Kumbar Lalathaksha, Peterson Ed, Zaborowicz Matthew, Besarab Anatole, Yee Jerry, Zasuwa Gerard
1 Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA.
2 Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA.
J Vasc Access. 2019 Jul;20(4):409-416. doi: 10.1177/1129729818812729. Epub 2018 Nov 27.
The vascular access pressure ratio test identifies dialysis vascular access dysfunction when three consecutive vascular access pressure ratios are >0.55. We tested whether the magnitude of the decline in vascular access pressure ratio 1-week post-intervention could alert of subsequent access failure.
DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: The retrospective study included all vascular access procedures at one institution from March 2014 to June 2016. Data included demographics, comorbidities, vascular access features, %ΔVAPR = ((Pre-Post)/Pre] × 100% assessed within the first 2 weeks post-percutaneous transluminal balloon angioplasty, time-to-next procedure, and patency. The log-rank test compared the area under the curve, receiver operating curve, Kaplan-Meier arteriovenous graft and arteriovenous fistula survival curves. A multivariable Cox proportional hazard (CP) model was used to determine the association of %ΔVAPR with access patency.
Analysis of 138 subjects (females 51%; Black 87%) included 64 arteriovenous fistulas with 104 angioplasties and 74 arteriovenous grafts with 134 angioplasties. The area under the receiver operating characteristic curve for fistula failure at 3 months was 0.59, with optimal screening characteristics of 33.3%, sensitivity of 56.1%, and specificity of 63.2%. Arteriovenous fistula with <33.3% decline compared to >33.3% required earlier subsequent procedure (136 vs 231 days), lower survival on Kaplan-Meier analysis (P = 0.01), and twofold greater risk of failure (P = .006). Area under the receiver operating characteristic for arteriovenous graft failure at 3 months had a sensitivity of 52.3% and specificity of 67.4%. Arteriovenous graft with a post-intervention vascular access pressure ratio decline of <28.8% also required earlier subsequent procedure (144 vs 189 days), lower survival on Kaplan-Meier (P = 0.04), and a 59% higher risk for failure. The area under the receiver operating characteristic curve for combined access failure (arteriovenous fistula + arteriovenous graft) at 3 months had an optimal cut-point value of 31.2%, a sensitivity of 54.6%, and a specificity of 63.1%. Access with a <31.2% drop had a 62% increase in the risk of failure (hazard ratio 1.62; confidence interval 1.16, 2.27; P = 0.005).
The magnitude of post-intervention reduction in vascular access pressure ratio provides a novel predictive measure of access outcomes.
当连续三个血管通路压力比>0.55时，血管通路压力比测试可识别透析血管通路功能障碍。我们测试了干预后1周血管通路压力比下降的幅度是否能提示后续通路失败。
设计、地点、参与者和测量方法：这项回顾性研究纳入了2014年3月至2016年6月在一家机构进行的所有血管通路手术。数据包括人口统计学、合并症、血管通路特征、经皮腔内球囊血管成形术后前2周内评估%ΔVAPR=((术前-术后)/术前)×100%、下次手术时间和通畅率。对数秩检验比较了曲线下面积、受试者操作曲线、Kaplan-Meier动静脉移植物和动静脉内瘘生存曲线。使用多变量Cox比例风险(CP)模型来确定%ΔVAPR与通路通畅率之间的关联。
对138名受试者（女性51%；黑人87%）的分析包括64例动静脉内瘘，进行了104次血管成形术，74例动静脉移植物，进行了134次血管成形术。3个月时内瘘失败的受试者操作特征曲线下面积为0.59，最佳筛查特征为33.3%，敏感性为56.1%，特异性为63.2%。与下降>33.3%相比，下降<33.3%的动静脉内瘘需要更早进行后续手术（136天对231天），Kaplan-Meier分析显示生存率较低（P=0.01），失败风险高出两倍（P=0.006）。3个月时动静脉移植物失败的受试者操作特征曲线下面积敏感性为52.3%，特异性为67.4%。干预后血管通路压力比下降<28.8%的动静脉移植物也需要更早进行后续手术（144天对189天），Kaplan-Meier分析显示生存率较低（P=0.04），失败风险高出59%。3个月时联合通路失败（动静脉内瘘+动静脉移植物）的受试者操作特征曲线下面积最佳切点值为31.2%，敏感性为54.6%，特异性为63.1%。下降<31.2%的通路失败风险增加62%（风险比1.62；置信区间1.16，2.27；P=0.005）。
干预后血管通路压力比下降的幅度为通路结局提供了一种新的预测指标。
