Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex; Audie L. Murphy VA Medical Center, San Antonio, Tex.
Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex.
J Vasc Surg. 2018 Jun;67(6):1813-1820. doi: 10.1016/j.jvs.2017.10.067. Epub 2018 Feb 13.
Duplex ultrasound (DUS) mapping of the veins and arteries of the upper extremity is a well-established practice in arteriovenous fistula creation for long-term hemodialysis access. Previous publications have shown that vein diameters varying from 2 to 3 mm are predictive of success. Regional anesthesia is known to result in vasodilation and thus to increase the diameter of upper extremity veins. This study compares the sizes of veins measured by preoperative DUS mapping with those obtained after regional anesthesia to determine whether intraoperative DUS results in increased vein diameters and thus changes in the operative plan. A second goal was to determine whether such changes resulted in functional access.
This was a prospective observational study conducted between July 2013 and December 2014. Consecutive patients were preoperatively mapped and then intraoperatively mapped after administration of a regional anesthetic. Comparison of vein mapping sizes and comparison of preoperative plan and operative procedure based on the preoperative and intraoperative DUS mapping, respectively, were analyzed with a repeated-measures linear model. Significance testing was two sided, with a significance level of 5%.
Sixty-five patients with end-stage renal disease underwent placement of arteriovenous access with preoperative and intraoperative DUS mapping after regional anesthesia. Comorbidities were representative of the vascular population. After regional anesthesia, intraoperative mid forearm and distal forearm cephalic veins were significantly larger than their respective preoperative measurements. Average increase in diameter of the mid forearm cephalic vein and distal forearm was 0.96 mm (P < .001) and 0.50 mm (P = .04), respectively. There was a significant difference in the number and configuration of arteriovenous accesses (P < .0001). There was more than a twofold significant increase in radial artery-based access procedures concomitant with a significant reduction of brachial-based access procedures and a reduction in graft access procedures. Overall functional access rate was 63%, and patency rates were comparable to those reported in the literature.
The routine use of intraoperative DUS mapping after regional anesthesia is recommended to determine the optimal access site for chronic hemodialysis access. Identifying additional access options not seen with physical examination and preoperative DUS mapping will provide end-stage renal disease patients with more fistula options and hence a longer access life span for a lifelong disease.
在上肢动静脉瘘的建立中，对静脉和动脉进行双功能超声（DUS）映射是一种成熟的实践，可用于长期血液透析通路。先前的出版物表明，直径为 2 至 3 毫米的静脉直径是成功的预测指标。众所周知，区域麻醉会导致血管扩张，从而增加上肢静脉的直径。本研究比较了术前 DUS 映射测量的静脉大小与区域麻醉后获得的静脉大小，以确定术中 DUS 是否会导致静脉直径增加，从而改变手术计划。第二个目标是确定这些变化是否导致功能通路。
这是一项 2013 年 7 月至 2014 年 12 月期间进行的前瞻性观察性研究。连续患者进行术前映射，然后在给予区域麻醉后进行术中映射。分别使用重复测量线性模型分析静脉映射大小的比较以及基于术前和术中 DUS 映射的术前计划和手术过程的比较。检验为双侧，显著性水平为 5%。
65 例终末期肾病患者在区域麻醉后行术前和术中 DUS 映射放置动静脉通路。合并症代表了血管人群。在区域麻醉后，术中前臂中部和远端前臂头静脉明显大于各自的术前测量值。前臂中部头静脉和远端前臂的平均直径增加分别为 0.96 毫米（P<.001）和 0.50 毫米（P=.04）。动静脉通路的数量和配置有显著差异（P<.0001）。以桡动脉为基础的介入程序显著增加了两倍以上，同时以肱动脉为基础的介入程序显著减少，移植物介入程序减少。总的功能通路率为 63%，通畅率与文献报道的相似。
建议常规使用区域麻醉后的术中 DUS 映射，以确定慢性血液透析通路的最佳接入部位。通过术前 DUS 映射发现的体格检查和术前 DUS 映射无法识别的其他接入选项，将为终末期肾病患者提供更多的瘘管选择，从而延长终生疾病的通路寿命。
