Alexander J B, Spence R K, Camishion R C
Department of Surgery, Cooper Hospital/University Medical Center, Camden, New Jersey 08103.
Ann Vasc Surg. 1991 Mar;5(2):176-81. doi: 10.1007/BF02016752.
Arteriovenous fistulas at the distal anastomosis have been suggested to improve the patency of prosthetic femorocrural bypasses. We have followed nine patient with bypasses to the crural vessels and distal arteriovenous fistulas using physical examination, pulse volume recordings, and segmental pressure indices. Duplex scans of the distal anastomosis were employed to determine the contribution of arterial and venous outflow to total graft flow. Early graft patency was achieved in all patients. One patient went on to amputation at one week postoperatively for progressive ischemia despite a patent graft. The other eight patients achieved successful revascularization. Healing of ulcers, relief of rest pain, the presence of palpable pulses, good pulse wave amplitude, and normal pressure indices are consistent findings as long as the bypass is patent. One patient died on the fourth postoperative day from a myocardial infarction. The remaining patients have been followed from one to 23 months with follow-up examination every three to four months. Sequential duplex scans show that flow continues into distal arteries while venous outflow diminishes. This corresponds to a reduction in the diameter of the outflow veins while the caliber of arterial runoff is maintained. Patency has been achieved up to 23 months with a mean of 12 months. Venous outflow occlusion precedes graft thrombosis by two to 15 months. Graft occlusion has uniformly necessitated amputation. It may be possible to improve long-term graft patency and limb salvage by surgical revision of the distal anastomosis to reestablish venous outflow.
有人提出，在远端吻合处建立动静脉瘘可提高人工股腘动脉旁路移植术的通畅率。我们对9例接受腘血管旁路移植术并伴有远端动静脉瘘的患者进行了随访，采用体格检查、脉搏容积记录和节段压力指数等方法。利用远端吻合处的双功扫描来确定动脉和静脉流出对总移植血流量的贡献。所有患者均实现了早期移植血管通畅。1例患者尽管移植血管通畅，但术后1周因进行性缺血而接受了截肢手术。其他8例患者实现了成功的血管再通。只要旁路移植血管通畅，溃疡愈合、静息痛缓解、可触及脉搏、良好的脉搏波振幅和正常的压力指数都是一致的表现。1例患者术后第4天死于心肌梗死。其余患者已随访1至23个月，每三到四个月进行一次随访检查。连续的双功扫描显示，血流持续流入远端动脉，而静脉流出减少。这与流出静脉直径的减小相对应，而动脉侧支的管径保持不变。移植血管通畅时间长达23个月，平均为12个月。静脉流出道闭塞比移植血管血栓形成早2至15个月。移植血管闭塞无一例外地需要截肢。通过对远端吻合口进行手术修正以重建静脉流出道，可能会提高移植血管的长期通畅率并挽救肢体。
