Department of Surgery, Johns Hopkins Hospital, Baltimore, Md.
The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md.
J Vasc Surg. 2019 Mar;69(3):890-897.e5. doi: 10.1016/j.jvs.2018.05.247.
Despite recent reports of improved patency with regional anesthesia (RA), general anesthesia (GA) remains the most common choice for anesthesia for patients undergoing arteriovenous fistula (AVF) or arteriovenous graft (AVG) creation, with nearly 85% utilization. Previous studies of the effect of anesthesia type on outcomes have been conducted through single institutions or a national database with poor granularity for vascular-specific data. Given the high variability of practice patterns and the high prevalence of end-stage renal disease requiring access creation, further study of the impact of anesthesia choice during AVF or AVG creation is warranted.
The Vascular Quality Initiative hemodialysis data set was queried to identify patients undergoing AVF or AVG creation between 2011 and 2017. Patients were grouped according to access type and anesthesia method (GA vs local anesthesia/RA). The primary outcome was early access failure within 120 days. Secondary outcomes were in-hospital and 30-day complications, including steal, swelling, hemorrhage, and wound infection.
There were 31,028 patients undergoing AVG (6961) or AVF (24,067) identified. Compared with patients with GA, patients undergoing access creation with RA had higher early failure rates (AVG, 26.2% vs 23%; AVF, 22.3% vs 20.6%; both P = .04). However, in the GA group undergoing AVF creation, there was a 26% increase (adjusted odds ratio, 1.26 [1.06-1.55]) in bleeding complications and a 3.4-fold increase (adjusted odds ratio, 3.43 [1.38-8.51]) in wound infection rates.
Whereas it is traditionally performed under GA, hemodialysis access with fistula or graft creation is increasingly being performed under RA. In our analysis, rates of perioperative complications, including infection and bleeding, may be lessened by using RA, especially among patients undergoing AVF creation. However, this was accompanied by a 3.2% absolute (21% relative) increased risk of early failure within the first 120 days after dialysis creation among patients undergoing AVG.
尽管最近有报道称区域麻醉（RA）可提高通畅率，但在接受动静脉瘘（AVF）或动静脉移植物（AVG）创建的患者中，全身麻醉（GA）仍然是最常见的麻醉选择，使用率接近 85%。先前关于麻醉类型对结果影响的研究是通过单一机构或全国数据库进行的，这些数据库的血管特定数据粒度较差。鉴于实践模式的高度可变性和需要创建通路的终末期肾病的高患病率，进一步研究 AVF 或 AVG 创建过程中麻醉选择的影响是必要的。
查询血管质量倡议血液透析数据集，以确定 2011 年至 2017 年间接受 AVF 或 AVG 创建的患者。根据血管通路类型和麻醉方法（GA 与局部麻醉/RA）对患者进行分组。主要结局是 120 天内早期通路失败。次要结局包括住院和 30 天内并发症，包括盗血、肿胀、出血和伤口感染。
共确定了 31028 例接受 AVG（6961 例）或 AVF（24067 例）创建的患者。与接受 GA 的患者相比，接受 RA 进行血管通路创建的患者早期失败率更高（AVG：26.2%比 23%；AVF：22.3%比 20.6%；均 P<0.04）。然而，在接受 GA 进行 AVF 创建的 GA 组中，出血并发症增加了 26%（调整后的优势比，1.26[1.06-1.55]），伤口感染率增加了 3.4 倍（调整后的优势比，3.43[1.38-8.51]）。
虽然传统上在 GA 下进行，但瘘管或移植物的血液透析通路创建越来越多地在 RA 下进行。在我们的分析中，包括感染和出血在内的围手术期并发症的发生率可能会因使用 RA 而降低，尤其是在接受 AVF 创建的患者中。然而，这伴随着接受 AVG 创建的患者在透析创建后 120 天内早期失败的绝对风险增加 3.2%（相对风险增加 21%）。
