溶栓后早期透析血管通路失败的预测因素

Crikis Sandra, Lee Darren, Brooks Mark, Power David A, Ierino Francesco L, Levidiotis Vicki

Department of Nephrology, Austin Health, Melbourne, Australia.

Am J Nephrol. 2008;28(2):181-9. doi: 10.1159/000110086. Epub 2007 Oct 24.

BACKGROUND

Vascular-access patency is critical for effective and uninterrupted haemodialysis. Limited literature exists evaluating if a surgical or repeated radiological approach is superior for reocclusion following failure of radiological recanalization. Few consistent early predictors of failure have been identified after radiological intervention for thrombosed vascular access.

METHODS

138 patients with thrombosed arteriovenous fistulas or prosthetic grafts treated by radiological intervention, over 10 years, were retrospectively investigated. Reocclusion was treated by either repeated thrombolysis or surgery. Radiological patency rates, after first and second episodes of access thrombosis at 12 months after intervention were analysed. Surgical and radiological patency rates for second access thrombosis were compared. The Cox and logistic regression models were used to identify potential factors associated with reocclusion.

RESULTS

In patients who experienced reocclusion within 1 month after radiological intervention, the 3-month repeated radiological patency rate (n = 13) was 38.5%, compared to a 60% surgical patency rate (n = 10), but this did not reach statistical significance. Radiological patency rates after first access thrombosis at 3 and 12 months were 56.6 and 39.5%, respectively. In contrast, radiological patency rates after a second access thrombosis were 51.1 and 24.4%, respectively; a statistical difference in success was not achieved. Native arteriovenous fistulas were 3.23 times as likely to remain patent over 12 months following a first radiological intervention (p < 0.02) and less likely to experience a second reocclusion event (p < 0.01). Anticoagulation was associated with a lower risk of second reocclusion, whilst a history of venous thrombosis was associated with a greater risk (p < 0.02).

CONCLUSION

Surgery achieves superior patency rates compared to repeated radiological interventions and should be considered if reocclusion occurs within a month following radiological thrombolysis.

背景

血管通路的通畅对于有效且不间断的血液透析至关重要。关于在放射介入再通失败后，手术或重复放射介入方法在治疗再闭塞方面是否更具优势的评估文献有限。对于血栓形成的血管通路进行放射介入后，几乎没有一致的早期失败预测因素被确定。

方法

回顾性调查了138例在10年期间接受放射介入治疗的血栓形成的动静脉内瘘或人工血管移植患者。再闭塞通过重复溶栓或手术进行治疗。分析了介入后12个月首次和第二次通路血栓形成发作后的放射通畅率。比较了第二次通路血栓形成的手术和放射通畅率。使用Cox和逻辑回归模型来确定与再闭塞相关的潜在因素。

结果

在放射介入后1个月内发生再闭塞的患者中，3个月的重复放射通畅率（n = 13）为38.5%，而手术通畅率为60%（n = 10），但这未达到统计学意义。首次通路血栓形成后3个月和12个月的放射通畅率分别为56.6%和39.5%。相比之下，第二次通路血栓形成后的放射通畅率分别为51.1%和24.4%；成功方面未实现统计学差异。在首次放射介入后12个月内，自体动静脉内瘘保持通畅的可能性是人工血管移植的3.23倍（p < 0.02），且发生第二次再闭塞事件的可能性较小（p < 0.01）。抗凝与第二次再闭塞风险较低相关，而静脉血栓形成病史与较高风险相关（p < 0.02）。