Woo Karen, Doros Gheorghe, Ng Tina, Farber Alik
Divison of Vascular Surgery, Scripps Green Hospital, La Jolla, Calif, USA.
J Vasc Surg. 2009 Dec;50(6):1405-11.e1-2. doi: 10.1016/j.jvs.2009.07.090. Epub 2009 Sep 26.
Direct comparison of transposed arteriovenous fistulas (tAVF) and arteriovenous grafts (AVG) has been hampered by inherent differences in patient characteristics between tAVF and AVG groups. In this study, using matching to control patient variables, we evaluated our outcomes with upper arm tAVF and upper arm prosthetic AVG.
A retrospective review of all newly created upper arm tAVF and AVG was performed. One hundred ninety upper arm tAVF were group matched for age, gender, race, diabetes, and history of previous failed access with 168 AVG chosen from a pool of 476 concurrently performed AVG procedures. Complication, patency, and intervention rates were compared using multivariate analysis.
Mean follow up for our cohort was 29.1 months. Transposed fistulae consisted of 119 basilic vein and 71 cephalic vein transpositions, which were found to have similar demographic parameters, complication rates, and patency rates. There were no differences in 30 day mortality, 24 hour thrombosis, bleeding requiring exploration, or ischemic steal requiring intervention between the tAVF and AVG groups. More AVG developed infection requiring operative exploration than tAVF (7.9% vs 1.6%, respectively. P = .004). Primary patency for tAVF was higher than for AVG: 48% vs 14% at five years (P < .0001). Secondary patency rate for tAVF was also higher than for AVG: 57% vs 19% at five years (P < .0001). Nine percent of tAVF compared with 53% of AVG required one or more surgical and/or percutaneous revisions to maintain secondary patency (P < .0001). Multivariate analysis revealed that utilization of a tAVF was associated with a reduced risk of primary (Hazard Ratio [HR] 0.47, 95% Confidence Interval [CI] 0.35-0.64, P < .0001) and secondary failure (HR 0.59, 95% CI 0.42-0.81, P = .0001).
Transposed arteriovenous fistulas have significantly higher primary and secondary patency rates, require fewer revisions, and are less likely to develop a significant infection than AVG. This study supports the contention that as long as a patient is a candidate for a tAVF based on anatomic criteria, a tAVF should be considered before an AVG.
转位动静脉内瘘（tAVF）与动静脉移植物（AVG）之间患者特征的固有差异阻碍了对二者的直接比较。在本研究中，我们通过匹配控制患者变量，评估了上臂tAVF和上臂人工血管AVG的治疗效果。
对所有新创建的上臂tAVF和AVG进行回顾性研究。将190例上臂tAVF与168例AVG按年龄、性别、种族、糖尿病以及既往血管通路失败史进行组间匹配，其中168例AVG选自同期进行的476例AVG手术。采用多变量分析比较并发症、通畅率和干预率。
我们队列的平均随访时间为29.1个月。转位内瘘包括119例贵要静脉转位和71例头静脉转位，发现它们具有相似的人口统计学参数、并发症发生率和通畅率。tAVF组和AVG组在30天死亡率、24小时血栓形成、需要探查的出血或需要干预的窃血综合征方面无差异。与tAVF相比，更多的AVG发生感染需要手术探查（分别为7.9%和1.6%，P = 0.004）。tAVF的初级通畅率高于AVG：五年时分别为48%和14%（P < 0.0001）。tAVF的次级通畅率也高于AVG：五年时分别为57%和19%（P < 0.0001）。9%的tAVF与53%的AVG需要一次或多次手术和/或经皮修复以维持次级通畅（P < 0.0001）。多变量分析显示，使用tAVF与初级失败风险降低相关（风险比[HR] 0.47，95%置信区间[CI] 0.35 - 0.64，P < 0.0001）和次级失败风险降低相关（HR 0.59，95% CI 0.42 - 0.81，P = 0.0001）。
转位动静脉内瘘的初级和次级通畅率显著更高，需要的修复次数更少，且比AVG发生严重感染的可能性更小。本研究支持这样的观点，即只要患者根据解剖标准适合行tAVF，就应在AVG之前考虑tAVF。
