Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
Division of Vascular and Endovascular Surgery, University of California San Diego Medical Center, University of California San Diego School of Medicine, La Jolla, Calif.
J Vasc Surg. 2021 Jan;73(1):291-300.e7. doi: 10.1016/j.jvs.2020.04.521. Epub 2020 May 20.
Rising intravenous drug use (IVDU) paralleled with an increasing dialysis-dependent end-stage renal disease population may pose a challenge for creating and maintaining arteriovenous (AV) access for hemodialysis. We aimed to elucidate baseline characteristics and outcomes of AV access creation in the IVDU population.
The Vascular Quality Initiative (2011-2018) was queried for patients undergoing AV access placement. Univariable and multivariable analyses comparing outcomes of patients with and without IVDU history were performed.
Of 33,404 patients undergoing AV access creation, 601 (1.8%) had IVDU history (21.8% current and 78.2% past users). IVDU patients receiving AV access were more often younger, male, nonwhite, smokers, homeless, Medicaid recipients, and hospitalized at the time of surgery (P < .001 for all). They exhibited higher rates of congestive heart failure, chronic obstructive pulmonary disease, and human immunodeficiency virus/acquired immunodeficiency syndrome (P < .05 for all). They more frequently had tunneled catheters at the time of access creation (53.6% vs 42%; P < .001) and had a previous AV access (25.3% vs 21.7%; P = .002). IVDU patients more often received prosthetic AV grafts (28.6% vs 18%; P < .001) and more often had anastomoses created to basilic veins (33.1% vs 23.2%; P < .001) but less often to cephalic veins (36.8% vs 57.7%; P < .001). IVDU patients had longer postoperative length of stay (2 ± 6 days vs 0.9 ± 5 days; P < .001) but no significant difference in 30-day mortality (1.7% vs 1.2%; P = .3). Comparing IVDU vs no IVDU cohorts, 1-year access infection-free survival (85.4% vs 86.6%; P = .382), primary patency loss-free survival (39.5% vs 37.9%; P = .335), endovascular/open reintervention-free survival (58% vs 57%; P = .705), and overall survival (89.7% vs 88.9%; P = .635) were similar. On multivariable analysis, IVDU was independently associated with postoperative length of stay (odds ratio, 1.64; 95% confidence interval, 1.35-2; P < .001) but not with 30-day mortality or 1-year infection-free survival, primary patency loss-free survival, reintervention-free survival, and all-cause mortality. The null results were confirmed in a propensity score-matched cohort.
IVDU history was uncommon among patients undergoing AV access creation at Vascular Quality Initiative centers and was not independently associated with major morbidity or mortality postoperatively. IVDU patients more often received grafts or autogenous access with anastomoses to basilic veins. Although these patients frequently have more comorbidities, IVDU should not deter AV access creation.
静脉内药物滥用（IVDU）的增加与依赖透析的终末期肾病患者人数的增加并行，这可能给血液透析的动静脉（AV）通路的建立和维持带来挑战。我们旨在阐明静脉内药物滥用患者的 AV 通路建立的基线特征和结果。
血管质量倡议（2011-2018 年）对接受 AV 通路置入的患者进行了查询。对有和没有 IVDU 病史的患者的结果进行了单变量和多变量分析。
在 33404 例接受 AV 通路建立的患者中，有 601 例（1.8%）有 IVDU 病史（21.8%为当前使用者，78.2%为既往使用者）。接受 AV 通路的 IVDU 患者更年轻、男性、非白人、吸烟者、无家可归者、接受医疗补助和手术时住院（所有 P<0.001）。他们表现出更高的心力衰竭、慢性阻塞性肺疾病和人类免疫缺陷病毒/获得性免疫缺陷综合征的发生率（所有 P<0.05）。他们在通路建立时更常使用隧道导管（53.6% vs 42%；P<0.001）和有先前的 AV 通路（25.3% vs 21.7%；P=0.002）。IVDU 患者更常接受假体 AV 移植物（28.6% vs 18%；P<0.001），并且更常进行与贵要静脉吻合（33.1% vs 23.2%；P<0.001），但与头静脉吻合较少（36.8% vs 57.7%；P<0.001）。IVDU 患者术后住院时间较长（2±6 天 vs 0.9±5 天；P<0.001），但 30 天死亡率无显著差异（1.7% vs 1.2%；P=0.3）。比较 IVDU 与非 IVDU 队列，1 年通路感染无生存（85.4% vs 86.6%；P=0.382），原发通畅无损失生存（39.5% vs 37.9%；P=0.335），血管内/开放再干预无生存（58% vs 57%；P=0.705），总生存（89.7% vs 88.9%；P=0.635）相似。多变量分析显示，IVDU 与术后住院时间独立相关（优势比，1.64；95%置信区间，1.35-2；P<0.001），但与 30 天死亡率或 1 年无感染生存、原发通畅无损失生存、再干预无生存和全因死亡率无关。在倾向评分匹配队列中也证实了这一结果。
在血管质量倡议中心接受 AV 通路建立的患者中，静脉内药物滥用史并不常见，与术后主要发病率或死亡率无关。IVDU 患者更常接受移植物或自体通路，吻合至贵要静脉。尽管这些患者经常有更多的合并症，但 IVDU 不应阻止 AV 通路的建立。
