Letachowicz Krzysztof, Banasik Mirosław, Królicka Anna, Mazanowska Oktawia, Gołębiowski Tomasz, Augustyniak-Bartosik Hanna, Zmonarski Sławomir, Kamińska Dorota, Kuriata-Kordek Magdalena, Krajewska Magdalena
Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wrocław, Poland.
Faculty of Medicine, Wroclaw Medical University, Wrocław, Poland.
Front Surg. 2021 Apr 28;8:640986. doi: 10.3389/fsurg.2021.640986. eCollection 2021.
More attention has been paid to the influence of arteriovenous fistula (AVF) on the cardiovascular system. In renal transplant recipients, some beneficial effect of an elective vascular access (VA) ligation was observed in patients with a high AVF flow. However, this strategy is not widely accepted and is in contradiction to the rule of vasculature preservation for possible future access. The aim of our study is to elucidate the vascular access function and VA perspective in the kidney transplantation (KTx) population. KTx patients with a stable graft function were recruited to participate in this single center observational study (NCT04478968). The measurement of VA flow and vessel mapping for future vascular access was performed by a color Doppler ultrasound. The study group included 99 (63%) males and 58 (37%) females; the median age was 57 (IQR 48-64) years. The median time from the transplantation to the baseline visit was 94 (IQR 61-149) months. Median serum creatinine concentration was 1.36 (IQR 1.13-1.67) mg/dl. Functioning VA was found in 83 out of 157 (52.9%) patients. The sites were as follows: snuffbox in six (7.2%), wrist in 41 (49.4%), distal forearm in 18 (21.7%), middle or proximal forearm in eight (9.6%), upper-arm AV graft in one (1.2%), and upper-arm AVFs in nine (10.8%) patients, respectively. Blood flow ranged from 248 to 7,830 ml/min; the median was 1,134 ml/min. From the transplantation to the study visit, 66 (44.6%) patients experienced access loss. Spontaneous thrombosis was the most common, and it occurred in 60 (90.9%) patients. The surgical closure of VA was performed only in six (4%) patients of the study group with a functioning VA at the time of transplantation. Access loss occurred within the 1st year after KTx in 33 (50%) patients. Majority (50 out of 83, 60.2%) of the patients with an active VA had options to create a snuffbox or wrist AVF on the contralateral extremity. In a group of 74 patients without a functioning VA, the creation of a snuffbox or wrist AVF on the non-dominant and dominant extremity was possible in seven (9.2%) and 40 (52.6%) patients, respectively. In 10 (13.1%) patients, the possibilities were limited only to the upper-arm or proximal forearm VA on both sides. Access ligation was considered by 15 out of 83 (18.1%) patients with a patent VA. In the majority of the patients, vascular access blood flow was below the threshold of the negative cardiovascular effect of vascular access. Creation of a distal AVF is a protective measure to avoid a high flow and preserve the vessels for future access. The approach to VA should be individualized and adjusted to the patient's profile.
动静脉内瘘（AVF）对心血管系统的影响已受到更多关注。在肾移植受者中，对于高AVF血流量的患者，观察到选择性血管通路（VA）结扎具有一些有益效果。然而，这种策略并未被广泛接受，并且与为未来可能的通路而保留脉管系统的原则相矛盾。我们研究的目的是阐明肾移植（KTx）人群中的血管通路功能和VA前景。招募具有稳定移植肾功能的KTx患者参与这项单中心观察性研究（NCT04478968）。通过彩色多普勒超声对VA血流量进行测量，并对未来的血管通路进行血管造影。研究组包括99名（63%）男性和58名（37%）女性；中位年龄为57岁（四分位间距48 - 64岁）。从移植到基线访视的中位时间为94个月（四分位间距61 - 149个月）。血清肌酐浓度中位数为1.36mg/dl（四分位间距1.13 - 1.67mg/dl）。157名患者中有83名（52.9%）存在功能性VA。其部位如下：鼻烟窝6例（7.2%），腕部41例（49.4%），前臂远端18例（21.7%），前臂中或近端8例（9.6%），上臂AV移植物1例（1.2%），上臂AVF 9例（10.8%）。血流量范围为248至7830ml/min；中位数为1134ml/min。从移植到研究访视期间，66例（44.6%）患者出现通路丧失。自发性血栓形成最为常见，发生在60例（90.9%）患者中。仅在研究组中6例（4%）移植时具有功能性VA的患者中进行了VA的手术闭合。KTx后第1年内，33例（50%）患者出现通路丧失。大多数（83例中的50例，60.2%）具有活跃VA的患者有在对侧肢体创建鼻烟窝或腕部AVF的选择。在一组74例无功能性VA的患者中，分别有7例（9.2%）和40例（52.6%）患者可以在非优势侧和优势侧肢体创建鼻烟窝或腕部AVF。10例（13.1%）患者的选择仅局限于双侧上臂或前臂近端VA。83例具有通畅VA的患者中有15例（18.1%）考虑进行通路结扎。在大多数患者中，血管通路血流量低于血管通路对心血管产生负面影响的阈值。创建远端AVF是一种保护措施，可避免高血流量并为未来通路保留血管。VA的处理方法应个体化，并根据患者情况进行调整。
