Caro Acevedo Pilar, Marchante Rosa, Thuissard Israel J, Sanz-Rosa David, Amann Raquel, Hernandez Beatriz, Delgado Ramón
Department of Nephrology, Hospital Ruber Juan Bravo, Madrid, Spain.
School of Doctoral Studies and Research, Universidad Europea, Madrid, Spain.
J Vasc Access. 2019 Nov;20(6):683-690. doi: 10.1177/1129729819838795. Epub 2019 Apr 19.
Graft is an alternative to native arteriovenous fistula to ensure permanent vascular access in hemodialysis patients. The most common complication is significant stenosis, which frequently causes thrombosis and graft loss. Periodic monitoring and surveillance with elective correction of stenotic lesions can prolong graft survival.
To describe the effect of early diagnosis of significant stenosis on the rate of thrombosis and graft patency.
Retrospective, observational study of a cohort of 86 prevalent patients undergoing hemodialysis with a graft as their vascular access. We applied a systematic follow-up protocol of 115 grafts based on various screening methods of monitoring (clinical monitoring, pre-pump arterial pressure, dynamic venous pressure, percentage of recirculation, and dose of dialysis) in conjunction with surveillance (normalized intra-access venous pressure and access flow). The annual rates of thrombosis, and primary, primary-assisted, and secondary patency were assessed.
The incidence of significant stenosis and thrombosis was 57.4% (65/115) and 39.0% (45/115), respectively. Of all screening procedures, normalized intra-access venous pressure was the best predictor of significant stenosis (hazards ratio, 7.71; 95% confidence interval, 3.06-19.46). The annual rate of thrombosis fluctuated from 0 to 0.26 thromboses/patient/year, with an average rate of 0.14 thromboses/patient/year. Primary, primary-assisted, and secondary patency were 74%/79%/82%, 50%/60%/66%, and 23%/35%/37% at 1, 2, and 5 years, respectively.
The implementation of a systematic graft follow-up protocol combined with monitoring and surveillance enabled early diagnosis and elective correction of significant stenosis, prolonged graft patency, and a low thrombosis rate.
移植物是自体动静脉内瘘的替代方案，用于确保血液透析患者获得永久性血管通路。最常见的并发症是严重狭窄，这常常导致血栓形成和移植物失功。定期监测并对狭窄病变进行选择性纠正可延长移植物存活时间。
描述严重狭窄的早期诊断对血栓形成率和移植物通畅率的影响。
对86例使用移植物作为血管通路的维持性血液透析患者进行回顾性观察研究。我们基于多种监测筛查方法（临床监测、泵前动脉压、动态静脉压、再循环百分比和透析剂量）并结合监测指标（血管通路内静脉压标准化值和通路血流量），对115个移植物实施了系统的随访方案。评估了血栓形成的年发生率以及初次通畅率、初次辅助通畅率和二次通畅率。
严重狭窄和血栓形成的发生率分别为57.4%（65/115）和39.0%（45/115）。在所有筛查程序中，血管通路内静脉压标准化值是严重狭窄的最佳预测指标（风险比，7.71；95%置信区间，3.06 - 19.46）。血栓形成的年发生率在0至0.26次/患者/年之间波动，平均发生率为0.14次/患者/年。1年、2年和5年时的初次通畅率、初次辅助通畅率和二次通畅率分别为74%/79%/82%、50%/60%/66%和23%/35%/37%。
实施系统的移植物随访方案并结合监测，能够实现严重狭窄的早期诊断和选择性纠正，延长移植物通畅时间，并降低血栓形成率。
