Maresca Barbara, Filice Fausta Barbara, Orlando Sara, Ciavarella Giuseppino Massimo, Scrivano Jacopo, Volpe Massimo, Pirozzi Nicola
Interventional Nephrology Unit, Nephrology and Dialysis Department, CdC Nuova ITOR, Roma, Italy.
Cardiology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
J Vasc Access. 2020 Sep;21(5):753-759. doi: 10.1177/1129729820907249. Epub 2020 Feb 27.
Arteriovenous fistula (AVF) for haemodialysis (HD) induces a volume/pressure overload which impairs bi-ventricular function and increases systolic pulmonary arterial pressure (PAPS) and left ventricular mass (LVM). In the presence of high blood flow (Qa) AVF (> 1.5 L/min/1.73 m) and cardio-pulmonary recirculation (>20%), high-output congestive heart failure (CHF) may occur and AVF flow reduction is recommended. Proximal Radial Artery Ligation (PRAL) is an effective technique for distal radio-cephalic (RC) AVF flow reduction.
we evaluated six HD and four transplant patients with high-flow RC AVF and symptoms of CHF who underwent PRAL. We compared echocardiographic (ECHO) findings before (T0) and 1 and 6 months (T1,T6) after PRAL. Preoperative ECHO was performed before (T0b) and after AVF anastomosis manual compression (T0c).
At T1 AVF flow reduction rate was 58.4% ± 13% and 80% of patients reported improved CHF symptoms. ECHO data showed an improvement of tricuspid annular plane systolic excursion (TAPSE) at T1 (p = 0.03) and a reduction of PAPS at T6 (p = 0.04). TAPSE improved after AVF anastomosis compression during preoperative ECHO (p = 0.03). Delta of TAPSE at the dynamic manoeuvre at T0 directly correlated with early (1 month after PRAL, p = 0.01) and late (6 months after PRAL, p = 0.04) deltas of TAPSE.
AVF flow reduction after PRAL induces immediate regression of CHF symptoms, early improvement of TAPSE and late improvement of PAPS, suggesting a prevalent right sections involvement in CHF. Preoperative TAPSE modification after AVF anastomosis compression could represent a useful evaluation tool to determine which patients would benefit of PRAL.
用于血液透析（HD）的动静脉内瘘（AVF）会引发容量/压力过载，损害双心室功能，增加收缩期肺动脉压（PAPS）和左心室质量（LVM）。在存在高血流量（Qa）的AVF（>1.5L/min/1.73m²）和心肺循环（>20%）的情况下，可能会发生高输出量充血性心力衰竭（CHF），建议减少AVF血流量。近端桡动脉结扎术（PRAL）是一种有效减少远端桡动脉-头静脉（RC）AVF血流量的技术。
我们评估了6例接受HD治疗和4例接受移植治疗且患有高流量RC AVF并伴有CHF症状的患者，这些患者接受了PRAL手术。我们比较了PRAL术前（T0）、术后1个月和6个月（T1、T6）的超声心动图（ECHO）检查结果。术前ECHO检查在AVF吻合口手动压迫前（T0b）和后（T0c）进行。
在T1时，AVF血流量减少率为58.4%±13%，80%的患者报告CHF症状有所改善。ECHO数据显示，T1时三尖瓣环平面收缩期位移（TAPSE）有所改善（p = 0.03），T6时PAPS有所降低（p = 0.04）。术前ECHO检查时，AVF吻合口压迫后TAPSE有所改善（p = 0.03）。T0时动态操作时TAPSE的变化与PRAL术后早期（术后1个月，p = 0.01）和晚期（术后6个月，p = 0.04）TAPSE的变化直接相关。
PRAL术后AVF血流量减少可使CHF症状立即缓解，TAPSE早期改善，PAPS晚期改善，提示CHF中右心室受累更为普遍。AVF吻合口压迫后术前TAPSE的改变可能是确定哪些患者将从PRAL中获益的有用评估工具。
