Patel Mitul S, Davies Mark G, Nassar George M, Naoum Joseph J
Department of Cardiovascular Surgery, Houston Methodist Hospital, Weill-Cornell Medical College, Houston, TX.
Department of Internal Medicine, Weill-Cornell Medical College, Dialysis Access Management Centers, Houston, TX.
Ann Vasc Surg. 2015 Jul;29(5):927-33. doi: 10.1016/j.avsg.2014.12.042. Epub 2015 Mar 7.
Vascular steal syndrome related to a dialysis arteriovenous fistula (AVF) can lead to symptoms of distal ischemia, limb loss, digit ulceration, and gangrene. Several complex procedures have been used to augment and restore distal limb perfusion while maintaining a functional AVF. We reviewed our experience in treating AVF-related vascular steal syndrome by simple plication of the initial AVF inflow segment.
Clinical data of 26 patients (15 men; mean age, 58 years; range, 26-80) with vascular steal syndrome related to their AVF underwent plication during a 36-month period. There were 18 brachial-cephalic AVFs and 8 brachial-basilic AVFs with vein transposition. Relevant clinical variables, imaging studies, and treatment variables were analyzed.
Eighty-four percent of patients had hypertension, 62% were diabetics, and 15% had a previous limb or digit amputated. Hand pain, skin ulceration, or gangrene was present in 96%, 15%, and 12% of patients, respectively; 19% of patients had more than one symptom. Twelve (46%) patients had an aortic arch and upper extremity arteriogram, of which 67% showed evidence of arterial disease. One patient required percutaneous balloon-expandable stent treatment of a proximal left subclavian artery stenosis to improve flow. Duplex-derived volume flow measurements of the AVF were obtained with an average flow of 1.95 ± 0.83 L/min. Open repair and venous inflow plication was performed in all 26 patients. Average flow reduction in patients with preoperative and postoperative flow measurements was 0.6 ± 0.5 L/min (P < 0.05). There was a 12% revision rate within 3 months. Symptom resolution was achieved in 92% of patients while maintaining a functioning access out to 1 year. Two remaining patients who did not improve and proceeded to ligation of the AVF.
Surgical plication of the initial AVF inflow segment offers a simple solution to preserve the dialysis access and resolve symptoms related to vascular steal associated with high volume flow through the AVF.
与透析动静脉内瘘（AVF）相关的血管窃血综合征可导致远端缺血、肢体缺失、手指溃疡和坏疽等症状。已经采用了几种复杂的手术来增加和恢复远端肢体灌注，同时维持功能性AVF。我们回顾了通过简单折叠初始AVF流入段治疗与AVF相关的血管窃血综合征的经验。
在36个月期间，对26例（15例男性；平均年龄58岁；范围26 - 80岁）与AVF相关的血管窃血综合征患者进行了折叠手术。其中有18例肱动脉 - 头臂干AVF和8例肱动脉 - 贵要静脉AVF并进行了静脉转位。分析了相关临床变量、影像学研究和治疗变量。
84%的患者患有高血压，62%为糖尿病患者，15%曾有肢体或手指截肢史。分别有96%、15%和12%的患者存在手部疼痛、皮肤溃疡或坏疽；19%的患者有不止一种症状。12例（46%）患者进行了主动脉弓和上肢动脉造影，其中67%显示有动脉疾病证据。1例患者需要对近端左锁骨下动脉狭窄进行经皮球囊扩张支架治疗以改善血流。通过双功超声获得的AVF血流量测量值平均为1.95±0.83L/min。所有26例患者均进行了开放修复和静脉流入段折叠。术前和术后进行血流量测量的患者平均血流量减少0.6±0.5L/min（P<0.05）。3个月内的翻修率为12%。92%的患者症状得到缓解，同时维持功能性通路达1年。其余2例患者病情未改善，随后结扎了AVF。
对初始AVF流入段进行手术折叠提供了一种简单的解决方案，既能保留透析通路，又能解决与通过AVF的高血流量相关的血管窃血症状。
