在至少50%的血液透析通路手术中应构建动静脉内瘘（AVF）。术前双功超声（US）扫描和静脉造影可通过识别临床上不明显的静脉来增加AVF的选择。然而，基于双功US扫描和静脉造影结果创建的自体动静脉内瘘的成熟情况尚未得到仔细研究。
1999年1月至2002年7月，在一家学术性三级医疗中心对202例患者进行了256例新的血液透析通路手术。如果体格检查未能发现足够的血管用于血液透析通路，则对患者进行双功US扫描定位。当在双功US扫描中未发现可用静脉或仅发现一条贵要静脉时，则进行静脉造影。确定功能成熟率和平均成熟时间（从动静脉内瘘创建到开始血液透析的时间）。将这一经验与一组128例患者的经验进行比较，在我们广泛使用术前双功US扫描和静脉造影之前（1997年1月至1998年12月），这组患者创建了148例血液透析通路动静脉内瘘。
1999年1月至2002年7月，68%的患者进行了术前双功US扫描，32%的患者进行了静脉造影。所有有血液透析通路动静脉内瘘的患者自体动静脉内瘘创建率从61%增至73%（P = 0.15），首次进行通路手术的患者中该比例从66%增至83%（P < 0.05）。贵要静脉转位的应用也有所增加，从早期的3%增至后期的13%（P < 0.05）。动静脉内瘘的平均成熟时间为70天。在实施术前影像学检查和更积极地利用静脉后，功能成熟率从73%降至57%（P < 0.05）。
将术前双功US扫描和静脉造影作为创建自体动静脉内瘘的更积极方案的一部分来实施，对于超过DOQI血液透析通路指南至关重要。然而，这种方法导致了动静脉内瘘成熟率下降这一意外后果。我们的经验表明需要基于术前影像学检查结果改进选择标准，以进一步完善和优化动静脉通路手术。
