Kim Jerry J, Koopmann Matthew, Ihenachor Ezinne, Zeng Annie, Ryan Timothy, deVirgilio Christian
Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; The Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA.
The Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA.
Ann Vasc Surg. 2016 May;33:109-15. doi: 10.1016/j.avsg.2016.02.001. Epub 2016 Mar 8.
Routine upper extremity vein mapping by ultrasound (Ven-US) is recommended by current National Kidney Foundation/Kidney Disease Outcomes Quality Initiative guidelines before arteriovenous fistula (AVF) creation. However, the impact of concomitant arterial US (Art-US) examination is not clear.
The Ven-US protocol at our institution was modified to include Art-US starting January 2013. Therefore, retrospective review of patients who received Ven-US with Art-US between January 2013 and July 2014 was performed. The Art-US component included distal brachial and radial artery diameters, level of brachial bifurcation, and Doppler Allen's test. A plan for hemodialysis (HD) access was proposed by 2 attending vascular surgeons (VS1 and VS2) and based on a set of criteria for fistula creation (CFC) using Ven-US findings alone. The Art-US findings were subsequently reviewed, and the plan was changed based on either vascular surgeon judgment (VS1 and VS2) or predetermined arterial anatomic criteria (CFC).
In total, 163 patients (326 arms) were included. The mean age was 53 years, most patients were male (60%), and most were HD dependent at the time of US evaluation (67%). The initial plan based on Ven-US was: 17-19% radiocephalic (RC) AVF, 33-48% brachiocephalic AVF, 20-27% brachiobasilic AVF, and 14-23% grafts. The Art-US revealed 159 radial arteries (49%) with diameter <2 mm, 16 brachial arteries (5%) with high bifurcation, 93 (29%) incomplete palmar arches, and 7 arms (2%) with arterial waveform blunting. Review of Art-US findings resulted in an overall change to the operative plan from 4% to 12% of patients. Those with an initially planned RC AVF were more likely to have a change in operative approach (21-57%) compared with all other types of planned access (1-3%, P < 0.001).
Preoperative Art-US may significantly change the operative plan, particularly when planning a RC AVF, and should be performed before HD access surgery at the wrist.
目前美国国立肾脏基金会/肾脏疾病预后质量倡议指南建议在动静脉内瘘（AVF）创建前通过超声进行常规上肢静脉造影（Ven-US）。然而，同时进行动脉超声（Art-US）检查的影响尚不清楚。
自2013年1月起，我们机构将Ven-US方案修改为包括Art-US。因此，对2013年1月至2014年7月期间接受Ven-US和Art-US检查的患者进行了回顾性研究。Art-US部分包括肱动脉远端和桡动脉直径、肱动脉分叉水平以及多普勒艾伦试验。由2名血管外科主治医师（VS1和VS2）根据仅使用Ven-US检查结果制定的一套内瘘创建标准（CFC）提出血液透析（HD）通路计划。随后对Art-US检查结果进行复查，并根据血管外科医生的判断（VS1和VS2）或预先确定的动脉解剖标准（CFC）对计划进行更改。
共纳入163例患者（326条手臂）。平均年龄为53岁，大多数患者为男性（60%），且大多数患者在超声评估时依赖HD（67%）。基于Ven-US的初始计划为：17 - 19%为桡动脉-头静脉（RC）AVF，33 - 48%为肱动脉-头静脉AVF，20 - 27%为肱动脉-尺静脉AVF，14 - 23%为移植血管。Art-US检查显示159条桡动脉（49%）直径<2 mm，16条肱动脉（5%）存在高位分叉，93条（29%）掌弓不完整，7条手臂（2%）动脉波形变钝。对Art-US检查结果的复查导致4%至12%的患者手术计划发生总体改变。与所有其他类型的计划通路相比，最初计划为RC AVF的患者更有可能改变手术方式（21 - 57%比1 - 3%，P < 0.001）。
术前Art-US可能会显著改变手术计划，尤其是在计划进行RC AVF时，并且应在腕部进行HD通路手术前进行。
