Yu Son Ha, Cook Patrick R, Canty Timothy G, McGinn Robert F, Taft Peter M, Hye Robert J
Department of Surgery, Southern California Permanente Medical Group and Kaiser Foundation Hospital, San Diego, CA 92120, USA.
Ann Vasc Surg. 2008 Mar;22(2):210-4. doi: 10.1016/j.avsg.2007.12.005.
Hand ischemia due to steal causes major disability in affected members of the hemodialysis population. Between February 2000 and March 2007, 24 patients aged 37-77 years were identified who developed hand ischemia distal to a hemodialysis access and required a distal revascularization-interval ligation (DRIL) procedure. Of the 24 patients, 22 (92%) were diabetic, 14 (58%) were women, 7 (29%) had prosthetic grafts, and 17 (71%) had fistulas, all originating from the brachial artery. Duration between the initial dialysis access and the DRIL procedures ranged 12 hours to 10 months. Conduits used were saphenous vein in 13 (54%) cases, cephalic vein in 3 (12%) cases, basilic vein in 5 (21%) cases, and prosthetic grafts in 3 (12%) cases. There were no operative deaths. Improved blood flow and relief of symptoms were observed in 23 (96%) patients. The procedure failed early in one patient who had thrombosis of a prosthetic graft. Two patients required digital amputations. At a median follow-up of 50 months, 14 (58%) patients died using the access requiring the DRIL, 2 (8%) did not require dialysis, 3 (12%) were using a new access, and 5 (21%) were still using the access that had required the DRIL. In late follow-up, only one DRIL bypass required revision and the remainder were patent. One patient developed an ischemic hand 5 years after his DRIL procedure despite a patent bypass. The development of ischemic steal requiring performance of a DRIL procedure is most likely to occur in diabetic patients with dialysis access originating from the brachial artery. The procedure is effective in ameliorating symptoms while preserving the vascular access. The high long-term mortality rate observed in this series underscores the fact that patients requiring a DRIL procedure represent a subset of dialysis patients with advanced diabetic vascular disease and a limited life expectancy. Despite the effectiveness of the DRIL procedure, efforts should be concentrated on prevention of ischemic steal in order to lessen the morbidity and expense of this condition in the dialysis population.
窃血导致的手部缺血会给血液透析人群中的患者带来严重残疾。在2000年2月至2007年3月期间，共确定了24例年龄在37至77岁之间的患者，他们在血液透析通路远端出现手部缺血，需要进行远端血管重建-间隔结扎（DRIL）手术。24例患者中，22例（92%）患有糖尿病，14例（58%）为女性，7例（29%）有假体移植物，17例（71%）有动静脉内瘘，均起源于肱动脉。从最初建立透析通路到进行DRIL手术的时间间隔为12小时至10个月。使用的血管移植物中，13例（54%）为大隐静脉，3例（12%）为头静脉，5例（21%）为贵要静脉，3例（12%）为假体移植物。无手术死亡病例。23例（96%）患者的血流改善，症状缓解。1例假体移植物血栓形成的患者手术早期失败。2例患者需要进行手指截肢。中位随访50个月时，14例（58%）患者使用需要DRIL手术的通路死亡，2例（8%）不再需要透析治疗，3例（12%）使用新的通路，5例（21%）仍在使用需要DRIL手术的通路。在后期随访中，只有1条DRIL旁路需要翻修，其余均通畅。1例患者在DRIL手术后5年出现缺血性手部，尽管旁路通畅。需要进行DRIL手术的缺血性窃血最常发生于透析通路起源于肱动脉的糖尿病患者。该手术在改善症状的同时能保留血管通路。本系列观察到的高长期死亡率突出了这样一个事实，即需要进行DRIL手术的患者是患有晚期糖尿病血管疾病且预期寿命有限的透析患者的一个亚组。尽管DRIL手术有效，但应集中精力预防缺血性窃血，以降低透析人群中这种疾病的发病率和费用。
