血管条件较差的患者采用自体桡动脉-头静脉或人工肱动脉-肘前前臂袢动静脉内瘘？一项关于初次血液透析通路通畅性的随机多中心研究。

Autogenous radial-cephalic or prosthetic brachial-antecubital forearm loop AVF in patients with compromised vessels? A randomized, multicenter study of the patency of primary hemodialysis access.

作者信息

Rooijens P P G M, Burgmans J P J, Yo T I, Hop W C J, de Smet A A E A, van den Dorpel M A, Fritschy W M, de Groot H G W, Burger H, Tordoir J H M

机构信息

Department of Surgery, Medical Center Rijnmond Zuid, The Netherlands.

出版信息

J Vasc Surg. 2005 Sep;42(3):481-6; discussions 487. doi: 10.1016/j.jvs.2005.05.025.

DOI:10.1016/j.jvs.2005.05.025

PMID:16171591

Abstract

OBJECTIVE

The construction of an autogenous radial-cephalic direct wrist arteriovenous fistula (RCAVF) is the primary and best option for vascular access for hemodialysis. However, 10%-24% of RCAVFs thrombose directly after operation or do not function adequately due to failure of maturation. In case of poor arterial and/or poor venous vessels for anastomosis, the outcome of RCAVFs may be worse and an alternative vascular access is probably indicated. A prosthetic graft implant may be a second best option. Therefore, a randomized multicenter study comparing RCAVF with prosthetic (polytetrafluoroethylene [PTFE]) graft implantation in patients with poor vessels was performed.

METHODS

A total of 383 consecutive new patients needing primary vascular access were screened for enrollment in a prospective randomized study. According to defined vessel criteria from the preoperative duplex scanning, 140 patients were allocated to primary placement of an RCAVF and 61 patients to primary prosthetic graft implantation. The remaining 182 patients were randomized to receive either an RCAVF (n = 92) or prosthetic graft implant (n = 90). Patency rate was defined as the percentage of AVFs that functioned well after implantation.

RESULTS

Primary and assisted primary 1-year patencies were 33% +/- 5.3% vs 44% +/- 6.2% (P = .03) and 48% +/- 5.5% vs 63% +/- 5.9% (P = .035) for the RCAVF and prosthetic AVF, respectively. Secondary patencies were 52% +/- 5.5% vs 79% +/- 5.1% (P = .0001) for the RCAVF and prosthetic AVF, respectively. Patients with RCAVFs developed a total of 102 (1.19/patient-year [py]) vs 122 (1.45/py; P = .739) complications in the prosthetic AVFs. A total of 43 (0.50/py) interventions in the RCAVF group and 79 (0.94/py) in the prosthetic graft group were needed for access salvage (P = .077).

CONCLUSIONS

Although there were more interventions needed for access salvage in the patients with prosthetic graft implants, we may conclude that patients with poor forearm vessels do benefit from implantation of a prosthetic graft for vascular access.

摘要

目的

自体桡动脉-头静脉直接腕部动静脉内瘘（RCAVF）的构建是血液透析血管通路的首选且最佳选择。然而，10%-24%的RCAVF术后直接发生血栓形成，或因成熟失败而功能不佳。若用于吻合的动脉和/或静脉血管条件差，RCAVF的结局可能更差，可能需要选择其他血管通路。人工血管移植可能是次优选择。因此，开展了一项随机多中心研究，比较血管条件差的患者中RCAVF与人工（聚四氟乙烯[PTFE]）血管移植的情况。

方法

对383例需要初次血管通路的连续新患者进行筛选，纳入一项前瞻性随机研究。根据术前双功超声扫描确定的血管标准，140例患者被分配接受RCAVF初次植入，61例患者接受人工血管初次植入。其余182例患者随机接受RCAVF（n = 92）或人工血管移植（n = 90）。通畅率定义为植入后功能良好的动静脉内瘘的百分比。

结果

RCAVF和人工动静脉内瘘的初次及辅助初次1年通畅率分别为33%±5.3%对44%±6.2%（P = .03）和48%±5.5%对63%±5.9%（P = .035）。RCAVF和人工动静脉内瘘的二次通畅率分别为52%±5.5%对79%±5.1%（P = .0001）。RCAVF患者共发生102例并发症（1.19/患者年[py]），人工动静脉内瘘患者发生122例并发症（1.45/py；P = .739）。为挽救通路，RCAVF组共需要43次（0.50/py）干预，人工血管组需要79次（0.94/py）干预（P = .077）。