Department of Surgery, The University of Oklahoma, College of Medicine, Tulsa, Okla.
Department of Vascular Surgery, Institut Mutualiste Montsouris, Paris, France.
J Vasc Surg. 2018 Jan;67(1):244-253. doi: 10.1016/j.jvs.2017.06.114. Epub 2017 Sep 11.
This study reviewed our experience with proximal radial artery-based arteriovenous fistulas (PRA-AVFs) for hemodialysis vascular access, evaluating characteristics of the patients, functional patency, risk of steal syndrome, survival of the patient, and technical considerations.
We retrospectively analyzed our database of consecutive patients, identifying those individuals with a PRA-AVF created during a 12-year period. In addition to physical examination, all patients underwent ultrasound vessel mapping by the operating surgeon, identifying the PRA-AVF configuration and outflow target most likely to succeed.
PRA-AVFs were created in 1396 individuals during the 12-year study period. The mean age was 59 years (standard deviation, ±15.9 years); 717 (51%) patients were women, 819 (59%) were diabetic, and 394 (28%) were obese. A transposition procedure was required in 400 patients, and 189 (47%) of these were completed in two-staged operations. Preoperative characteristics with a negative impact on PRA-AVF cumulative patency included female gender (hazard ratio, 1.90; 95% confidence interval, 1.37-2.65), obesity (hazard ratio, 1.92; 95% confidence interval, 1.40-2.65), and younger age. Dialysis-associated steal syndrome (DASS) requiring an intervention occurred in 39 (2.8%) patients, and 85% of these were diabetic. The most common procedures required to restore hand perfusion while preserving the AVF were banding and outflow branch ligation or coil occlusion to decrease access flow. DASS emerged spontaneously in 15 (1.1%) of the patients, and 24 (1.7%) individuals developed hand ischemia requiring intervention after fistulography with balloon angioplasty of the PRA-AVF anastomosis during the first years of the study period. Limiting angioplasty balloon size for such patients avoided these uncommon angioplasty-induced DASS events in later years. Primary, primary assisted, and cumulative (secondary) patency rates were 60%, 90%, and 93% at 12 months and 47%, 86%, and 91% at 24 months, respectively. Follow-up was 0.7 to 127 months (median, 25 months).
PRA-AVFs offer excellent functional patency with low risk of dialysis access-related steal syndrome. The antecubital site has a wide range of venous outflow options for both direct PRA-AVFs and transposition procedures.
本研究回顾了我们在经皮桡动脉动静脉瘘（PRA-AVF）用于血液透析血管通路方面的经验，评估了患者的特征、功能通畅性、窃血综合征风险、患者生存率和技术考虑因素。
我们回顾性分析了连续患者的数据库，确定了在 12 年期间创建 PRA-AVF 的个体。除了体格检查外，所有患者均由手术医生进行超声血管成像，以确定最有可能成功的 PRA-AVF 配置和流出目标。
在 12 年的研究期间，共为 1396 名患者创建了 PRA-AVF。平均年龄为 59 岁（标准差，±15.9 岁）；717 名（51%）患者为女性，819 名（59%）为糖尿病患者，394 名（28%）为肥胖患者。400 名患者需要进行转位手术，其中 189 名（47%）分两期完成。对 PRA-AVF 累积通畅率有负面影响的术前特征包括女性（风险比，1.90；95%置信区间，1.37-2.65）、肥胖（风险比，1.92；95%置信区间，1.40-2.65）和较年轻的年龄。需要干预的透析相关窃血综合征（DASS）发生在 39 名（2.8%）患者中，其中 85%为糖尿病患者。为恢复手部灌注而保留动静脉瘘时，最常见的需要进行的手术是绑扎和流出分支结扎或线圈闭塞，以减少通路流量。DASS 在研究期间的最初几年中，15 名（1.1%）患者自发性出现，24 名（1.7%）患者在手动脉造影后出现手部缺血，需要进行球囊血管成形术干预。为这类患者限制球囊扩张器的尺寸，避免了后来几年中不常见的血管成形术引起的 DASS 事件。12 个月时，主、次通畅率和累积（二次）通畅率分别为 60%、90%和 93%，24 个月时分别为 47%、86%和 91%。随访时间为 0.7 至 127 个月（中位数为 25 个月）。
PRA-AVF 提供了出色的功能通畅性，窃血综合征相关透析通路的风险低。肘前区有广泛的静脉流出选择，可用于直接 PRA-AVF 和转位手术。
