Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
J Vasc Surg Venous Lymphat Disord. 2021 Nov;9(6):1473-1478. doi: 10.1016/j.jvsv.2021.02.010. Epub 2021 Mar 3.
Central venous stenosis is one of the most challenging complications in patients requiring hemodialysis. Venous thoracic outlet syndrome is an underappreciated cause of central venous stenosis in patients requiring dialysis that can result in failed percutaneous intervention and loss of a functioning dialysis access. Limited data exist about the safety and outcomes of first rib resection in patients requiring hemodialysis, and the results have been confounded by the various surgical approaches used. The purpose of the present study was to evaluate the safety, operative outcomes, and patency of the existing dialysis access after transaxillary thoracic outlet decompression.
A retrospective medical record review was performed from January 2008 to December 2019 of patients who had undergone thoracic outlet decompression for subclavian vein stenosis with ipsilateral upper extremity hemodialysis access. The baseline characteristics and comorbidities were reviewed. The operative and postoperative course were evaluated. The survival and patency rates were analyzed using the life-table method and Kaplan-Meier curve.
A total of 18 extremities in 18 patients were identified. Their mean age was 59 ± 11 years, and 89% were men. A total of 13 fistulas and 5 grafts were included. All patients had undergone repair via a transaxillary approach. First rib resection, anterior scalenectomy, and circumferential venolysis were performed in all 18 patients. The mean operative time was 99 ± 19 minutes, with an estimated blood loss of 78 ± 66 mL. The median length of stay was 2 days. No patient had died at 30 days. The survival rate at 1 year was 83%. The primary, primary-assisted, and secondary patency at 1 year were 42%, 69%, and 93%, respectively.
Thoracic outlet decompression via the transaxillary approach is a technically feasible and safe operation in patients with ipsilateral upper extremity hemodialysis access. Patients with threatened dialysis access due to subclavian vein stenosis should be carefully evaluated for possible extrinsic compression at the costoclavicular junction. These patients might benefit from transaxillary first rib resection, scalenectomy, and venolysis.
中心静脉狭窄是需要血液透析的患者最具挑战性的并发症之一。静脉胸廓出口综合征是透析患者中心静脉狭窄的一个被低估的原因，如果治疗不当，可能会导致经皮介入治疗失败和丧失功能的透析通路。目前关于需要血液透析的患者行第一肋骨切除术的安全性和结果的数据有限，并且由于使用了各种不同的手术方法，结果受到了混淆。本研究的目的是评估经腋路胸廓出口减压术治疗锁骨下静脉狭窄伴同侧上肢血液透析通路的安全性、手术结果和通路通畅性。
回顾性分析 2008 年 1 月至 2019 年 12 月期间接受经腋路胸廓出口减压术治疗锁骨下静脉狭窄伴同侧上肢血液透析通路的患者的病历资料。分析患者的基线特征和合并症。评估手术和术后过程。采用寿命表法和 Kaplan-Meier 曲线分析生存率和通畅率。
共确定了 18 例患者的 18 侧肢体。患者的平均年龄为 59 ± 11 岁，89%为男性。共包括 13 例瘘管和 5 例移植物。所有患者均经腋路手术修复。18 例患者均行第一肋骨切除术、前斜角肌切除术和环形静脉松解术。手术时间平均为 99 ± 19 分钟，估计失血量为 78 ± 66 mL。中位住院时间为 2 天。术后 30 天无患者死亡。1 年生存率为 83%。1 年时的主要通畅率、主要辅助通畅率和次要通畅率分别为 42%、69%和 93%。
经腋路胸廓出口减压术在同侧上肢血液透析通路的患者中是一种技术上可行且安全的手术。由于锁骨下静脉狭窄而导致透析通路受到威胁的患者应仔细评估是否存在肋锁关节处的外在压迫。这些患者可能受益于经腋路第一肋骨切除术、斜角肌切除术和静脉松解术。
