Choi Kenneth L, Salman Loay, Krishnamurthy Gururaj, Mercado Carlos, Merrill Donna, Thomas Ian, Artikov Shukrat, Contreras Gabriel, Khan Rao Ali Hashim, Warda Ali, Asif Arif
Section of Interventional Nephrology, Division of Nephrology, University of Miami Miller School of Medicine, Miami, Florida 33136, USA.
Semin Dial. 2008 Jul-Aug;21(4):341-5. doi: 10.1111/j.1525-139X.2008.00446.x. Epub 2008 Jun 28.
According to the "Fistula First Initiative" surgeon selection should be based on best outcomes, willingness, and ability to provide access services. This analysis presents arteriovenous access placement and outcomes in 75 patients when surgery was performed by one of two dedicated high-volume vascular access surgeons (community [surgeon I] and academic medical center [surgeon II]). Preoperative vascular mapping was performed in all the patients. Demographic characteristics were similar except that patients referred to surgeon I (n = 40) were older (52.7 +/- 16.2 years vs. 45.4 +/- 13.7 years; p = 0.04) and tended to have more previously failed accesses (50% vs. 29%; p = 0.06) and black race (65% vs. 43%; p = 0.055) including a history of previously failed accesses (50% for surgeon I and 29% for surgeon II; p = 0.06). Similarly, there was no significant difference in the size of forearm ([surgeon I: 2.0 +/- 1.0 mm], [surgeon II: 1.9 +/- 0.8 mm]; p = 0.45) or upper arm veins (cephalic vein: surgeon I = 3.2 +/- 1.4 mm, surgeon II = 2.9 +/- 1.2 mm, p = 0.34; basilic vein: surgeon I = 5.0 +/- 1.2 mm, surgeon II = 4.7 +/- 1.3 mm, p = 0.25). Fistulae placement occurred in 98% vs. 71% (p = 0.001) for surgeon I and II, respectively. Characteristics predictive of fistula placement over an arteriovenous graft were surgeon selection (odds ratio [OR] = 19.52; p = 0.01) and no history of diabetes (OR = 7.61; p = 0.016). Kaplan-Meier analysis revealed 6 and 12 months overall access survival rates of 82%, 58% and 82% and 47% for surgeon I and II, respectively (p = 0.007). This analysis demonstrates that surgeon selection can have a significant impact on the rate of fistula placement and its overall survival despite similar findings on preoperative vascular mapping.
根据“动静脉内瘘优先倡议”，外科医生的选择应基于最佳手术效果、意愿以及提供通路服务的能力。本分析呈现了由两位专业的高流量血管通路外科医生（社区医生[医生I]和学术医疗中心医生[医生II]）之一进行手术的75例患者的动静脉通路置入情况及手术效果。所有患者均进行了术前血管造影。除了转诊至医生I的患者（n = 40）年龄更大（52.7±16.2岁 vs. 45.4±13.7岁；p = 0.04），且既往通路失败的情况更多（50% vs. 29%；p = 0.06）以及黑人种族比例更高（65% vs. 43%；p = 0.055）（包括既往通路失败史：医生I为50%，医生II为29%；p = 0.06）外，两组患者的人口统计学特征相似。同样，前臂静脉大小（[医生I：2.0±1.0 mm]，[医生II：1.9±0.8 mm]；p = 0.45）或上臂静脉（头静脉：医生I = 3.2±1.4 mm，医生II = 2.9±1.2 mm，p = 0.34；贵要静脉：医生I = 5.0±1.2 mm，医生II = 4.7±1.3 mm，p = 0.25）也无显著差异。医生I和医生II的内瘘置入率分别为98%和71%（p = 0.001）。预测内瘘置入优于动静脉移植物的特征为外科医生的选择（优势比[OR] = 19.52；p = 0.01）和无糖尿病史（OR = 7.61；p = 0.016）。Kaplan-Meier分析显示，医生I和医生II的6个月和12个月总体通路生存率分别为82%、58%和82%、47%（p = 0.007）。本分析表明，尽管术前血管造影结果相似，但外科医生的选择对内瘘置入率及其总体生存率可能有显著影响。
