Levin Scott R, Farber Alik, Malas Mahmoud B, Tan Tze-Woei, Conley Christopher M, Salavati Seroos, Arinze Nkiruka, Cheng Thomas W, Rybin Denis, Siracuse Jeffrey J
Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
Division of Vascular and Endovascular Surgery, University of California San Diego School of Medicine, La Jolla, CA.
Ann Vasc Surg. 2020 Oct;68:67-75. doi: 10.1016/j.avsg.2020.05.067. Epub 2020 Jun 3.
Brachiocephalic arteriovenous fistulas (BCFs) are commonly placed in outpatient settings. The impact of general anesthesia (GA), regional anesthesia (RA), or local anesthesia (LA) on perioperative recovery and fistula maturation/patency after outpatient BCF creations is unknown. We evaluated whether outcomes of outpatient BCF creations vary based on anesthesia modality.
The Vascular Quality Initiative (2011-2018) national database was queried for outpatient BCF creations. Anesthesia modalities included GA, RA, and LA. Perioperative, 3-month, and 1-year outcomes were compared between GA versus RA/LA anesthesia types.
Among 3,527 outpatient BCF creations, anesthesia types were GA in 1,043 (29.6%), RA in 1,150 (32.6%), and LA in 1,334 (37.8%). Patients receiving GA were more often younger, obese, Medicaid recipients, without coronary artery disease, and treated in non-office-based settings (P < 0.05 for all). GA compared with RA/LA cohorts were more often admitted postoperatively (5.3% vs. 2.4%, P < 0.001) but had similar rates of thirty-day mortality (0.9 vs. 0.6%, P = 0.39). 3-month access utilization for hemodialysis was lower in GA than in RA/LA cohorts (12.6% vs. 23.6%, P < 0.001). The Kaplan-Meier analysis showed that GA and RA/LA cohorts had similar 1-year primary access occlusion-free survival (43.6% vs. 47.1%, P = 0.24) and endovascular/open reintervention-free survival (57.2% vs. 57.6%, P = 0.98). On multivariable analysis, GA compared with RA/LA use was independently associated with increased postoperative admission (odds ratio [OR]: 1.7, 95% confidence interval [CI]: 1.08-2.67, P = 0.02) and decreased 3-month access utilization (OR: 0.39, 95% CI: 0.25-0.61, P < 0.001) but had similar 1-year access occlusion (hazard ratio [HR]: 1.09, 95% CI: 0.9-1.32, P = 0.36) and reintervention (HR: 1.02, 95% CI: 0.82-1.26, P = 0.88). On subgroup analysis of the RA/LA cohort, RA compared with LA was associated with increased 3-month access utilization (OR: 1.6, 95% CI: 1.01-2.5; P = 0.04) and 1-year access reintervention (HR: 1.46, 95% CI: 1.12-1.89), but had similar 1-year access occlusion (HR: 1.2, 95% CI: 0.95-1.51, P = 0.13).
Compared with RA/LA use, GA use in patients undergoing outpatient BCF creations was associated with increased hospital admissions, decreased access utilization at 3 months, and similar 1-year access occlusion and reintervention. RA/LA is preferable to expedite recovery and access utilization.
头臂动静脉内瘘（BCF）通常在门诊进行。全身麻醉（GA）、区域麻醉（RA）或局部麻醉（LA）对门诊BCF造瘘术后围手术期恢复及内瘘成熟/通畅情况的影响尚不清楚。我们评估了门诊BCF造瘘术的结果是否因麻醉方式而异。
查询血管质量改进计划（2011 - 2018年）全国数据库中的门诊BCF造瘘术病例。麻醉方式包括GA、RA和LA。比较GA与RA/LA麻醉类型的围手术期、3个月和1年的结果。
在3527例门诊BCF造瘘术中，麻醉类型为GA的有1043例（29.6%），RA的有1150例（32.6%），LA的有1334例（37.8%）。接受GA的患者更常为年轻、肥胖、医疗补助受助人，无冠状动脉疾病，且在非门诊环境中接受治疗（所有P均<0.05）。与RA/LA组相比，GA组术后更常需住院（5.3%对2.4%，P<0.001），但30天死亡率相似（0.9%对0.6%，P = 0.39）。GA组3个月用于血液透析的通路使用率低于RA/LA组（12.6%对23.6%，P<0.001）。Kaplan-Meier分析显示，GA组和RA/LA组1年的初次通路无闭塞生存率相似（43.6%对47.1%，P = 0.24），且无血管腔内/开放再次干预生存率相似（57.2%对57.6%，P = 0.98）。多变量分析显示，与使用RA/LA相比，使用GA独立与术后住院增加相关（比值比[OR]：1.7，95%置信区间[CI]：1.08 - 2.67，P = 0.02），且3个月通路使用率降低（OR：0.39，95%CI：0.25 - 0.61，P<0.001），但1年通路闭塞情况相似（风险比[HR]：1.09，95%CI：0.9 - 1.32，P = 0.36），再次干预情况也相似（HR：1.
