Jiménez-Almonacid Pedro, Gruss Enrique, Lasala Manuel, Del Riego Silvia, López Guillermo, Rueda José A, Vega Laura, Linacero Santiago, Celi Edgardo, Colás Enrique, Martín Libertad, Lorenzo Susana, Quintáns Antonio
Nefrologia. 2014 May 21;34(3):377-82. doi: 10.3265/Nefrologia.pre2014.Feb.12347. Epub 2014 Mar 25.
When a patient undergoing haemodialysis suffers from arteriovenous fistula (AVF) thrombosis, (s)he needs an urgent procedure before the next dialysis session. Two different treatment options are available: placing a central venous catheter (CVC) or repairing the AVF. The objective of this study is to assess the possibility of urgent repair of thrombosed AVFs within the emergency care activity of a general surgery department and to determine the possible economic repercussions of implementing this working protocol in an area of healthcare.
We completed the prospective collection of all the urgent surgical interventions made to repair thrombosed AVFs for the period 2000-2011 at our centre. The clinical results were analysed using two variables: rate of thrombosis (episodes/patient/year) and percentage of recovery. Recovery was deemed effective if after the surgery the patient was able to undergo dialysis of his/her AVF without the need to place a CVC. The "thrombosed AVF" clinical process was defined and implemented, and its economic cost was analysed via a detailed analysis conducted by our centre's Financial Department. This analysis was also conducted for the alternative clinical process (new AVF), using the data published by the Ministry of Health (weight of the Diagnosis-Related Group: vascular accesses for haemodialysis, hospital complexity unit, public cost of outpatient procedures and percentage of economic repercussions of the implementation of this process, comparing the costs of both procedures).
During the study period 268 episodes of thrombosis occurred, a rate of 0.1 episodes/patient/year (0.05 on autologous AVFs and 0.43 on grafts). 203 (75%) were treated urgently by the surgery department, of which 168 AVFs (82%) were recovered. The cost of urgently repairing an AVF was estimated at €999. The average cost of a scheduled AVF intervention, plus the cost of placing and maintaining a CVC, was estimated at €6,397. The saving made by urgent repair of AVFs in our area of healthcare is €107,940/year. Extrapolating this to the entire country for a population of 23,000 patients on haemodialysis, the total would be €9,930,480/year.
It is possible to perform urgent surgical recovery on the majority of AVFs for haemodialysis. Implementing multidisciplinary protocol avoids fitting these patients with catheters, reducing the cost this entails.
接受血液透析的患者发生动静脉内瘘（AVF）血栓形成时，需要在下一次透析治疗前进行紧急处理。有两种不同的治疗选择：置入中心静脉导管（CVC）或修复AVF。本研究的目的是评估在普通外科的急诊活动中对血栓形成的AVF进行紧急修复的可能性，并确定在医疗保健领域实施该工作方案可能产生的经济影响。
我们前瞻性收集了2000年至2011年期间在我们中心为修复血栓形成的AVF而进行的所有紧急外科手术干预。使用两个变量分析临床结果：血栓形成率（发作次数/患者/年）和恢复百分比。如果手术后患者能够在无需置入CVC的情况下通过其AVF进行透析，则认为恢复有效。定义并实施了“血栓形成的AVF”临床过程，并通过我们中心财务部门进行的详细分析对其经济成本进行了分析。还使用卫生部公布的数据（诊断相关组权重：血液透析的血管通路、医院复杂程度单位、门诊手术的公共成本以及实施该过程的经济影响百分比）对替代临床过程（新的AVF）进行了此分析，比较了两种手术的成本。
在研究期间发生了268次血栓形成事件，发生率为0.1次/患者/年（自体AVF为0.05次，移植物为0.43次）。203例（75%）由外科进行了紧急治疗，其中168例AVF（82%）恢复。紧急修复AVF的成本估计为999欧元。计划性AVF干预的平均成本，加上置入和维护CVC的成本，估计为6397欧元。我们医疗保健领域通过紧急修复AVF每年节省107,940欧元。将此推算至全国23,000名血液透析患者，总计每年为9,930,480欧元。
对大多数血液透析用AVF进行紧急手术恢复是可行的。实施多学科方案可避免为这些患者置入导管，降低由此带来的成本。
