Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794-8191, USA.
J Vasc Surg. 2011 May;53(5):1291-7. doi: 10.1016/j.jvs.2010.11.100. Epub 2011 Jan 26.
This study was designed to determine the clinical presentation, characteristics, and management of true aneurysms in dialysis access fistulas.
Patients presenting with symptoms or functional arteriovenous fistula (AVF) problems and aneurysmal enlargement of the outflow vein were evaluated with duplex ultrasound scans. Dilatation to more than three times the native vessel diameter was considered aneurysmal. Pseudoaneurysms were excluded from the study. Patients' demographics, aneurysm characteristics (diameter, location, thrombus, association with stenosis, and outflow obstruction), symptoms, type of treatment, and follow-up were recorded.
Twenty-three patients with a mean age of 55 years were found to have 29 upper extremity aneurysms of the outflow vein on duplex ultrasound scan. Nine patients (39%) had radiocephalic, 11 patients (48%) had brachiocephalic, 2 patients (9%) had brachiobasilic, and 1 patient (4%) had radiobasilic arteriovenous fistula. The average aneurysm size was 3.3 cm and the mean time from fistula placement to treatment was 47.1 months. Four patients (17%) were asymptomatic and were repaired due to technical and mechanical problems with AVFs, including stenosis and lack of normal vein for cannulation, compromising continued use. Nineteen patients (83%) presented with symptoms, including pain (48%), skin changes (30%), venous hypertension (22%), steal syndrome (22%), and high output failure (9%). Four patients (17%) were found to have outflow vein stenosis, 2 patients (9%) had central venous stenosis, and 2 patients (9%) had central venous occlusion. In 13 patients (56%) who had a functioning kidney transplant, the fistula was ligated with or without aneurysm excision. Three of the 13 patients developed superficial phlebitis with 1 patient requiring surgical evacuation of a clot; the other 2 patients were managed conservatively. Two of the 13 patients required creation of new access due to renal transplant failure. In the remaining 10 patients, the aneurysm was treated and the fistula salvaged due to a persistent need for hemodialysis. The median follow-up of these patients was 19 months ranging from 8 to 25 months. Seven patients (30%) underwent excision and repair with the great saphenous vein and 3 patients (13%) had excision and repair with prosthetic material, 2 of which underwent central venous angioplasty and stenting. Two patients developed thrombosis of their repair requiring new access in the contralateral arm. Three patients needed secondary percutaneous interventions for anastomotic stenosis.
Although true aneurysms in patients with dialysis access are uncommon, significant complications may occur as a consequence of their presence. These complications can be treated and the fistulas can usually be salvaged.
本研究旨在确定透析通路瘘管中真性动脉瘤的临床表现、特征和处理方法。
对出现症状或功能动静脉瘘（AVF）问题以及流出静脉动脉瘤样扩张的患者进行双功能超声扫描评估。扩张超过原血管直径的三倍被认为是动脉瘤。本研究排除假性动脉瘤。记录患者的人口统计学资料、动脉瘤特征（直径、位置、血栓形成、与狭窄的关系以及流出道阻塞）、症状、治疗类型和随访情况。
在双功能超声扫描中发现 23 例上腔静脉流出静脉动脉瘤，患者平均年龄为 55 岁。9 例（39%）为头臂静脉，11 例（48%）为肱动脉，2 例（9%）为肱动脉，1 例（4%）为桡动脉。平均动脉瘤大小为 3.3cm，从瘘管置管到治疗的平均时间为 47.1 个月。4 例（17%）患者无症状，因 AVF 出现技术和机械问题，包括狭窄和缺乏正常的血管进行穿刺，导致瘘管无法继续使用，而进行修复。19 例（83%）患者出现症状，包括疼痛（48%）、皮肤改变（30%）、静脉高压（22%）、盗血综合征（22%）和高输出衰竭（9%）。4 例（17%）患者存在流出静脉狭窄，2 例（9%）患者存在中心静脉狭窄，2 例（9%）患者存在中心静脉闭塞。在 13 例（56%）有功能的肾移植患者中，瘘管被结扎，同时或不切除动脉瘤。13 例患者中有 3 例发生浅表静脉炎，其中 1 例需要手术清除血栓；另外 2 例患者接受保守治疗。13 例患者中有 2 例因肾移植失败需要建立新的通路。在其余 10 例患者中，由于需要持续进行血液透析，对动脉瘤进行了治疗，并保留了瘘管。这些患者的中位随访时间为 19 个月，范围为 8 至 25 个月。7 例（30%）患者采用大隐静脉进行切除和修复，3 例（13%）患者采用人工材料进行切除和修复，其中 2 例患者接受了中心静脉血管成形术和支架置入。2 例患者出现修复后血栓形成，需要在对侧手臂建立新的通路。3 例患者需要进行经皮介入治疗吻合口狭窄。
尽管透析通路患者的真性动脉瘤并不常见，但由于其存在可能会发生严重并发症。这些并发症可以得到治疗，瘘管通常可以保留。
