Zanow Jurgen, Kruger Ulf, Scholz Hans
Department of Vascular Surgery, Queen Elisabeth Hospital, Berlin, Germany.
J Vasc Surg. 2006 Jun;43(6):1216-21; discussion 1221. doi: 10.1016/j.jvs.2006.01.025.
Arteriovenous access-related ischemia is an uncommon but serious and occasionally devastating complication. Distal revascularization-interval ligation (DRIL) has been established as a standard treatment procedure; however, an axial artery is ligated and the distal perfusion is maintained by the construction of an arterial bypass. Because such an approach, in principle, appears undesirable, we developed and applied an alternative technique referred to as proximalization of the arterial inflow (PAI). This procedure converts the arterial supply of the arteriovenous access to a more proximal artery with higher capacity by using a small-caliber polytetrafluoroethylene graft as a feeder.
From January 1999 to June 2005, the PAI technique was applied in 30 patients. The indication was seen in patients with severe distal ischemia who had a flow volume rate of <800 mL/min in a native fistula and <1000 mL/min in prosthetic access.
Pain was the dominant symptom of ischemia in most patients before surgery. In 37%, a tissue loss was observed. The symptoms of access-related ischemia disappeared completely in 84% of patients and improved significantly in 16%. The significant hemodynamic improvement was confirmed by an increase of the intraoperatively measured mean distal arterial pressure from 32 +/- 9 mm Hg to 63 +/- 8 mm Hg. The digital-brachial index increased from 0.40 +/- 0.10 to 0.83 +/- 0.07. The mean access flow rate was 658 +/- 80 mL/min after PAI and did not differ significantly with the preoperative value (634 +/- 181 mL/min). With a mean follow-up interval of 26.1 +/-19.1 months, the primary and secondary patency rates were, respectively, 87% and 90% at 1 year and 67% and 78% at 3 years.
The PAI procedure represents a well-suited alternative to the DRIL technique for the treatment of patients who develop ischemia after creation of an arteriovenous access. Results for access salvage and disappearance of ischemic symptoms are equivalent to the DRIL technique. In contrast to the DRIL procedure, the PAI technique preserves the natural arterial pathway. Hence, PAI is preferable for surgeons who are reluctant to ligate an axial artery and are concerned about potentially disastrous consequences.
动静脉通路相关缺血是一种罕见但严重且偶尔具有毁灭性的并发症。远端血管重建-间隔结扎术（DRIL）已成为一种标准治疗方法；然而，该方法需结扎一条轴动脉，并通过构建动脉旁路来维持远端灌注。由于这种方法原则上似乎不可取，我们开发并应用了一种替代技术，称为动脉血流近端化（PAI）。该手术通过使用小口径聚四氟乙烯移植物作为供血管道，将动静脉通路的动脉供血转换为来自容量更大的更近端动脉。
1999年1月至2005年6月，30例患者接受了PAI技术治疗。适应症为严重远端缺血患者，自体动静脉内瘘血流量<800 mL/分钟，人工血管通路血流量<1000 mL/分钟。
大多数患者术前缺血的主要症状为疼痛。37%的患者出现组织缺损。84%的患者动静脉通路相关缺血症状完全消失，16%的患者症状明显改善。术中测量的平均远端动脉压从32±9 mmHg升至63±8 mmHg，证实血流动力学有显著改善。数字臂指数从0.40±0.10升至0.83±0.07。PAI术后平均通路血流量为658±80 mL/分钟，与术前值（634±181 mL/分钟）无显著差异。平均随访间隔为26.1±19.1个月，1年时的一期和二期通畅率分别为87%和90%，3年时分别为67%和78%。
对于动静脉通路建立后发生缺血的患者，PAI手术是DRIL技术的一种合适替代方法。通路挽救和缺血症状消失的结果与DRIL技术相当。与DRIL手术不同，PAI技术保留了天然动脉路径。因此，对于不愿结扎轴动脉且担心潜在灾难性后果的外科医生而言，PAI更为可取。
