Division of Vascular Surgery, University of Arizona College of Medicine, Tucson, Ariz.
Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass.
J Vasc Surg. 2019 Apr;69(4):1187-1195.e2. doi: 10.1016/j.jvs.2018.07.049. Epub 2018 Oct 6.
An upper arm brachiobasilic arteriovenous fistula (BBAVF) is a reliable autogenous hemodialysis access created with a one-stage or two-stage technique. Although both techniques are variably used, the optimal approach is uncertain. In this study, we compared the outcomes of one-stage and two-stage BBAVF procedures.
We identified 2648 patients who had received BBAVFs within the Vascular Quality Initiative data set (2010-2016) and compared those created using the one-stage and two-stage technique. The primary outcome measures were primary and secondary patency rates at 12 months. Other outcomes assessed were wound infection, steal, and swelling at 3 months. The log-rank test was used to evaluate patency by Kaplan-Meier analysis. Cox proportional hazards models were used to examine the adjusted association between surgical technique and outcomes.
There were 1234 (47%) one-stage and 1414 (53%) two-stage BBAVFs in the study cohort, including 1848 (70%) patients who were on dialysis at the time of surgery and 1795 (68%) patients with a history of previous access. Patients who underwent a one-stage BBAVF were more likely to be male (54% vs 45%; P < .001), to be white (60% vs 41%; P < .001), and to have a history of coronary artery disease (22% vs 17%; P = .001). Patients undergoing one-stage BBAVFs have larger vein diameters (4.1 vs 3.4 mm; P < .001) and have the procedure in an inpatient setting (21% vs 13%; P < .001) compared with patients undergoing a two-stage procedure. The 12-month primary patency rate was higher for the one-stage BBAVF (49.1% vs 40.4%; P = .005), although the secondary patency rate was comparable (80.0% vs 77.9%; P = .54). Postoperative bleeding (4% vs 1.5%; P < .001), wound infection (1.01% vs 0.4%; P = .047), and arm swelling (2.1 % vs 0.8%; P = .006) were higher for one-stage BBAVFs. In multivariable analysis, although loss of primary patency at 12 months (adjusted hazard ratio [aHR], 1.12; 95% confidence interval [CI], 0.97-1.30; P = .12) and 3-month wound infection (aHR, 0.42; 95% CI, 0.14-1.25, P = .12) were similar between the two approaches, the risk of 3-month arm swelling was significantly lower for two-stage BBAVFs (aHR, 0.35; 95% CI, 0.16-0.77; P = .009).
Whereas surgeons were more likely to perform a two-stage BBAVF in patients with a history of previously failed access and smaller basilic vein, our data show no difference in primary or secondary patency of one-stage and two-stage BBAVFs at 12 months.
在上臂肱动脉-贵要静脉动静脉瘘（BBAVF）中，使用一期或两期技术可创建可靠的自体血液透析通路。虽然这两种技术都有不同程度的应用，但最佳方法尚不确定。在这项研究中，我们比较了一期和两期 BBAVF 手术的结果。
我们在血管质量倡议（Vascular Quality Initiative，VQI）数据集中确定了 2648 名接受 BBAVF 的患者，并比较了使用一期和两期技术创建的 BBAVF。主要的观察终点是 12 个月时的一级和二级通畅率。其他评估的结果是 3 个月时的伤口感染、窃血和肿胀。采用对数秩检验对 Kaplan-Meier 分析的通畅率进行评估。Cox 比例风险模型用于检验手术技术与结果之间的调整关联。
在研究队列中，1234 例（47%）为一期，1414 例（53%）为两期 BBAVF，包括 1848 例（70%）在手术时接受透析的患者和 1795 例（68%）有既往通路史的患者。行一期 BBAVF 的患者更可能为男性（54% vs. 45%；P<0.001）、白人（60% vs. 41%；P<0.001）和有冠状动脉疾病史（22% vs. 17%；P=0.001）。与行两期手术的患者相比，行一期 BBAVF 的患者静脉直径更大（4.1 毫米 vs. 3.4 毫米；P<0.001），且在住院环境中进行手术（21% vs. 13%；P<0.001）。一期 BBAVF 的 12 个月一级通畅率较高（49.1% vs. 40.4%；P=0.005），尽管二级通畅率相当（80.0% vs. 77.9%；P=0.54）。一期 BBAVF 的术后出血（4% vs. 1.5%；P<0.001）、伤口感染（1.01% vs. 0.4%；P=0.047）和手臂肿胀（2.1% vs. 0.8%；P=0.006）发生率更高。多变量分析显示，虽然 12 个月时一级通畅率的丧失（调整后的危险比[aHR]，1.12；95%置信区间[CI]，0.97-1.30；P=0.12）和 3 个月时的伤口感染（aHR，0.42；95% CI，0.14-1.25，P=0.12）在两种方法之间相似，但两期 BBAVF 术后 3 个月手臂肿胀的风险显著降低（aHR，0.35；95% CI，0.16-0.77；P=0.009）。
尽管外科医生更倾向于对有既往失败通路史和较小贵要静脉的患者进行两期 BBAVF，但我们的数据显示，一期和两期 BBAVF 在 12 个月时的一级和二级通畅率没有差异。
