Aslam Anoosha, Thomas Shannon D, Vijayan Vikram, Crowe Phillip, Varcoe Ramon L, Swinnen John
Department of Vascular Surgery, Westmead Hospital, Westmead, NSW, Australia.
Department of Vascular Surgery, Prince of Wales Hospital, Randwick, NSW, Australia.
J Vasc Access. 2020 Nov;21(6):908-916. doi: 10.1177/1129729820911787. Epub 2020 Mar 24.
The native arteriovenous fistula may remain immature despite adequate arterial inflow after formation. This may occur when the puncturable vein segment (cannulation zone) is too small to be reliably punctured, occluded or too deep under the skin for needle access. We performed stenting (stent-assisted maturation) of arteriovenous fistulas with an immature cannulation zone, allowing for a large subcutaneous channel which could then be immediately punctured for dialysis.
We performed a retrospective review of 49 patients (mean age was 58.7 ± 16.09 (12-83) years, mean arteriovenous fistula age of 162.6 ± 27.28 days) with end-stage renal failure who underwent balloon dilatation and bare-metal stent implantation (1.6 ± 0.67 (1-3) stents, median diameter and length of 8 (5-14) mm and 80 (40-150) mm, respectively) through their cannulation zone (forced maturation). Radiocephalic (35 arteriovenous fistulas), brachiocephalic (10 arteriovenous fistulas) and autogenous loop arteriovenous fistulas (4 arteriovenous fistulas) were included with 30 patients (61.2%) having an inadequate cannulation zone venous diameter, 9 patients (18.4%) having an absent cannulation zone and 10 patients (20.4%) having a patent cannulation zone deeper than 1 cm which was not reliably puncturable. The study was conducted over 9 years (January 2008-December 2016) with implantation of the SMART stent and Absolute Pro stent in 61.2% and 38.8%, respectively. Long-term outcomes including primary useable segmental and access circuit patency as well as assisted primary access circuit patency, rate of re-intervention, technical success and complications were analysed.
At 6 months, 12 months and 4 years, respectively, cannulation zone primary patency was 84.4%, 74.4% and 56.1% and access circuit primary patency was 62.2%, 45.3% and 23.2%; however, assisted primary access circuit patency was 95.6%, 91.1% and 83.8%, achieved with an endovascular re-intervention rate of 0.53 procedures/year with only four thrombosed circuits occurring.
Forced maturation using nitinol stents allows for long-term haemodialysis access with a low rate of re-intervention.
尽管自体动静脉内瘘形成后动脉流入充足，但仍可能不成熟。当可穿刺静脉段（穿刺区域）过小无法可靠穿刺、闭塞或在皮下过深难以进行穿刺时，就会出现这种情况。我们对穿刺区域不成熟的动静脉内瘘进行了支架置入术（支架辅助成熟术），形成一个大的皮下通道，随后可立即进行穿刺以进行透析。
我们对49例终末期肾衰竭患者（平均年龄58.7±16.09（12 - 83）岁，动静脉内瘘平均年龄162.6±27.28天）进行了回顾性研究，这些患者通过其穿刺区域接受了球囊扩张和裸金属支架植入术（1.6±0.67（1 - 3）个支架，中位直径和长度分别为8（5 - 14）mm和80（40 - 150）mm）（强制成熟）。包括头静脉桡动脉内瘘（35例）、头臂静脉内瘘（10例）和自体袢式动静脉内瘘（4例），30例患者（61.2%）穿刺区域静脉直径不足，9例患者（18.4%）无穿刺区域，10例患者（20.4%）穿刺区域通畅但深度超过1 cm，无法可靠穿刺。该研究历时9年（2008年1月至2016年12月），分别有61.2%和38.8%的患者植入了SMART支架和Absolute Pro支架。分析了长期结果，包括初次可用节段通畅率和通路循环通畅率、辅助初次通路循环通畅率、再次干预率、技术成功率和并发症。
在6个月、12个月和4年时，穿刺区域初次通畅率分别为84.4%、74.4%和56.1%，通路循环初次通畅率分别为62.2%、45.3%和23.2%；然而，辅助初次通路循环通畅率分别为95.6%、91.1%和83.8%，血管内再次干预率为0.53次/年，仅出现4例血栓形成的通路。
使用镍钛合金支架进行强制成熟可实现长期血液透析通路，再次干预率较低。
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