Illig Karl A, Surowiec Scott, Shortell Cynthia K, Davies Mark G, Rhodes Jeffrey M, Green Richard M
Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY 14642, USA.
Ann Vasc Surg. 2005 Mar;19(2):199-207. doi: 10.1007/s10016-004-0162-y.
Distal revascularization-interval ligation (DRIL) empirically corrects steal after arteriovenous fistula (AVF) creation in most cases, but because there is no topologic alteration in anatomy, it is unclear as to why it is effective. To explore this issue, nine symptomatic patients underwent intravascular pressure and flow measurements before and after DRIL following upper arm autologous AVFs. Mean pre-DRIL systolic pressure (mmHg; mean +/- SD) in the proximal brachial artery (PROX) was 102 +/- 17, while that at the AV anastomosis (AV ANAST) was 47 +/- 38 (p < 0.0006). Flow (mL/min) distal to AV ANAST was retrograde with the fistula open (-21 +/- 64) but became antegrade (58 +/- 29; p < 0.03) with occlusion of the fistula. Following DRIL, pressures at both PROX and AV ANAST sites did not change (104 +/- 24 and 51 +/- 43, respectively). However, pressure at the point at which the blood flow split to supply the hand or the fistula, now PROX, increased from 47 +/- 38 (pre-DRIL AV ANAST) to 104 +/- 24 (p < 0.0001). Pressure in the brachial artery distal to the ligature increased to 104 +/- 27 (p < 0.0001), flow at this point (to the hand) became antegrade (51 +/- 39; p < 0.03), and occlusion of the fistula did not significantly change pressure at this site. We hypothesize that improvement in hand perfusion following DRIL is due to a higher pressure at the point at which the blood flow splits to supply both hand and fistula (pre-DRIL: AV ANAST; post-DRIL: PROX), allowing antegrade flow down the new bypass to the lower pressure forearm. This increased pressure must be due to the increased resistance of the fistula created by interposing the arterial segment between the original AV ANAST and new PROX ANAST. As such, DRIL is schematically equivalent to banding, but resistance is increased in a fashion that is physiologically and empirically acceptable.
远端血管重建-间隔结扎术（DRIL）在大多数情况下可凭经验纠正动静脉内瘘（AVF）建立后的窃血现象，但由于解剖结构未发生拓扑学改变，其为何有效尚不清楚。为探究此问题，9例有症状的患者在接受上臂自体AVF术后进行了DRIL，分别测量了术前和术后的血管内压力及血流量。肱动脉近端（PROX）术前DRIL时的平均收缩压（mmHg；均值±标准差）为102±17，而在动静脉吻合口（AV ANAST）处为47±38（p<0.0006）。动静脉吻合口远端的血流量（mL/min）在瘘开放时呈逆行状态（-21±64），但在瘘闭塞时变为顺行（58±29；p<0.03）。DRIL术后，PROX和AV ANAST部位的压力均未改变（分别为104±24和51±43）。然而，血流分流以供应手部或瘘的部位（现为PROX）的压力从47±38（术前DRIL时的AV ANAST）升至104±24（p<0.0001）。结扎远端肱动脉的压力升至104±27（p<0.0001），此时（流向手部）的血流变为顺行（51±39；p<0.03），瘘闭塞对此部位压力无显著影响。我们推测，DRIL术后手部灌注改善是由于血流分流以供应手部和瘘的部位（术前DRIL：AV ANAST；术后DRIL：PROX）压力升高，使得新的旁路血流顺行至压力较低的前臂。这种压力升高必定是由于在原始AV ANAST和新的PROX ANAST之间插入动脉段所形成的瘘阻力增加所致。因此，DRIL在示意图上等同于绑扎，但阻力增加的方式在生理和经验上是可接受的。
