Keuter Xavier H A, De Smet André A E A, Kessels Alfons G H, van der Sande Frank M, Welten Rob J Th J, Tordoir Jan H M
Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands.
J Vasc Surg. 2008 Feb;47(2):395-401. doi: 10.1016/j.jvs.2007.09.063. Epub 2007 Dec 26.
Vascular access is a necessity for patients with end-stage renal disease who need chronic intermittent hemodialysis. According to Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, radial-cephalic (RC) and brachial-cephalic (BC) arteriovenous fistulas (AVF) are the first and second choice for vascular access, respectively. If these options are not possible, an autogenous brachial-basilic fistula in the upper arm (BBAVF) or a prosthetic brachial-antecubital forearm loop (PTFE loop) may be considered. Until now, it was not clear which access type was preferable. We have performed a randomized study comparing BBAVF and prosthetic implantation in patients without the possibility for RCAVF or BCAVF.
Patients with failed primary/secondary access or inadequate arterial and/or venous vessels were randomized for either BBAVF or PTFE loop creation. The numbers of complications and interventions were recorded. Kaplan-Meier method was used to calculate primary, assisted-primary and secondary patency rates. The patency rates were compared with the log-rank test. Complication and intervention rates were compared with the Mann-Whitney test.
A total of 105 patients were randomized for a BBAVF or PTFE loop (52 vs 53, respectively). Primary and assisted-primary 1-year patency rates were significantly higher in the BBAVF group: 46% +/- 7.4% vs 22% +/- 6.1% (P = .005) and 87% +/- 5.0% vs 71% +/- 6.7% (P = .045) for the BBAVF and PTFE group, respectively. Secondary patencies were comparable for both groups; 89% +/- 4.6% vs 85% +/- 5.2% for the BBAVF and PTFE group, respectively. The incidence rate of complications was 1.6 per patient-year in the BBAVF group vs 2.7 per patient-year in the PTFE group. Patients in the BBAVF group needed a total of 1.7 interventions per patient-year vs 2.7 per patient-year for the PTFE group.
These data show a significantly better primary and assisted-primary patency in the BBAVF group compared with the PTFE group. Furthermore, in the BBAVF group, fewer interventions were needed. Therefore, we conclude that BBAVF is the preferred choice for vascular access if RCAVF or BCAVF creation is impossible, or when these types of access have already failed.
血管通路对于需要长期间歇性血液透析的终末期肾病患者来说是必不可少的。根据《肾脏病预后质量倡议》（KDOQI）指南，桡动脉-头静脉（RC）和肱动脉-头静脉（BC）动静脉内瘘（AVF）分别是血管通路的第一和第二选择。如果这些选择不可行，可以考虑在上臂建立自体肱动脉-贵要静脉内瘘（BBAVF）或人工肱动脉-肘前襻（PTFE襻）。到目前为止，尚不清楚哪种通路类型更可取。我们进行了一项随机研究，比较了在无法建立RCAVF或BCAVF的患者中BBAVF和人工血管植入的情况。
原发性/继发性血管通路失败或动脉和/或静脉血管不足的患者被随机分为BBAVF组或PTFE襻组。记录并发症和干预的数量。采用Kaplan-Meier法计算初次、辅助初次和二次通畅率。采用对数秩检验比较通畅率。采用Mann-Whitney检验比较并发症和干预率。
共有105例患者被随机分为BBAVF组或PTFE襻组（分别为52例和53例）。BBAVF组的初次和辅助初次1年通畅率显著更高：BBAVF组为46%±7.4%，PTFE组为22%±6.1%（P = 0.005）；BBAVF组为87%±5.0%，PTFE组为71%±6.7%（P = 0.045）。两组的二次通畅率相当；BBAVF组为89%±4.6%，PTFE组为85%±5.2%。BBAVF组的并发症发生率为每年每例患者1.6次，而PTFE组为每年每例患者2.7次。BBAVF组的患者每年每例总共需要1.7次干预，而PTFE组为每年每例2.7次。
这些数据表明，与PTFE组相比，BBAVF组的初次和辅助初次通畅率显著更好。此外，BBAVF组需要的干预更少。因此，我们得出结论，如果无法建立RCAVF或BCAVF，或者这些类型的通路已经失败，BBAVF是血管通路的首选。
