DFW Vascular Group, Dallas, TX; Department of Surgery, Methodist Dallas Medical Center, Dallas, TX.
DFW Vascular Group, Dallas, TX; Department of Surgery, Methodist Dallas Medical Center, Dallas, TX; Division of Cardiothoracic Surgery, Methodist Dallas Medical Center, Dallas, TX; TCU School of Medicine, Fort Worth, TX.
Ann Vasc Surg. 2021 Jul;74:321-329. doi: 10.1016/j.avsg.2021.01.099. Epub 2021 Mar 6.
Superior vena cava (SVC) occlusion in dialysis patients is a serious complication that can cause SVC syndrome and vascular access dysfunction. While endovascular therapy has advanced to become the first line of treatment, open surgical treatment may still be needed occasionally. However, no long term outcome data has been previously reported.
We performed a retrospective review of 5 dialysis patients treated with bypass graft to the right atrium from 2012 to 2014. Four patients had severe dysfunction of their upper arm dialysis access as well as superior vena cava syndrome, and one patient with a femoral tunneled dialysis catheter (TDC) had SVC occlusion. None of the patients were candidates for lower extremity access creation or peritoneal dialysis (PD). Three patients underwent a left brachiocephalic-right atrial bypass and 2 underwent a bypass from the cephalic fistula to the right atrium.
All procedures were technically successful and maintained function of the arteriovenous fistulas or allowed creation of a new upper extremity dialysis graft. One-year secondary patency rate of the bypass was 100%. Longer follow up revealed that one patient died of leg sepsis and another one of a stroke within 14 months after the procedure. Another patient did well for 16 months when recurrent graft thrombosis occurred; and ultimately the graft failed after 31 months despite multiple interventions. Two patients maintained bypass graft patency during a follow up of 78 months; however, they underwent multiple endovascular interventions (23) and open vascular access procedures (4) to maintain hemodialysis function.
Bypass grafts to the right atrium in dialysis patients with SVC occlusion are successful in maintaining function of already existing vascular access or new ones. Long term secondary patency can be achieved but requires strict follow up and a proactive endovascular strategy to treat lesions in the access and or the bypass graft.
透析患者上腔静脉（SVC）阻塞是一种严重的并发症，可导致 SVC 综合征和血管通路功能障碍。虽然血管内治疗已经发展成为一线治疗方法，但有时仍需要开放手术治疗。然而，以前没有报道过长期的结果数据。
我们回顾性分析了 2012 年至 2014 年间 5 例接受旁路移植至右心房治疗 SVC 阻塞的透析患者。4 例患者上臂透析通路严重功能障碍和 SVC 综合征，1 例股部隧道透析导管（TDC）SVC 阻塞。所有患者均不适合建立下肢通路或腹膜透析（PD）。3 例患者行左头臂静脉-右心房旁路移植，2 例行头静脉-右心房旁路移植。
所有手术均技术成功，维持了动静脉瘘的功能或允许建立新的上肢透析移植物。旁路 1 年通畅率为 100%。更长的随访显示，1 例患者术后 14 个月死于下肢败血症，1 例患者死于中风。另 1 例患者在术后 16 个月时复发性移植物血栓形成，但最终在 31 个月后移植物失功；尽管进行了多次干预，但仍失功。2 例患者在 78 个月的随访中保持旁路通畅；然而，他们需要多次血管内介入（23 次）和开放血管通路手术（4 次）来维持血液透析功能。
在 SVC 阻塞的透析患者中，旁路移植至右心房可成功维持已存在的血管通路或新通路的功能。可实现长期的通畅，但需要严格的随访和积极的血管内策略来治疗通路和/或旁路移植物中的病变。
