Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung 802, Taiwan.
Korean J Radiol. 2013 Jan-Feb;14(1):70-80. doi: 10.3348/kjr.2013.14.1.70. Epub 2012 Dec 28.
The current study retrospectively evaluated whether the percutaneous N-butyl cyanoacrylate (NBCA) seal-off technique is an effective treatment for controlling the angioplasty-related ruptures, which are irresponsive to prolonged balloon tamponade, during interventions for failed or failing hemodialysis vascular accesses.
We reviewed 1588 interventions performed during a 2-year period for dysfunction and/or failed hemodialysis vascular access sites in 1569 patients. For the angioplasty-related ruptures, which could not be controlled with repeated prolonged balloon tamponade, the rupture sites were sealed off with an injection of a glue mixture (NBCA and lipiodol), via a needle/needle sheath to the rupture site, under a sonographic guidance. Technical success rate, complications and clinical success rate were reported. The post-seal-off primary and secondary functional patency rates were calculated by a survival analysis with the Kaplan-Meier method.
Twenty ruptures irresponsive to prolonged balloon tamponade occurred in 1588 interventions (1.3%). Two technical failures were noted; one was salvaged with a bailout stent-graft insertion and the other was lost after access embolization. Eighteen accesses (90.0%) were salvaged with the seal-off technique; of them, 16 ruptures were completely sealed off, and two lesions were controlled as acute pseudoaneurysms. Acute pseudoaneurysms were corrected with stentgraft insertion in one patient, and access ligation in the other. The most significant complication during the follow-up was delayed pseudoaneurysm, which occurred in 43.8% (7 of 16) of the completely sealed off accesses. Delayed pseudoaneurysms were treated with surgical revision (n = 2), access ligation (n = 2) and observation (n = 3). During the follow-up, despite the presence of pseudoaneurysms (acute = 1, delayed = 7), a high clinical success rate of 94.4% (17 of 18) was achieved, and they were utilized for hemodialysis at the mean of 411.0 days. The post-seal-off primary patency vs. secondary patency at 90, 180 and 360 days were 66.7 ± 11.1% vs. 94.4 ± 5.4%; 33.3 ± 11.1% vs. 83.3 ± 8.8%; and 13.3 ± 8.5% vs. 63.3 ± 12.1%, respectively.
Our results suggest that the NBCA seal-off technique is effective for immediate control of a venous rupture irresponsive to prolonged balloon tamponade, during interventions for hemodialysis accesses. Both high technical and clinical success rates can be achieved. However, the treatment is not durable, and about 40% of the completely sealed off accesses are associated with developed delayed pseudoaneurysms in a 2-month of follow-up. Further repair of the vascular tear site, with surgery or stent-graft insertion, is often necessary.
本研究回顾性评估了经皮正丁基氰基丙烯酸酯（NBCA）封堵技术是否可有效治疗经皮腔内血管成形术（PTCA）相关破裂，对于无法通过长时间球囊填塞控制的血管破裂，在介入治疗失败或功能不良的血液透析血管通路时，可采用该技术封闭破裂部位。
我们回顾性分析了 1569 例患者的 1588 次介入治疗，这些患者因功能障碍和/或血液透析血管通路部位出现故障而接受治疗。对于无法通过反复长时间球囊填塞控制的 PTCA 相关破裂，采用超声引导下经针/针鞘向破裂部位注射胶混合物（NBCA 和碘化油）的方法封闭破裂部位。报告了技术成功率、并发症和临床成功率。采用 Kaplan-Meier 方法的生存分析计算闭塞后的一级和二级通畅率。
在 1588 次介入治疗中，有 20 次破裂（1.3%）对长时间球囊填塞无反应。有 2 次技术失败，其中 1 次经 bailout 支架置入术得到挽救，另 1 次在通路栓塞后丢失。18 个通路（90.0%）采用封堵技术得以挽救，其中 16 次完全封闭，2 次病变被控制为急性假性动脉瘤。1 例患者采用支架置入术，另 1 例患者采用通路结扎术矫正急性假性动脉瘤。在随访期间，最显著的并发症是迟发性假性动脉瘤，在 16 次完全封闭的通路中，有 7 次（43.8%）发生迟发性假性动脉瘤。迟发性假性动脉瘤通过手术修复（n=2）、通路结扎（n=2）和观察（n=3）进行治疗。尽管存在假性动脉瘤（急性=1，迟发性=7），但在随访期间仍获得了 94.4%（17/18）的高临床成功率，并且在平均 411.0 天的时间内用于血液透析。闭塞后 90、180 和 360 天的一级通畅率与二级通畅率分别为 66.7±11.1%比 94.4±5.4%；33.3±11.1%比 83.3±8.8%；13.3±8.5%比 63.3±12.1%。
我们的结果表明，在血液透析通路介入治疗中，NBCA 封堵技术可有效立即控制对长时间球囊填塞无反应的静脉破裂。可实现较高的技术和临床成功率。然而，治疗效果并不持久，约 40%的完全封闭通路在 2 个月的随访中出现迟发性假性动脉瘤。通常需要进一步修复血管撕裂部位，采用手术或支架置入术。
