Nephrology and Dialysis Unit, USL Toscana Nord Ovest-Versilia Hospital, Lido di Camaiore, Lucca, Italy.
Nephrology and Dialysis Unit, USL Toscana Nord Ovest-Versilia Hospital, Lido di Camaiore, Lucca, Italy; Department of Mathematics and Computer Science, Freie Universität Berlin, Berlin, Germany.
J Vasc Surg. 2019 Jul;70(1):199-207.e4. doi: 10.1016/j.jvs.2018.10.101. Epub 2019 Mar 17.
The arteriovenous fistula (AVF) is recommended as the preferred hemodialysis access. However, placing an AVF in all patients may result in poor access outcomes and increased central venous catheter (CVC) use because of increased comorbid conditions, age, and suboptimal vessels. In patients with inadequate superficial veins for AVFs, the use of the brachial veins for creation of forearm arteriovenous grafts (AVGs) has received limited attention. This retrospective study aimed to evaluate outcomes of forearm brachial-brachial AVGs (BB-AVGs) placed in patients with poor superficial veins.
We identified 111 BB-AVGs created in 111 consecutive patients, using standard-walled polytetrafluoroethylene grafts, between January 2010 and December 2015. After excluding 6 patients (non-dialysis initiation, missing information, and death within 1 month), we included 105 patients from 21 dialysis centers. We analyzed primary failures, time to cannulation, patency, complications, and revisions. Patency rates were calculated by the Kaplan-Meier method. The incidence of complications and revisions was expressed as number of events per person-year.
A total of 105 patients (median age, 69 years) were followed up for a median time of 21.2 months (interquartile range, 9.2-36.5 months). Of the patients, 72.4% were on chronic hemodialysis and had previously undergone one or more access procedures. At the time of BB-AVG placement, prior accesses were 39 AVFs, 20 tunneled CVCs, and 17 AVGs. BB-AVG rates of primary failure and revision before cannulation were 7.6% and 5.7%, respectively. BB-AVGs were cannulated after a median time of 3.4 weeks (interquartile range, 2.8-4.1 weeks). Primary patency rates at 12, 24, and 36 months were 49.5%, 29.5%, and 19.5%. Secondary patency rates at 12, 24, and 36 months were 76.3%, 62.7%, and 54.6%. After cannulation, the incidence of complications and revisions was 1.054 and 0.649 per person-year, respectively. Most complications and interventions were due to thrombosis (0.527 per person-year) or stenosis (0.381 per person-year) and related interventions (0.490 per person-year). A minority of patients experienced AVG infections (0.052 per person-year), with only two requiring access removal.
In patients with poor superficial veins, the forearm BB-AVG is a reliable access because of low access-related morbidity and considerable long-term access survival. BB-AVG placement has the advantage of preserving proximal vessels. In these patients, such an approach can delay both rapid exhaustion of vascular sites and early recourse to CVC permanent use.
动静脉瘘（AVF）被推荐为首选的血液透析通路。然而，由于合并症增加、年龄增长和血管条件不佳，所有患者都放置 AVF 可能导致通路效果不佳和中心静脉导管（CVC）使用率增加。对于浅静脉不适合建立 AVF 的患者，使用肱静脉建立前臂动静脉移植物（AVG）的应用受到限制。本回顾性研究旨在评估在浅静脉条件不佳的患者中使用前臂肱-肱 AVG（BB-AVG）的结果。
我们在 2010 年 1 月至 2015 年 12 月期间使用标准壁聚四氟乙烯移植物，对 111 例连续患者中的 111 个 BB-AVG 进行了评估。排除 6 例患者（非透析起始、信息缺失和 1 个月内死亡）后，我们纳入了来自 21 个透析中心的 105 例患者。我们分析了主要失功、可穿刺时间、通畅率、并发症和修复。通畅率通过 Kaplan-Meier 法计算。并发症和修复的发生率用每例患者发生的事件数表示。
105 例患者（中位年龄 69 岁）中位随访时间为 21.2 个月（四分位距，9.2-36.5 个月）。72.4%的患者正在接受慢性血液透析，且之前已进行过一次或多次通路手术。在 BB-AVG 置入时，之前的通路分别为 39 个 AVF、20 个隧道式 CVC 和 17 个 AVG。BB-AVG 置入后首次失功和修复前的失功率分别为 7.6%和 5.7%。BB-AVG 中位可穿刺时间为 3.4 周（四分位距，2.8-4.1 周）。12、24 和 36 个月时的主通畅率分别为 49.5%、29.5%和 19.5%。12、24 和 36 个月时的次通畅率分别为 76.3%、62.7%和 54.6%。穿刺后，并发症和修复的发生率分别为 1.054 和 0.649 例/患者年。大多数并发症和干预措施是由于血栓形成（0.527 例/患者年）或狭窄（0.381 例/患者年）及其相关干预（0.490 例/患者年）引起。少数患者发生 AVG 感染（0.052 例/患者年），仅 2 例需要移除通路。
在浅静脉条件不佳的患者中，前臂 BB-AVG 是一种可靠的通路，因为其与通路相关的发病率较低，且长期通路存活率较高。BB-AVG 置入具有保留近端血管的优势。在这些患者中，这种方法可以延缓血管部位的快速耗竭和早期对 CVC 永久性使用的需求。
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