DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex.
DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex; Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, Tex.
J Vasc Surg Venous Lymphat Disord. 2022 Jan;10(1):118-124. doi: 10.1016/j.jvsv.2021.05.002. Epub 2021 May 18.
Hemodialysis patients with upper extremity vascular access and subclavian vein stenosis at the thoracic outlet can present with significant arm edema and threatened dialysis access that is frequently refractory to endovascular therapy without bone decompression. We have presented our long-term results of first rib resection, followed by endovascular therapy.
We performed a retrospective review of 15 consecutive hemodialysis patients with subclavian vein stenosis treated with first rib resection and endovascular therapy from 2013 to January 2021. The diagnosis was confirmed by ultrasound and venography. Bone decompression was performed with transaxillary or infraclavicular rib resection.
During the study period, we treated 1440 unique dialysis patients. Of these 1440 patients, 346 had undergone subclavian vein angioplasty. Of the 346 patients, 15 had undergone first rib resection and were the subject of the present report. Of the 15 patients, 10 were women and 5 were men. Their mean age was 56.4 years (range, 30-82 years). The most commonly associated medical conditions were hypertension and diabetes. The mean previous hemodialysis duration was 5.4 years (range, 1-13 years). Fourteen patients had preexisting functioning access and severe arm edema. Nine patients (60%) with subclavian vein occlusion had undergone vein recanalization before the bone decompression procedure. Of the 15 patients, 5 had undergone transaxillary and 10 had undergone infraclavicular first rib resection. In addition, nine patients had undergone simultaneous vein stenting, six had undergone vein stenting within 4 weeks, and one had undergone stenting at 13 months. A stent-graft was used in eight patients and a bare metal stent was used in seven. All preexisting dialysis access sites were used the day after the procedure. The average postoperative stay was 2.6 days (range, 1-8 days). No complications developed. The average follow-up was 35.13 months (range, 4-86 months). The freedom from any subsequent intervention was 50% at 10.5 months. The average number of endovascular procedures per patient during follow-up was 4.6. Ten patients had required access surgery during follow-up. Secondary patency was 100%. The median patient survival was 69.3 months.
Symptomatic hemodialysis patients with threatened vascular access caused by subclavian vein stenosis at the thoracic outlet were safely and successfully treated with first rib resection, followed by endovascular techniques. The procedure resulted in no morbidity and preserved dialysis access function in all patients during follow-up. Our experience has confirmed that excellent secondary patency and long-term clinical success can be obtained with regular follow-up, although with multiple secondary interventions. The median survival of 69 months after the procedure suggests it is worthwhile to expend this effort to maintain the hemodialysis access function of these patients.
患有上肢血管通路和锁骨下静脉狭窄的血液透析患者在胸廓出口处可能会出现明显的手臂水肿，并威胁到透析通路，而如果不进行骨减压，这种通路通常对血管内治疗有抗性。我们介绍了我们在 2013 年至 2021 年 1 月期间对 15 例锁骨下静脉狭窄接受第一肋骨切除术和血管内治疗的血液透析患者的长期结果。通过超声和静脉造影术来确诊。通过经锁骨下或锁骨下入路切除肋骨来进行骨减压。
在研究期间，我们治疗了 1440 名独特的透析患者。在这 1440 名患者中，有 346 名患者接受了锁骨下静脉血管成形术。在这 346 名患者中，有 15 名患者接受了第一肋骨切除术，这是本报告的主题。在 15 名患者中，有 10 名女性和 5 名男性。他们的平均年龄为 56.4 岁（范围，30-82 岁）。最常见的合并症是高血压和糖尿病。平均先前的血液透析持续时间为 5.4 年（范围，1-13 年）。14 名患者存在已有的功能良好的通路和严重的手臂水肿。9 名（60%）锁骨下静脉闭塞的患者在进行骨减压手术之前已经进行了静脉再通。在 15 名患者中，有 5 名患者接受了经锁骨下入路切除术，10 名患者接受了锁骨下入路切除术。此外，有 9 名患者同时接受了静脉支架置入术，有 6 名患者在 4 周内接受了静脉支架置入术，有 1 名患者在 13 个月时接受了支架置入术。8 名患者使用了支架移植物，7 名患者使用了裸金属支架。所有现有的透析通路在手术后的第二天均被使用。平均术后住院时间为 2.6 天（范围，1-8 天）。没有发生任何并发症。平均随访时间为 35.13 个月（范围，4-86 个月）。10.5 个月时，无任何后续干预措施的无复发生存率为 50%。在随访期间，每名患者平均接受了 4.6 次血管内治疗。10 名患者在随访期间需要进行通路手术。二次通畅率为 100%。中位患者生存时间为 69.3 个月。
患有因胸廓出口处锁骨下静脉狭窄引起的血管通路受到威胁的症状性血液透析患者，通过第一肋骨切除术和血管内技术进行了安全有效的治疗。在随访期间，所有患者均未出现任何并发症，并且保持了透析通路功能。我们的经验证实，通过定期随访，虽然需要进行多次二次干预，但可以获得出色的二次通畅率和长期临床成功率。手术后的中位生存时间为 69 个月，这表明为了维持这些患者的血液透析通路功能，值得付出这一努力。
