Solesky Beverly C, Huber Thomas S, Berceli Scott A
Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL, USA.
J Vasc Access. 2010 Jan-Mar;11(1):31-7. doi: 10.1177/112972981001100107.
Dialysis access literature has traditionally focused on fistula patency as the primary outcome measure, but this approach falls short in describing the entire spectrum of dialysis access care. Using our prospectively maintained vascular access data base, a comprehensive, patient-centered analysis of arteriovenous access placement and interventions, central venous catheter use, and associated complications is performed.
Twenty-six patients receiving 39 arteriovenous fistula (AVF), eight prosthetic grafts and 52 catheters were followed longitudinally for an average of 4.1 yrs to determine the time of initial cannulation, need for revision, and the time of abandonment for each AV access. Access complications secondary to infection, thrombosis, stenosis, and aneurysmal degeneration were tabulated. The time of permanent dialysis catheter placement and removal was collected, along with infection and thrombotic complications related to their use.
Fifty-four percent of the AVFs matured without the need for intervention, while 13% required revision to promote maturation. One-third of the AVFs failed primarily or following revision and were never used for dialysis. Fistulae were initially cannulated an average of 9.5 months following implantation and lasted 27.2 months before abandonment. AVF revisions were performed an average of 7.5 months following maturation and provided an additional 19.8 months of usability. Fifty percent of prosthetic grafts could be used without intervention, while 25% were used only after revision and 25% were abandoned without being used. Grafts were accessed an average of 2.7 months after implantation and lasted 14.1 months after the initial cannulation. Twenty-three patients received a total of 52 catheters during the study, with an average implantation time of 6.5 months. Sixty-three percent of the catheters developed one or more complications, for a rate of 1.3 complications per year of indwelling catheter.
The current study provides a novel approach for the comprehensive evaluation of access care for patients undergoing hemodialysis through the development of a patient-centric approach to examine the complexities and shortcomings in dialysis access care. Despite some difficulties in achieving fistula maturation, an AVF prevalence rate was 66%, meeting the 65% goal set by the Fistula First Initiative. Unfortunately, a significant portion of the remainder of the dialysis support was provided by catheters, with a 27% catheter prevalence rate.
传统上，透析通路文献一直将内瘘通畅作为主要结局指标，但这种方法在描述透析通路护理的全貌方面存在不足。利用我们前瞻性维护的血管通路数据库，对动静脉通路的建立与干预、中心静脉导管的使用及相关并发症进行了全面的、以患者为中心的分析。
对26例接受39个动静脉内瘘（AVF）、8个人工血管移植物和52根导管的患者进行纵向随访，平均随访4.1年，以确定每个动静脉通路的首次穿刺时间、修复需求及废弃时间。将感染、血栓形成、狭窄和动脉瘤样变性等继发于通路的并发症制成表格。收集永久性透析导管的置入和拔除时间，以及与导管使用相关的感染和血栓形成并发症。
54%的AVF无需干预即可成熟，13%需要进行修复以促进成熟。三分之一的AVF在初次使用或修复后失败，从未用于透析。内瘘在植入后平均9.5个月开始首次穿刺，在废弃前持续使用27.2个月。AVF修复平均在成熟后7.5个月进行，可额外使用19.个月。50%的人工血管移植物无需干预即可使用，25%仅在修复后使用，25%未使用就被废弃。人工血管移植物在植入后平均2.7个月开始使用，首次穿刺后持续使用14.1个月。23例患者在研究期间共接受了52根导管，平均植入时间为6.5个月。63%的导管出现了一种或多种并发症，留置导管每年的并发症发生率为1.3次。
本研究通过开发一种以患者为中心的方法来检查透析通路护理中的复杂性和不足，为接受血液透析患者的通路护理综合评估提供了一种新方法。尽管在实现内瘘成熟方面存在一些困难，但AVF的使用率为66%，达到了“内瘘优先倡议”设定的65%的目标。不幸的是，其余透析支持的很大一部分由导管提供，导管使用率为27%。
