Margoles Hannah R, Shlansky-Goldberg Richard D, Soulen Michael C, Trerotola Scott O
Department of Internal Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, USA.
J Vasc Access. 2012 Jul-Sep;13(3):374-80. doi: 10.5301/jva.5000061.
Fistulae between an arteriovenous hemodialysis graft (AVG) or fistula (AVF) and an adjacent vein are an unusual complication of hemodialysis access. Such fistulae may theoretically cause steal syndrome, extremity edema, or access dysfunction. We sought to use our experience and existing literature to develop a management algorithm for this access complication.
Twelve patients with AVG/AVF to adjacent vein fistulae found on fistulography were identified using a quality assurance database. Indications for fistulography, treatment rendered for both the fistulae and access stenosis, and outcome of treatment were determined. AVG/AVF to adjacent vein fistulae, when identified and considered to be significant, were treated with embolization.
Five out of twelve patients had successful embolization of their AVG/AVF to adjacent vein fistulae. Reasons for treatment included partial thrombosis of the access to the level of the fistula (n=1), contribution to bleeding during dialysis (n=1), and concern for competing flow causing thrombosis (n=5). No recurrence was identified. Seven patients did not undergo embolization either because of failure to recognize the fistula (n=3) or determination that treatment was not indicated (n=4). Two untreated fistulae were found occluded at follow-up. Additional access treatment included angioplasty (n=11), covered stent (n=1), and mechanical thrombectomy (n=3).
The significance of AVG/AVF to adjacent vein fistulae remains unclear; some resolve spontaneously, possibly related to PTA of outflow stenosis. Embolotherapy is an effective treatment for such fistulae when determined to be significant.
动静脉血液透析移植物（AVG）或内瘘（AVF）与相邻静脉之间的瘘管是血液透析通路的一种罕见并发症。从理论上讲，这种瘘管可能导致窃血综合征、肢体水肿或通路功能障碍。我们试图利用我们的经验和现有文献来制定针对这种通路并发症的管理算法。
使用质量保证数据库识别出12例在瘘管造影中发现有AVG/AVF至相邻静脉瘘管的患者。确定瘘管造影的指征、针对瘘管和通路狭窄所采取的治疗措施以及治疗结果。当AVG/AVF至相邻静脉瘘管被识别并被认为具有重要意义时，采用栓塞治疗。
12例患者中有5例成功栓塞了其AVG/AVF至相邻静脉的瘘管。治疗原因包括通路至瘘管水平的部分血栓形成（n = 1）、透析期间出血的原因（n = 1）以及担心竞争血流导致血栓形成（n = 5）。未发现复发情况。7例患者未接受栓塞治疗，原因要么是未识别出瘘管（n = 3），要么是确定无需治疗（n = 4）。在随访中发现2例未治疗的瘘管闭塞。额外的通路治疗包括血管成形术（n = 11）、覆膜支架置入术（n = 1）和机械性血栓切除术（n = 3）。
AVG/AVF至相邻静脉瘘管的重要性仍不明确；一些瘘管可自发缓解，可能与流出道狭窄的经皮腔内血管成形术有关。当确定具有重要意义时，栓塞治疗是治疗此类瘘管的有效方法。
