Kim Jerry J, Gifford Edward, Nguyen Virginia, Kaji Amy H, Chisum Patrick, Zeng Annie, Dukkipati Ramanath, de Virgilio Christian
Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif.
Division of Nephrology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, Calif; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, Calif.
J Vasc Surg. 2015 Aug;62(2):442-7. doi: 10.1016/j.jvs.2015.03.019. Epub 2015 Apr 30.
As vascular surgeons strive to meet the Fistula First Initiative, some authors have observed a decrease in arteriovenous fistula (AVF) maturation rates in association with an increase in AVF creation. In May 2012, we adopted a practice change in an attempt to maintain the same high level of AVF creation while leading to a decrease in fistula failures.
A retrospective study was conducted of all dialysis access procedures performed by a single vascular surgeon before (period 1; before May 1, 2012) and after (period 2; after May 1, 2012) the change in practice pattern. The adopted change included favoring the brachiocephalic location unless the patient was an ideal anatomic candidate for a radiocephalic AVF, creating a larger and standardized arteriotomy, and using a large venous footplate whenever possible. The main outcome measure was primary functional patency at 1 year. Secondary outcome measures included primary patency at 1 year, time to maturation, type of fistula created, steal syndrome, and tunneled hemodialysis catheter infections.
Of 213 vascular access procedures performed, 191 (90%) were AVFs. There was no difference in use of AVFs between period 1 (93% AVFs) and period 2 (88% AVFs; P = .2). Use of brachiocephalic AVFs increased from 38% in period 1 to 56% in period 2 (P = .01), with a corresponding trend toward a decrease in radiocephalic AVFs in period 2 (36% in period 1 to 27% in period 2; P = .2). Primary functional patency at 1 year was 47% in period 1 and 63% in period 2 (P = .03). Primary patency at 1 year was 51% in period 1 and 70% in period 2 (P = .001). Time to reach functional maturation was decreased in period 2 (median, 76 vs 82.5 days; P = .046). There was no difference in steal syndrome (P = 1.0), and the incidence of hemodialysis catheter infections was lower in period 2 (0 vs 7 [7%]; P = .006).
Increasing brachiocephalic AVF creation and reducing our reliance on radiocephalic AVFs resulted in a significant increase in primary functional patency at 1 year. This was achieved while maintaining the same high percentage of fistulas, a lower rate of central catheter infections, and the same low incidence of steal syndrome.
随着血管外科医生努力实现“内瘘优先倡议”，一些作者观察到动静脉内瘘（AVF）成熟率下降，同时AVF创建数量增加。2012年5月，我们采取了一项实践变革，试图在保持相同高水平AVF创建数量的同时，降低内瘘失败率。
对一位血管外科医生在实践模式改变之前（第1阶段；2012年5月1日前）和之后（第2阶段；2012年5月1日后）进行的所有透析通路手术进行回顾性研究。所采用的变革包括：除非患者是桡动脉-头静脉内瘘的理想解剖学候选者，否则优先选择头臂部位置；创建更大且标准化的动脉切开术；尽可能使用大的静脉足板。主要结局指标是1年时的初级功能通畅率。次要结局指标包括1年时的初级通畅率、成熟时间、创建的内瘘类型、窃血综合征和带隧道的血液透析导管感染。
在213例血管通路手术中（其中191例[90%]为AVF），第1阶段（93%为AVF）和第2阶段（88%为AVF；P = 0.2）的AVF使用情况无差异。头臂部AVF的使用从第1阶段的38%增加到第2阶段的56%（P = 0.01），相应地，第2阶段桡动脉-头静脉内瘘有减少趋势（第1阶段为36%，第2阶段为27%；P = 0.2）。第1阶段1年时的初级功能通畅率为47%，第2阶段为63%（P = 0.03）。第1阶段1年时的初级通畅率为51%，第2阶段为70%（P = 0.001）。第2阶段达到功能成熟的时间缩短（中位数，76天对82.5天；P = 0.046）。窃血综合征无差异（P = 1.0），第2阶段血液透析导管感染的发生率较低（0例对7例[7%]；P = 0.006）。
增加头臂部AVF的创建并减少对桡动脉-头静脉内瘘的依赖，使1年时的初级功能通畅率显著提高。这一目标在保持相同高比例内瘘、较低的中心静脉导管感染率和相同低发生率的窃血综合征的情况下得以实现。
