Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands.
Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands.
J Vasc Surg. 2021 Dec;74(6):2040-2046. doi: 10.1016/j.jvs.2021.07.127. Epub 2021 Jul 26.
The Allen test is a simple bedside method for determining hand perfusion. Earlier studies in patients on hemodialysis (HD) found that an Allen test before access construction did not predict hand ischemia later on. The study aimed to assess whether an Allen test combined with finger plethysmography before access surgery has a potential to predict the onset of severe HD access induced distal ischemia (HAIDI).
Before the first access construction in patients with chronic kidney disease, systolic finger pressures (Pdig, in millimeters of mercury) were obtained using plethysmography at rest and after serial compression of the radial and ulnar artery. A decrease in Pdig (∂Pdig) was calculated as the difference between Pdig-rest and Pdig-compression. The severity of postoperative HAIDI was graded as suggested by a 2016 consensus meeting. Patients with a severe type of HAIDI (grade 2b-4, intolerable pain, invasive treatment required) were compared with controls not having HAIDI.
A total of 105 patients with chronic kidney disease (mean age 70 ± 13 years; 65% males) receiving their first access between January 2009 and December 2018 in one center fulfilled study criteria. Ten patients (10%) developed severe HAIDI at 14 ± 5 months after access construction. Before access creation, all patients with HAIDI demonstrated a radial or ulnar dominant hand perfusion pattern compared with just 57% in controls (P = .010). Compression resulted in an almost two-fold greater ∂Pdig in patients with severe HAIDI (51 ± 8 mm Hg vs 27 ± 3 mm Hg; P = .005). A 40-mm Hg ∂Pdig cut-off value demonstrated optimal tests characteristics (sensitivity of 80%, specificity of 77%, positive predictive value of 27%, negative predictive value of 97%) indicating a 10 times greater risk of developing severe HAIDI.
Finger plethysmography quantifying ∂Pdig during an Allen test before access creation may identify patients who have a substantially increased risk of developing severe hand ischemia after HD access surgery.
Allen 试验是一种用于确定手部灌注的简单床边方法。先前在血液透析（HD）患者中的研究发现，在血管通路构建前进行 Allen 试验并不能预测之后手部缺血。本研究旨在评估在血管通路手术前结合手指体积描记术进行 Allen 试验是否有可能预测严重 HD 通路引起的远端缺血（HAIDI）的发生。
在慢性肾脏病患者首次构建通路前，使用体积描记法在休息时和连续压迫桡动脉和尺动脉后获得手指收缩压（Pdig，以毫米汞柱为单位）。计算 Pdig 减少量（∂Pdig）作为 Pdig-休息和 Pdig-压迫之间的差异。根据 2016 年共识会议的建议对术后 HAIDI 的严重程度进行分级。将发生严重 HAIDI（2b-4 级，无法忍受的疼痛，需要侵入性治疗）的患者与未发生 HAIDI 的对照组进行比较。
在一个中心，2009 年 1 月至 2018 年 12 月期间，共有 105 名接受首次通路构建的慢性肾脏病患者（平均年龄 70±13 岁；65%为男性）符合研究标准。在通路构建后 14±5 个月，有 10 名患者（10%）发生严重 HAIDI。与对照组的 57%相比，所有发生严重 HAIDI 的患者在通路构建前均表现出桡侧或尺侧优势手部灌注模式（P=0.010）。与对照组相比，严重 HAIDI 患者的 ∂Pdig 压迫值几乎增加了两倍（51±8mmHg 与 27±3mmHg；P=0.005）。40mmHg ∂Pdig 截断值具有最佳的测试特征（敏感性为 80%，特异性为 77%，阳性预测值为 27%，阴性预测值为 97%），表明发生严重 HAIDI 的风险增加了 10 倍。
在血管通路构建前，通过 Allen 试验结合手指体积描记术定量测量 ∂Pdig 可能会识别出那些在 HD 通路手术后手部严重缺血风险显著增加的患者。
