Berman S S, Mendoza B, Westerband A, Quick R C
The Southern Arizona Vascular Institute, Tucson, Arizona 85745, USA.
J Vasc Access. 2008 Oct-Dec;9(4):241-7.
To establish the criteria for intraoperative blood flow measurements taken at the time of autologous arteriovenous fistula (AVF) construction to predict future access maturation and thereby avoid waiting periods for futile fistulas to declare themselves.
From April 2006 through to March 2007 consecutive patients undergoing native AVF construction at one institution underwent intraoperative measurements of blood flow using transit-time ultrasound technology. No action was taken based upon the flow measurement at the time of surgery. Patients were followed and data collected comprising demographics and AVF maturation. A fistula was considered mature when it was successfully accessed for hemodialysis (HD) at least three times. Statistical analysis was performed including receiver operating characteristics (ROC), ANOVA, and Chi square using the JMP software package.
During the 12-month period, 70 autologous AVFs were created including 41 antecubital brachiocephalic, 21 radiocephalic, and 8 basilic vein transpositions in 35 females and 33 males with a mean age of 58+/-1.7 (mean+/-SEM). The group included 37 Hispanic, 17 Native American, 10 Caucasian, 3 African American and 1 Asian patient. The etiology of renal failure comprised 53 diabetics, 13 hypertensives, 1 polycystic kidney disease and 1 congenital abnormality. Complete follow-up was available in 69/70 AVFs in 67 patients. Patients were excluded from analysis if they had not yet started dialysis (n=12), stopped or died (n=4) before their fistula was accessed. Patients whose AVFs were patent, but required a secondary procedure to achieve a functional access were considered non-functional. There was a significant difference between the maximal intraoperative flow rates between functional and non-functional AVFs (573.6+/-103 mL/min vs. 216.8+/-35.8 mL/min; p<0.05). There was no difference between groups in regard to age, gender, race or etiology of renal failure. ROC analysis suggested a threshold value of 140 mL/min for radiocephalic and 308 mL/min for brachiocephalic AVFs to predict maturation to a functional access.
Intraoperative blood flow measurements obtained at the time of autologous AVF construction can identify fistulas that are unlikely to mature; and therefore, that require immediate revision or abandonment which will ultimately expedite the establishment of a useful access in the HD patient. This is the first study to establish the minimal flow values uniquely needed for both radial artery and brachial artery AVFs to expect primary maturation to a functional access.
建立自体动静脉内瘘（AVF）构建时术中血流测量的标准，以预测未来通路的成熟情况，从而避免等待无用的内瘘自行显露的时期。
从2006年4月至2007年3月，在一家机构连续接受自体AVF构建的患者，使用渡越时间超声技术进行术中血流测量。手术时未根据血流测量采取任何措施。对患者进行随访并收集包括人口统计学和AVF成熟情况的数据。当内瘘成功用于血液透析（HD）至少三次时，认为其成熟。使用JMP软件包进行统计分析，包括受试者工作特征（ROC）、方差分析和卡方检验。
在12个月期间，创建了70个自体AVF，包括41个肘前肱头型、21个桡头型和8个贵要静脉转位型，其中35名女性和33名男性，平均年龄为58±1.7（平均±标准误）。该组包括37名西班牙裔、17名美洲原住民、10名白种人、3名非裔美国人和1名亚洲患者。肾衰竭的病因包括53名糖尿病患者、13名高血压患者、1名多囊肾病患者和1名先天性异常患者。67名患者中的69/70个AVF有完整的随访资料。如果患者尚未开始透析（n = 12）、在内瘘可用之前停止透析或死亡（n = 4），则将其排除在分析之外。AVF通畅但需要二次手术才能获得功能性通路的患者被视为无功能。功能性和无功能性AVF之间的最大术中流速存在显著差异（573.6±103 mL/分钟对216.8±35.8 mL/分钟；p<0.05）。在年龄、性别、种族或肾衰竭病因方面，各组之间没有差异。ROC分析表明，桡头型AVF预测成熟为功能性通路的阈值为140 mL/分钟，肱头型AVF为308 mL/分钟。
自体AVF构建时获得的术中血流测量可以识别不太可能成熟的内瘘；因此，需要立即进行修复或放弃，这最终将加快HD患者建立有用通路的进程。这是第一项确定桡动脉和肱动脉AVF预期主要成熟为功能性通路所需的最低流速值的研究。
