Marcus Richard J, Marcus Dawn A, Sureshkumar Kalathil K, Hussain Sabiha M, McGill Rita L
Division of Nephrology and Hypertension, Allegheny General Hospital, and Department of Anesthesiology, University of Pittsburgh Medical Center, Pennsylvania 15212, USA.
Gend Med. 2007 Sep;4(3):193-204. doi: 10.1016/s1550-8579(07)80040-4.
Patients undergoing chronic hemodialysis (HD) require placement of permanent vascular access with the creation of an arteriovenous fistula (AVF), an arteriovenous prosthetic graft (AVG), or a tunneled central venous catheter. AVFs provide greater long-term patency, fewer complications, and lower infection rates than do either AVGs or catheters. Despite these advantages, women continue to be underrepresented among AVF patients, possibly because of concerns about smaller vascular diameters and higher rates of early primary fistula failure in female HD patients. The numerous clinical benefits of AVF suggest that a greater effort should be made to promote AVF placement in women.
This review analyzes risk factors for AVF failure in women and describes clinical strategies to improve AVF utilization and success for female HD patients.
English-language publications were identified through a MEDLINE database search from January 1997 to March 2007, using the search terms arteriovenous fistula, vascular access, hemodialysis, female, and gender. Reference lists of identified articles were also reviewed.
There are significant benefits to using AVFs instead of AVGs or catheters in HD patients: greater long-term fistula patency, superior flow rates, and fewer complications. Vascular anatomical differences between the sexes contribute to the underutilization of AVF in women. AVF placement rates can be improved if patients and staff are adequately educated and provided with the tools to facilitate AVF placement. Noninvasive preoperative screening is important to identify superior access sites in women. Intraoperative monitoring of blood flow is a reliable predictor of early radiocephalic AVF patency. Routine postoperative vascular monitoring may improve overall success with AVF, and exercise may improve vascular diameter and may be even more beneficial for women, who may have smaller preoperative veins.
Concerns about smaller vascular diameters and reports of higher failure rates in women may prevent nephrologists and surgeons from considering AVF for female HD patients. The numerous advantages associated with AVF suggest that a greater effort should be made to increase its utilization in women. With appropriate motivation, care, and diligence by treating clinicians, the success of AVFs in women can approach the good results typically expected in men.
接受慢性血液透析（HD）的患者需要建立永久性血管通路，可选择创建动静脉内瘘（AVF）、动静脉人工血管移植物（AVG）或带隧道的中心静脉导管。与AVG或导管相比，AVF具有更高的长期通畅率、更少的并发症和更低的感染率。尽管有这些优势，但在AVF患者中女性的比例仍然较低，这可能是因为担心女性血液透析患者血管直径较小以及早期原发性内瘘失败率较高。AVF的诸多临床益处表明，应做出更大努力来促进女性患者使用AVF。
本综述分析女性AVF失败的危险因素，并描述提高女性血液透析患者AVF利用率和成功率的临床策略。
通过检索1997年1月至2007年3月的MEDLINE数据库，使用检索词动静脉内瘘、血管通路、血液透析、女性和性别，确定英文出版物。还对已识别文章的参考文献列表进行了审查。
在血液透析患者中使用AVF而非AVG或导管有显著益处：更高的长期内瘘通畅率、更好的血流量以及更少的并发症。男女之间的血管解剖差异导致女性对AVF的利用率较低。如果对患者和工作人员进行充分教育并提供有助于AVF建立的工具，AVF的建立率可以提高。术前无创筛查对于确定女性的优质血管通路部位很重要。术中血流监测是早期桡动脉头静脉内瘘通畅的可靠预测指标。术后常规血管监测可能会提高AVF的总体成功率，运动可能会增加血管直径，对术前静脉可能较小的女性可能更有益。
对女性血管直径较小的担忧以及女性较高失败率的报道可能会阻止肾病学家和外科医生考虑为女性血液透析患者使用AVF。AVF的众多优势表明，应做出更大努力来提高其在女性中的利用率。通过治疗临床医生的适当激励、护理和勤勉工作，女性AVF的成功率可以接近男性通常预期的良好结果。
