Department of Surgery, Medstar Franklin Square Hospital, Baltimore, Md.
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md.
J Vasc Surg. 2022 Apr;75(4):1395-1402.e5. doi: 10.1016/j.jvs.2021.10.027. Epub 2021 Oct 28.
Preoperative vein mapping before arteriovenous fistula (AVF) or arteriovenous graft (AVG) placement has been debated as a possible method of improving hemodialysis access outcomes for patients. However, high-quality national studies that have addressed this relationship are lacking. Thus, we assessed the association of preoperative vein mapping with hemodialysis access configuration and outcomes.
In the present cohort study, we analyzed all patients who had undergone AVF or AVG placement with data captured in the Vascular Quality Initiative hemodialysis access dataset from August 2011 to September 2019. The patients were stratified by whether they had undergone preoperative vein mapping. The primary (configuration) outcomes were access type (AVF vs AVG) and location (upper arm vs forearm). The secondary (longitudinal) outcomes were the successful initiation of hemodialysis, maintenance of secondary patency, and the need for reintervention 1 year after the index operation.
Overall, 85.6% of the 46,010 included patients had undergone preoperative vein mapping. Of the 46,010 patients, 76.1% and 23.9% had undergone AVF and AVG creation, respectively. AVF creation (77.6% vs 67.3%) and forearm location (54.6% vs 47.3%) were more frequent for the patients who had undergone preoperative vein mapping than for those who had not (P < .001). After adjusting for baseline differences between the groups, preoperative vein mapping was associated with increased odds of receiving an AVF vs AVG (adjusted odds ratio, 1.64; 95% confidence interval [CI], 1.55-1.75) and forearm vs upper arm access (adjusted odds ratio, 1.22; 95% CI, 1.16-1.30). The incidence of the loss of secondary patency was lower for patients with preoperative vein mapping (P < .001), and persisted after risk adjustment (adjusted hazard ratio, 0.81; 95% CI, 0.75-0.88).
Preoperative vein mapping was associated with favorable hemodialysis access configurations and outcomes in real-world practice. These data suggest that the use of preoperative vein mapping could improve the likelihood of favorable outcomes for patients requiring hemodialysis access.
动静脉瘘（AVF）或动静脉移植物（AVG）放置前的术前静脉映射一直存在争议，它可能是一种改善血液透析患者通路结果的方法。然而，缺乏高质量的全国性研究来解决这个问题。因此，我们评估了术前静脉映射与血液透析通路配置和结果的关系。
在本队列研究中，我们分析了 2011 年 8 月至 2019 年 9 月期间血管质量倡议血液透析通路数据集中接受 AVF 或 AVG 放置的所有患者的数据。根据是否进行术前静脉映射对患者进行分层。主要（配置）结局是通路类型（AVF 与 AVG）和位置（上臂与前臂）。次要（纵向）结局是开始血液透析的成功率、二级通畅的维持以及索引手术后 1 年内需要再次干预。
总体而言，46010 例纳入患者中 85.6%接受了术前静脉映射。在 46010 例患者中，分别有 76.1%和 23.9%接受了 AVF 和 AVG 治疗。与未接受术前静脉映射的患者相比，接受术前静脉映射的患者更倾向于接受 AVF 治疗（77.6%比 67.3%）和前臂位置（54.6%比 47.3%）（P<0.001）。在调整组间基线差异后，术前静脉映射与接受 AVF 治疗而非 AVG 治疗的可能性增加相关（调整后的优势比，1.64；95%置信区间[CI]，1.55-1.75）和前臂通路而非上臂通路（调整后的优势比，1.22；95%CI，1.16-1.30）。与未接受术前静脉映射的患者相比，接受术前静脉映射的患者二级通畅的丧失发生率较低（P<0.001），并且在风险调整后仍然存在（调整后的风险比，0.81；95%CI，0.75-0.88）。
在真实世界的实践中，术前静脉映射与有利的血液透析通路配置和结果相关。这些数据表明，术前静脉映射的使用可以提高需要血液透析通路的患者获得有利结果的可能性。
