Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
J Vasc Surg. 2019 Aug;70(2):554-561. doi: 10.1016/j.jvs.2018.11.030. Epub 2019 Mar 2.
Radial artery-based wrist arteriovenous fistulas (AVFs) are commonly created as an initial upper extremity arteriovenous access. A more distal access site, such as the anatomic snuffbox AVF, can also be created. Although much has been written about wrist AVFs, outcomes of snuffbox AVFs are unclear. Our goal was to compare perioperative and midterm outcomes between these two types of distal access.
The Vascular Quality Initiative database was queried for all patients undergoing snuffbox AVFs and wrist AVFs from 2011 to 2017. Unmatched and matched analyses were performed for baseline characteristics and outcomes at 6 months for ischemic steal, wound infection, and arm swelling. Multivariable analysis was performed for unmatched and matched analyses for primary patency, surgical or endovascular repair, and patient survival. Kaplan-Meier matched analysis was performed for primary patency, freedom from surgical or endovascular intervention, and survival.
We identified 4525 distal forearm fistulas: 179 (4%) snuffbox AVFs and 4346 (96%) wrist AVFs. The average age was 59 ± 14.7 years, and 72.3% of patients were male. There were no significant differences in baseline demographics or comorbidities of patients with snuffbox AVFs and wrist AVFs except that patients with snuffbox AVFs had fewer tunneled lines at access creation (70.2% vs 65.2%; P = .046) and had a lower American Society of Anesthesiologists class. There were no significant differences in unmatched outcomes at 6 months for ischemic steal (0.8% vs 1.9%; P = .336), wound infection (0% vs 0.2%; P = .649), and arm swelling (0.8% vs 1.3%; P = .592). Matched analysis showed no significant differences in baseline characteristics and outcomes at 6 months for ischemic steal (0% vs 1.8%; P = .146), wound infection (0% vs 0%), and arm swelling (0.9% vs 1.2%; P = .789). Kaplan-Meier matched analysis showed no significant differences between snuffbox AVFs and wrist AVFs at 6 months for primary patency (51% vs 48%; P = .61), freedom from endovascular intervention (84.5% vs 82.5%; P = .98), freedom from surgical intervention (90% vs 86%; P = .08), and survival (92% vs 96%; P = .1). In multivariable analysis of unmatched data, snuffbox AVFs and wrist AVFs had similar primary patency (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.75-1.26; P = .83), likelihood of surgical intervention (HR, 0.61; 95% CI, 0.35-1.05; P = .074) and endovascular intervention (HR, 0.96; 95% CI, 0.65-1.42; P = .83), and survival (HR, 1.47; 95% CI, 0.9-2.4; P = .128).
Snuffbox AVFs have midterm results similar to those of wrist AVFs.
桡动脉为基础的腕部动静脉瘘（AVF）通常作为上肢动静脉初始通路。也可以创建更靠近远端的通路，例如解剖鼻烟窝 AVF。虽然已经有很多关于腕部 AVF 的文献，但鼻烟窝 AVF 的结果尚不清楚。我们的目标是比较这两种类型的远端通路的围手术期和中期结果。
从 2011 年到 2017 年，我们在血管质量倡议数据库中查询了所有接受鼻烟窝 AVF 和腕部 AVF 的患者。对于缺血性窃血、伤口感染和手臂肿胀，我们进行了未配对和配对分析，以比较 6 个月时的基线特征和结果。对于未配对和配对分析，我们进行了多变量分析，以确定主要通畅率、手术或血管内修复以及患者生存率。Kaplan-Meier 匹配分析用于主要通畅率、免于手术或血管内干预以及生存的无差异分析。
我们共确定了 4525 例远端前臂瘘：179 例（4%）鼻烟窝 AVF 和 4346 例（96%）腕部 AVF。平均年龄为 59±14.7 岁，72.3%的患者为男性。鼻烟窝 AVF 和腕部 AVF 患者的基线人口统计学和合并症无显著差异，除了鼻烟窝 AVF 患者在建立通路时的隧道线较少（70.2%对 65.2%；P=0.046）和美国麻醉医师协会（ASA）分级较低。在缺血性窃血（0.8%对 1.9%；P=0.336）、伤口感染（0%对 0.2%；P=0.649）和手臂肿胀（0.8%对 1.3%；P=0.592）方面，6 个月时的未配对结果无显著差异。匹配分析显示，缺血性窃血（0%对 1.8%；P=0.146）、伤口感染（0%对 0%）和手臂肿胀（0.9%对 1.2%；P=0.789）的基线特征和 6 个月时的结果无显著差异。Kaplan-Meier 匹配分析显示，6 个月时鼻烟窝 AVF 和腕部 AVF 的主要通畅率（51%对 48%；P=0.61）、免于血管内干预（84.5%对 82.5%；P=0.98）、免于手术干预（90%对 86%；P=0.08）和生存率（92%对 96%；P=0.1）无显著差异。在未配对数据的多变量分析中，鼻烟窝 AVF 和腕部 AVF 的主要通畅率（HR，0.97；95%CI，0.75-1.26；P=0.83）、手术干预的可能性（HR，0.61；95%CI，0.35-1.05；P=0.074）和血管内干预（HR，0.96；95%CI，0.65-1.42；P=0.83）以及生存率（HR，1.47；95%CI，0.9-2.4；P=0.128）相似。
鼻烟窝 AVF 的中期结果与腕部 AVF 相似。
