Lipari Giovanni, Tessitore Nicola, Poli Albino, Bedogna Valeria, Impedovo Antonella, Lupo Antonio, Baggio Elda
General and Vascular Surgery Department, University of Verona, and Servizio Emodialisi Ospedale PoliclinicoGB RossiPiazzale LA Scuro 1037134 Verona, Italy.
Nephrol Dial Transplant. 2007 Sep;22(9):2605-12. doi: 10.1093/ndt/gfm239. Epub 2007 May 21.
Surgery is an established treatment for stenosed and thrombosed forearm arteriovenous fistulae (AVFs), but the literature on its outcome is limited. We report our experience of the surgical repair of stenosis in patent and thrombosed forearm AVFs and evaluate the outcome of two procedures, proximal neo-anastomosis (NEO) vs replacement of the stenosed segment with a polytetrafluoroethylene graft interposition (GI).
Sixty-four stenosed forearm AVFs underwent surgery, 32 pre-emptively and 32 post-thrombosis. End points of the study were initial success, restenosis and access loss rates. After treatment, AVFs were surveilled for restenosis by measuring access flow quarterly and performing at least one follow-up angiogram.
Initial procedural success was 92%; 100% for patent and 84% for thrombosed AVFs. The restenosis rate was 0.189 events/AVF-year for both patent and thrombosed AVFs, while the access loss rate was 0.016 events/AVF-year in patent and 0.148 in thrombosed AVFs. Stenosis was corrected by NEO in 27 AVFs and by GI in 30. The restenosis and access loss rates were 0.151 vs 0.214 and 0.033 vs 0.019 events/AVF-year for NEO vs GI, respectively. At Cox's hazard analysis, no variable was significantly associated with restenosis, while the timing of intervention was the only significant determinant of access loss, repaired clotted accesses carrying an 8.0-fold relative risk of access loss compared with patent AVFs (P=0.048).
Our study shows that surgery remains a valid option for the pre-emptive repair of stenosis and to salvage clotted forearm AVFs, offering an excellent initial success rate and low restenosis rate. It confirms that it is better to treat stenosis pre-emptively than post-thrombosis (though the restenosis rate appears to be uninfluenced by the timing of intervention) and suggests that GI compares favourably with conventional NEO.
手术是治疗狭窄和血栓形成的前臂动静脉内瘘（AVF）的既定方法，但关于其结果的文献有限。我们报告了我们对通畅和血栓形成的前臂AVF狭窄进行手术修复的经验，并评估了两种手术方法的结果，即近端新吻合术（NEO）与用聚四氟乙烯移植物置换狭窄段（GI）。
64例狭窄的前臂AVF接受了手术，其中32例为预防性手术，32例为血栓形成后手术。研究的终点是初始成功率、再狭窄率和通路丢失率。治疗后，通过每季度测量通路血流量并至少进行一次随访血管造影来监测AVF是否发生再狭窄。
初始手术成功率为92%；通畅的AVF为100%，血栓形成的AVF为84%。通畅和血栓形成的AVF的再狭窄率均为0.189次事件/AVF年，而通畅的AVF的通路丢失率为0.016次事件/AVF年，血栓形成的AVF为0.148次事件/AVF年。27例AVF通过NEO纠正狭窄，30例通过GI纠正狭窄。NEO与GI的再狭窄率和通路丢失率分别为0.151次事件/AVF年对0.214次事件/AVF年和0.033次事件/AVF年对0.019次事件/AVF年。在Cox风险分析中，没有变量与再狭窄显著相关，而干预时机是通路丢失的唯一显著决定因素，与通畅的AVF相比，修复血栓形成的通路发生通路丢失的相对风险高8.0倍（P=0.048）。
我们的研究表明，手术仍然是预防性修复狭窄和挽救血栓形成的前臂AVF的有效选择，初始成功率高且再狭窄率低。它证实了预防性治疗狭窄比血栓形成后治疗更好（尽管再狭窄率似乎不受干预时机的影响），并表明GI与传统的NEO相比具有优势。
