Doelman Cornelis, Duijm Lucien E M, Liem Ylian S, Froger Clemence L, Tielbeek Alexander V, Donkers-van Rossum Astrid B, Cuypers Philippe W M, Douwes-Draaijer Petra, Buth Jaap, van den Bosch Harrie C M
Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands.
J Vasc Surg. 2005 Oct;42(4):739-46. doi: 10.1016/j.jvs.2005.06.006.
Several imaging modalities are available for the evaluation of dysfunctional hemodialysis shunts. Color Doppler ultrasonography (CDUS) and digital subtraction angiography (DSA) are most widely used for the detection of access stenoses, and contrast-enhanced magnetic resonance angiography (CE-MRA) of shunts has recently been introduced. To date, no study has compared the value of these three modalities for stenosis detection in dysfunctional shunts. We prospectively compared CDUS and CE-MRA with DSA for the detection of significant (> or = 50%) stenoses in failing dialysis accesses, and we determined whether the interventionalist would benefit from CDUS performed before DSA and endovascular intervention.
CDUS, CE-MRA, and DSA were performed of 49 dysfunctional hemodialysis arteriovenous fistulas and 32 grafts. The vascular tree of the accesses was divided into three to eight segments depending on the access type (arteriovenous fistula or arteriovenous graft) and the length of venous outflow. CDUS was performed and assessed by a vascular technician, whereas CE-MRA and DSA were interpreted by two magnetic resonance radiologists and two interventional radiologists, respectively. All readers were blinded to information from each other and from other studies. DSA was used as reference standard for stenosis detection.
DSA detected 111 significant (> or = 50%) stenoses in 433 vascular segments. Sensitivity and specificity of CDUS for the detection of significant stenosed vessel segments were 91% (95% CI, 84%-95%) and 97% (95% CI, 94%-98%), respectively. We found a positive predictive value of 91% (95% CI, 84%-95%) and a negative predictive value of 97% (95% CI, 94%-98%). The sensitivity, specificity, positive predictive value, and negative predictive value of MRA were 96% (95% CI, 90%-98%), 98% (95% CI, 96%-99%), 94% (95% CI, 88%-97%), and 98% (95% CI, 96%-99%), respectively. CDUS and CE-MRA depicted respectively three and four significant stenoses in six nondiagnostic DSA segments. The interventionalist would have chosen an alternative cannulation site in 38% of patients if the CDUS results had been available.
We suggest that CDUS be used as initial imaging modality of dysfunctional shunts, but complete access should be depicted at DSA and angioplasty to detect all significant stenoses eligible for intervention. CE-MRA should be considered only if DSA is inconclusive.
有几种成像方式可用于评估功能失调的血液透析分流。彩色多普勒超声（CDUS）和数字减影血管造影（DSA）最广泛用于检测通路狭窄，并且最近已引入分流的对比增强磁共振血管造影（CE-MRA）。迄今为止，尚无研究比较这三种方式在功能失调分流中检测狭窄的价值。我们前瞻性地比较了CDUS和CE-MRA与DSA在检测功能衰竭的透析通路中显著（≥50%）狭窄方面的情况，并确定介入医生在DSA和血管内介入之前进行CDUS是否会从中受益。
对49个功能失调的血液透析动静脉内瘘和32个移植物进行了CDUS、CE-MRA和DSA检查。根据通路类型（动静脉内瘘或动静脉移植物）和静脉流出长度，将通路的血管树分为三到八个节段。CDUS由一名血管技术人员进行并评估，而CE-MRA和DSA分别由两名磁共振放射科医生和两名介入放射科医生解读。所有阅片者对彼此及其他研究的信息均不知情。DSA用作狭窄检测的参考标准。
DSA在433个血管节段中检测到111个显著（≥50%）狭窄。CDUS检测显著狭窄血管节段的敏感性和特异性分别为91%（95%CI，84%-95%）和97%（95%CI，94%-98%）。我们发现阳性预测值为91%（95%CI，84%-95%），阴性预测值为97%（95%CI，94%-98%）。MRA的敏感性、特异性、阳性预测值和阴性预测值分别为96%（95%CI，90%-98%）、98%（95%CI，96%-99%）、94%（95%CI，88%-97%）和98%（95%CI，96%-99%）。在六个非诊断性DSA节段中，CDUS和CE-MRA分别描绘出三个和四个显著狭窄。如果有CDUS结果，介入医生会在38%的患者中选择另一个插管部位。
我们建议将CDUS用作功能失调分流的初始成像方式，但应通过DSA和血管成形术描绘完整的通路，以检测所有符合干预条件的显著狭窄。仅当DSA结果不明确时才应考虑CE-MRA。
