Napoli M, Montinaro A, Russo F, De Pascalis A, Patruno P, Proia S, Valletta A, Vitale O, Buongiorno E
Nephrology, Dialysis and Renal Transplantation Unit, V. Fazzi Hospital, Lecce, Italy.
J Vasc Access. 2007 Apr-Jun;8(2):97-102.
In recent years the high prevalence of diabetes and atherosclerosis in elderly uremic patients starting hemodialysis (HD) has led to the increase in the risk of vascular access (VA) failure caused by pre-existing arterial diseases, including both VA slow maturation and early failure, and upper limb ischemic symptoms. Recently, in performing radial (R), brachial (B) and ulnar (U) artery (A) percutaneous transluminal angioplasty (PTA) in HD patients affected by access thrombosis, with insufficient blood flow and severe upper limb ischemia, good outcomes have been reported. Nevertheless, these procedures were performed after arteriovenous fistula (AVF) creation. About 2 years ago, we approached an intra-operative ultrasound-guided transluminal angioplasty (IUTA) performed during AVF creation, using the arterial incision, necessary because of the anastomosis, to introduce the necessary devices for the IUTA. The arterial stenosis having undergone IUTA was diagnosed by a preliminary ultrasound examination. Ultrasound guidance during the procedure is necessary for correct balloon location in the stenosis site. We treated seven patients (four diabetics), mean age 76 + 5 yrs. In all cases, the radial arteries because of hyposphygmia, were unfit for AVF creation. Four distal radio-cephalic AVFs at the wrist were created in patients 1, 3, 4 and 5; in the other three patients (2, 6 and 7), with failure or thrombosis of previous distal AVFs, an immediately upstream anastomosis was performed. In all cases, first, the area selected to perform the AV anastomosis was exposed, then the AR was incised, and the introductory metallic guide wire and the angioplasty catheter (with dimensions decided after PUS), were introduced. The balloon was inflated to 8-13 atm for 30-35 sec. In two patients a stent was also positioned. Later, a side-to-side AVF was created, closing the distal venous vessel. Patient follow-up ranged from 6-22 months. The ultrasound evaluation after IUTA showed the correction of all the stenosis treated. AVF maturation was good, except for the stented ones, which were inadequate. In conclusion, our early experience shows IUTA could be an adequate and effective procedure allowing the use of the stenotic arteries (otherwise unsuitable) for AVF creation. In our experience, stenting after IUTA does not add any other advantages.
近年来，开始进行血液透析（HD）的老年尿毒症患者中糖尿病和动脉粥样硬化的高患病率导致了由先前存在的动脉疾病引起的血管通路（VA）失败风险增加，包括VA成熟缓慢和早期失败以及上肢缺血症状。最近，在对因通路血栓形成、血流不足和严重上肢缺血而接受HD治疗的患者进行桡动脉（R）、肱动脉（B）和尺动脉（U）经皮腔内血管成形术（PTA）时，已报道了良好的结果。然而，这些手术是在动静脉内瘘（AVF）建立后进行的。大约2年前，我们采用了在AVF建立过程中进行的术中超声引导腔内血管成形术（IUTA），利用由于吻合术而必需的动脉切口来引入IUTA所需的器械。通过初步超声检查诊断出接受IUTA的动脉狭窄。手术过程中的超声引导对于将球囊正确定位在狭窄部位是必要的。我们治疗了7例患者（4例糖尿病患者）平均年龄76±5岁。在所有病例中，由于脉搏微弱，桡动脉不适合建立AVF。在患者1、3、4和5中创建了4个腕部远端桡动脉-头静脉内瘘；在其他3例患者（2、6和7）中，由于先前远端AVF失败或血栓形成，进行了紧邻上游的吻合术。在所有病例中，首先暴露选择进行AV吻合的区域，然后切开动脉，引入引导金属导丝和血管成形术导管（尺寸在超声检查后确定）。将球囊充气至8 - 13个大气压，持续30 - 35秒。2例患者还放置了支架。随后，建立了侧侧AVF，封闭远端静脉血管。患者随访时间为6 - 22个月。IUTA后的超声评估显示所有治疗的狭窄均得到纠正。除了放置支架的内瘘，AVF成熟良好。总之，我们的早期经验表明IUTA可能是一种合适且有效的手术方法，可使原本不适合的狭窄动脉用于建立AVF。根据我们的经验，IUTA后放置支架并没有带来任何其他优势。
