Virginia Commonwealth University Health System, Richmond, VA; Central Virginia Veterans Administration Health System, Richmond, VA.
Central Virginia Veterans Administration Health System, Richmond, VA; Virginia Commonwealth University School of Medicine, Richmond, VA.
Ann Vasc Surg. 2022 Oct;86:236-241. doi: 10.1016/j.avsg.2022.04.043. Epub 2022 May 14.
Central venous stenosis is a common problem that diminishes vascular access lifespan. Current national guidelines recommend that central catheters and arteriovenous grafts (AVGs) be placed contralateral to an existing hemodialysis access. We set forth to delineate any clinically significant outcomes based on laterality in patients undergoing AVG placement with an existing central catheter for dialysis treatments.
Using a Veterans Administration Hospital dialysis access database over a four-year period (May 2014 to April 2018), we identified all patients who underwent AVG placement in an upper extremity with an existing ipsilateral (Ipsi-CL) or contralateral (Contra-CL) central line for hemodialysis. AVG outcomes examined included successful cannulation, functional patency, thrombosis events, and endovascular interventions per access site. Clinical records were also examined for location of AVG, arteriovenous fistula or AVG precursors, prior central line placement, peripherally inserted central catheter, and cardiac venous access. All outcomes were followed until July 2021. Student's t-test, Fisher's exact test, and multivariable analysis were used.
A total of 71 AVGs: 55 (77%) were placed contralateral to existing central venous catheters and 16 (23%) were placed on the ipsilateral side. Baseline characteristics between the two groups were not found to be significantly different. This included a history of hypertension, smoking history, prior arteriovenous access, body mass index, race, glucose, creatinine, blood urea nitrogen, hemoglobin, mean corpuscular volume, platelet count, antiplatelet agent, and anticoagulation. 100% (n = 16) of patients in the Ipsi-CL group had previous central venous access compared to 49.1% (n = 27) in Contra-CL (P = <0.001). The mean functional patency for AVG with Contra-CL was 724.78 ± 593.98 days compared to AVGs with Ipsi-CL with mean days of 350.94 ± 431.23 days (P = 0.001). A history of previous central venous catheterization and graft on ipsilateral side of a catheter at the time of surgery was associated with decreased functional duration of graft (odds ratio, 0.25; P = 0.03).
Within this cohort of patients that underwent AVG, we noted a statistically significant decrease in the duration of functional patency of grafts ipsilateral to central venous catheters. We did not find a difference in cannulation rates, thrombosis events, or overall endovascular interventions. Ipsilateral central access appears to be associated with decreased functional patency of AVGs. These findings highlight a discrepancy that is potentially clinically relevant and further studies are warranted.
中心静脉狭窄是一种常见的问题，会缩短血管通路的寿命。目前的国家指南建议将中心导管和动静脉移植物（AVG）放置在现有血液透析通路的对侧。我们旨在根据接受 AVG 放置的患者的侧别来描述任何具有临床意义的结果，这些患者因透析治疗而存在现有的中心导管。
在四年期间（2014 年 5 月至 2018 年 4 月），我们使用退伍军人事务部医院透析通路数据库，确定了所有在同侧（同侧-CL）或对侧（对侧-CL）中央导管上行 AVG 放置的患者。AVG 结果检查包括成功的血管穿刺、功能通畅性、血栓事件和每个通路部位的血管内介入治疗。临床记录还检查了 AVG、动静脉瘘或 AVG 前体、先前的中央导管放置、外周插入的中央导管和心静脉通路的位置。所有结果均随访至 2021 年 7 月。使用学生 t 检验、Fisher 确切检验和多变量分析。
共进行了 71 次 AVG：55 次（77%）放置在现有的中心静脉导管对侧，16 次（23%）放置在同侧。两组之间的基线特征无显著差异。这包括高血压病史、吸烟史、先前的动静脉通路、体重指数、种族、血糖、肌酐、尿素氮、血红蛋白、平均红细胞体积、血小板计数、抗血小板药物和抗凝剂。同侧-CL 组 100%（n=16）的患者有先前的中央静脉通路，而对侧-CL 组为 49.1%（n=27）（P<0.001）。对侧-CL 组 AVG 的平均功能通畅时间为 724.78±593.98 天，而同侧-CL 组 AVG 的平均时间为 350.94±431.23 天（P=0.001）。术前同侧中心静脉导管和移植物史与移植物功能持续时间缩短相关（比值比，0.25；P=0.03）。
在接受 AVG 的患者队列中，我们注意到与中心静脉导管同侧的移植物功能通畅时间明显缩短。我们没有发现血管穿刺率、血栓事件或总体血管内介入治疗的差异。同侧中央通路似乎与 AVG 的功能通畅时间缩短有关。这些发现突出了一种潜在的临床相关差异，需要进一步研究。
