Cheung Alfred K, Imrey Peter B, Alpers Charles E, Robbin Michelle L, Radeva Milena, Larive Brett, Shiu Yan-Ting, Allon Michael, Dember Laura M, Greene Tom, Himmelfarb Jonathan, Roy-Chaudhury Prabir, Terry Christi M, Vazquez Miguel A, Kusek John W, Feldman Harold I
Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah;
Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah.
J Am Soc Nephrol. 2017 Oct;28(10):3005-3013. doi: 10.1681/ASN.2016121355. Epub 2017 Jul 14.
Intimal hyperplasia and stenosis are often cited as causes of arteriovenous fistula maturation failure, but definitive evidence is lacking. We examined the associations among preexisting venous intimal hyperplasia, fistula venous stenosis after creation, and clinical maturation failure. The Hemodialysis Fistula Maturation Study prospectively observed 602 men and women through arteriovenous fistula creation surgery and their postoperative course. A segment of the vein used to create the fistula was collected intraoperatively for histomorphometric examination. On ultrasounds performed 1 day and 2 and 6 weeks after fistula creation, we assessed fistula venous stenosis using pre-specified criteria on the basis of ratios of luminal diameters and peak blood flow velocities at certain locations along the vessel. We determined fistula clinical maturation using criteria for usability during dialysis. Preexisting venous intimal hyperplasia, expressed per 10% increase in a hyperplasia index (range of 0%-100%), modestly associated with lower fistula blood flow rate (relative change, -2.5%; 95% confidence interval [95% CI], -4.6% to -0.4%; =0.02) at 6 weeks but did not significantly associate with stenosis (odds ratio [OR], 1.07; 95% CI, 1.00 to 1.16; =0.07) at 6 weeks or failure to mature clinically without procedural assistance (OR, 1.07; 95% CI, 0.99 to 1.15; =0.07). Fistula venous stenosis at 6 weeks associated with maturation failure (OR, 1.98; 95% CI, 1.25 to 3.12; =0.004) after controlling for case mix factors, dialysis status, and fistula location. These findings suggest that postoperative fistula venous stenosis associates with fistula maturation failure. Preoperative venous hyperplasia may associate with maturation failure but if so, only modestly.
内膜增生和狭窄常被认为是动静脉内瘘成熟失败的原因，但缺乏确凿证据。我们研究了术前静脉内膜增生、造瘘后静脉狭窄与临床成熟失败之间的关联。血液透析内瘘成熟研究对602名男性和女性进行了前瞻性观察，观察内容包括动静脉内瘘造瘘手术及其术后过程。术中采集用于造瘘的一段静脉进行组织形态计量学检查。在造瘘后1天、2周和6周进行超声检查时，我们根据血管特定位置的管腔直径和峰值血流速度比值，采用预先设定的标准评估静脉狭窄情况。我们根据透析时的可用性标准确定内瘘的临床成熟情况。术前静脉内膜增生，以增生指数每增加10%表示（范围为0%-100%），与6周时较低的内瘘血流量（相对变化，-2.5%；95%置信区间[95%CI]，-4.6%至-0.4%；P=0.02）有适度关联，但与6周时的狭窄（比值比[OR]，1.07；95%CI，1.00至1.16；P=0.07）或无手术辅助时临床成熟失败（OR，1.07；95%CI，0.99至1.15；P=0.07）无显著关联。在控制病例组合因素、透析状态和内瘘位置后，6周时的静脉狭窄与成熟失败相关（OR，1.98；95%CI，1.25至3.12；P=0.004）。这些发现表明，术后静脉狭窄与内瘘成熟失败相关。术前静脉增生可能与成熟失败有关，但即便有关，关联程度也较小。
