O'shea Susan I, Lawson Jeffrey H, Reddan Donal, Murphy Michael, Ortel Thomas L
Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
J Vasc Surg. 2003 Sep;38(3):541-8. doi: 10.1016/s0741-5214(03)00321-5.
Vascular access site thrombosis is a major cause of morbidity in patients receiving hemodialysis. The role of hypercoagulable states in recurrent vascular access site thrombosis remains poorly understood. Data are limited regarding systemic anticoagulation to improve access graft patency, because of concern about hemorrhagic complications. We determined the prevalence of hypercoagulable states and clinical outcome (thrombotic and hemorrhagic) after initiation of antithrombotic therapy in a series of patients with recurrent vascular access site thrombosis. We evaluated 31 patients who had sustained 119 thrombotic events that resulted in vascular access graft failure during the year before evaluation. Sixty-eight percent of patients tested had elevated concentrations of antibody to anticardiolipin or topical bovine thrombin, and 18% of patients tested had heparin-induced antibodies. More than 90% of patients had elevated factor VIII concentration, 62% had elevated fibrinogen concentrations, and 42% had elevated C-reactive protein concentrations. Twenty-nine patients were given antithrombotic therapy: 13 with warfarin sodium, 12 with unfractionated heparin (UFH), and 11 with low molecular weight heparin (LMWH). Seven patients received more than one antithrombotic agent, sequentially. Nineteen patients have had no thrombotic events since beginning antithrombotic therapy (10 with warfarin, 3 with UFH, 6 with LMWH). Mean follow-up was 8.6 months (median, 7 months). Eight patients sustained 10 bleeding complications (5 with warfarin, 3 with UFH, and 2 with LMWH). In conclusion, hypercoagulable states are common in patients with recurrent vascular access site thrombosis. Antithrombotic therapy may increase vascular access graft patency, but is associated with significant risk for hemorrhage. Prospective studies are needed to evaluate the role and safety of antithrombotic agents in improving vascular access graft patency.
血管通路部位血栓形成是接受血液透析患者发病的主要原因。高凝状态在复发性血管通路部位血栓形成中的作用仍知之甚少。由于担心出血并发症，关于全身抗凝以改善血管通路移植物通畅性的数据有限。我们确定了一系列复发性血管通路部位血栓形成患者在开始抗血栓治疗后的高凝状态患病率和临床结局（血栓形成和出血）。我们评估了31例患者，这些患者在评估前一年发生了119次血栓形成事件，导致血管通路移植物失败。检测的患者中有68%抗心磷脂抗体或外用牛凝血酶浓度升高，18%检测的患者有肝素诱导抗体。超过90%的患者因子VIII浓度升高，62%纤维蛋白原浓度升高，42%C反应蛋白浓度升高。29例患者接受了抗血栓治疗：13例使用华法林钠，12例使用普通肝素（UFH），11例使用低分子量肝素（LMWH）。7例患者依次接受了不止一种抗血栓药物。自开始抗血栓治疗以来，19例患者未发生血栓形成事件（10例使用华法林，3例使用UFH，6例使用LMWH）。平均随访8.6个月（中位数，7个月）。8例患者发生了10次出血并发症（5例使用华法林，3例使用UFH，2例使用LMWH）。总之，高凝状态在复发性血管通路部位血栓形成患者中很常见。抗血栓治疗可能会提高血管通路移植物的通畅性，但伴有显著的出血风险。需要进行前瞻性研究来评估抗血栓药物在改善血管通路移植物通畅性方面的作用和安全性。
