Georgiadis George S, Lazarides Miltos K, Panagoutsos Stelios A, Kantartzi Konstantia M, Lambidis Constantinos D, Staramos Dimitrios N, Vargemezis Vassilios A
Department of Vascular Surgery, Demokritos University Hospital, Alexandroupolis, Greece.
J Vasc Surg. 2008 Jun;47(6):1284-1291. doi: 10.1016/j.jvs.2008.01.051.
This prospective observational study examined the effect of revision surgery in patients who present solely with complicated arteriovenous access (AVA)-related aneurysms.
The demographics and comorbid conditions of 44 hemodialysis access patients who presented with complicated true or false AVA-related aneurysms and underwent revision surgery during a 7-year period were prospectively entered into our AVA database. Also recorded were AVA characteristics before and after revision. Arteriovenous access anatomy was evaluated preoperatively using color Doppler ultrasonography, and AVA adequacy was assessed in all patients postoperatively after the first needle puncture and every month thereafter. Postintervention access function and primary patency rates were analyzed. Patency was evaluated using the Kaplan-Meier method and compared between groups of patients with different AVA characteristics before and after revision using the log-rank test.
The cases of initial AVA with complicated aneurysms comprised 16 radiocephalic, 8 brachiocephalic, 2 basilic vein transposition, and 18 prosthetic fistulas (7 and 11 of the lower and upper arm, respectively), of which 42 were dysfunctional and 2 had thrombosed early at presentation. Primary indications for revision were danger of aneurysm rupture in 26, duplication in graft aneurysm diameter in 18, painful aneurysm in 12, stenosis due to partial aneurysm thrombosis in 12, shortness of the potential cannulation area in 12, aneurysm enlargement in 4, infected aneurysm in 2, and completely thrombosed aneurysm in 2. The mean postintervention primary patencies were 93%, 82%, 57%, and 32% at 3, 6, 12, and 24 months, respectively. The outcomes was better in autogenous than prosthetic corrections, in true than false aneurysms, in patients with two or fewer than more than 2 previous AVAs on revised arms, and in forearm than upper-arm corrections (P = .0197, P = .004, P = .0022, and P = .0225, respectively).
Surgical revision of complicated false and true AVA-related aneurysms reveals acceptable postintervention primary patency rates and therefore is justified. This outcome measure was superior in the following specific groups of corrections: autogenous were better than prosthetic, true aneurysms were better than false aneurysms, patients with one or two previous AVAs in the revised arm were better than those with more than two previous accesses in the revised arm, and finally, forearms were better than those in the upper arm.
本前瞻性观察性研究探讨了单纯出现复杂动静脉通路（AVA）相关动脉瘤的患者行翻修手术的效果。
对44例因复杂真性或假性AVA相关动脉瘤而接受翻修手术的血液透析通路患者的人口统计学资料和合并症情况，在7年期间前瞻性地录入我们的AVA数据库。还记录了翻修前后的AVA特征。术前使用彩色多普勒超声评估动静脉通路解剖结构，所有患者在首次穿刺后及此后每月评估AVA的通畅情况。分析干预后通路功能和初次通畅率。使用Kaplan-Meier方法评估通畅情况，并使用对数秩检验比较翻修前后具有不同AVA特征的患者组之间的通畅情况。
最初伴有复杂动脉瘤的AVA病例包括16例桡动脉-头静脉、8例肱动脉-头静脉、2例贵要静脉转位和18例人工血管内瘘（分别位于上臂和下臂的有7例和11例），其中42例功能不良，2例在就诊时早期发生血栓形成。翻修的主要指征为26例存在动脉瘤破裂风险、18例移植血管动脉瘤直径增倍、12例动脉瘤疼痛、12例因部分动脉瘤血栓形成导致狭窄、12例潜在穿刺区域短缩、4例动脉瘤增大、2例感染性动脉瘤和2例完全血栓形成的动脉瘤。干预后3个月、6个月、12个月和24个月的初次通畅率分别为93%、82%、57%和32%。自体血管修复比人工血管修复效果更好，真性动脉瘤比假性动脉瘤效果更好，翻修侧之前有两个或更少动静脉通路的患者比有两个以上动静脉通路的患者效果更好，前臂修复比上臂修复效果更好（分别为P = 0.0197、P = 0.004、P = 0.0022和P = 0.0225）。
对复杂的假性和真性AVA相关动脉瘤进行手术翻修后，初次通畅率可接受，因此是合理的。在以下特定的修复组中，这一结果指标更优：自体血管修复优于人工血管修复，真性动脉瘤优于假性动脉瘤，翻修侧之前有一两个动静脉通路的患者优于有两个以上动静脉通路的患者，最后，前臂修复优于上臂修复。
