Department of Interventional Radiology, Yuan's General Hospital, No.162, Cheng-gong 1st Rd., Lingya District, Kaohsiung City, 802, Taiwan.
Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
BMC Nephrol. 2020 Jul 25;21(1):304. doi: 10.1186/s12882-020-01968-6.
Hyper-pulsatility of hemodialysis arteriovenous fistula (AVF) is the basic physical examination finding when there is outflow stenosis. The arm elevation test can also be utilized to detect outflow stenosis. If there is no significant outflow stenosis, the AVF should collapse, at least partially, because of the effect of gravity when the AVF-bearing arm is elevated to a level above that of the heart. However, if there is significant outflow stenosis, the portion of the AVF downstream of the stenosis will collapse, while the portion upstream of the stenosis will remain distended (Clin J Am Soc Nephro 8:1220-7, 2013). In our daily practice, when performing the arm elevation test, we not only observe the collapsibility of the access outflow but also palpate the outflow to identify a background thrill that sometimes disappears with the arm at rest, only to reappear when the arm is elevated. If there is no thrill upon arm elevation, we assume that the outflow stenosis is severe and refer to this condition as "physical examination significant outflow stenosis" (PESOS). The aim of this study is to characterize PESOS using percentage stenosis and Doppler flow parameters.
We performed a case-control study using data collected prospectively between June 2019 and December 2019. A pulse- and thrill-based score system was developed to assess the severity of AVF outflow stenosis. We recorded the outflow scores and Doppler measurements performed in 84 patients with mature fistulas over a 6-month period. Angiograms were reviewed to determine the severity of outflow stenosis, which was assessed by calculation of percentage stenosis.
Receiver operating characteristic analysis showed that a cutoff value of ≥74.44% stenosis discriminated PESOS from other AVF outflow scores, with an area under the curve of 0.9011. PESOS diagnosed cases with ≥75% outflow stenosis in an AVF, with a sensitivity of 80.39%, a specificity of 78.79%, a positive predictive value of 85.42%, and a negative predictive value of 72.22%.
PESOS can be used to diagnose ≥75% outflow stenosis in an AVF, with or without a significant collateral vein, and its diagnostic accuracy is high. The use of PESOS as an indicator for treatment implies that physical examination may represent a useful surveillance tool.
当存在流出道狭窄时，高流量的血液透析动静脉瘘（AVF）是基本的物理检查发现。手臂抬高试验也可用于检测流出道狭窄。如果没有明显的流出道狭窄，当 AVF 臂抬高到高于心脏的水平时，AVF 至少会部分塌陷，因为重力的影响。然而，如果存在明显的流出道狭窄，那么狭窄下游的 AVF 部分会塌陷，而狭窄上游的部分仍会扩张（Clin J Am Soc Nephro 8:1220-7, 2013）。在我们的日常实践中，当进行手臂抬高试验时，我们不仅观察通路流出的可塌陷性，还触诊流出道以识别背景性震颤，该震颤有时在手臂休息时消失，只有当手臂抬高时才会再次出现。如果手臂抬高时没有震颤，我们认为流出道狭窄严重，并将这种情况称为“体格检查显著流出道狭窄”（PESOS）。本研究的目的是使用狭窄百分比和多普勒流量参数来描述 PESOS。
我们进行了一项病例对照研究，使用 2019 年 6 月至 2019 年 12 月期间前瞻性收集的数据。开发了一种基于脉搏和震颤的评分系统来评估 AVF 流出道狭窄的严重程度。我们记录了在 6 个月期间对 84 例成熟瘘管进行的流出评分和多普勒测量。回顾了血管造影以确定流出道狭窄的严重程度，通过计算狭窄百分比进行评估。
受试者工作特征分析显示，≥74.44%的狭窄截断值可区分 PESOS 与其他 AVF 流出评分，曲线下面积为 0.9011。PESOS 诊断 AVF 中≥75%的流出道狭窄，灵敏度为 80.39%，特异性为 78.79%，阳性预测值为 85.42%，阴性预测值为 72.22%。
PESOS 可用于诊断 AVF 中≥75%的流出道狭窄，无论是否存在明显的侧支静脉，其诊断准确性均较高。将 PESOS 用作治疗指标意味着体格检查可能是一种有用的监测工具。
