Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK.
J Vasc Access. 2024 May;25(3):863-871. doi: 10.1177/11297298221141497. Epub 2022 Dec 6.
The reduction in distal arterial flow following arteriovenous fistula (AVF) creation can cause a perfusion deficit known as haemodialysis access induced distal ischemia (HAIDI). Various techniques have been advocated to treat this difficult problem with varying success. We present the long-term outcomes following a novel banding technique.
46 patients in this cohort from 2008 to 2021 underwent a novel banding procedure using a Dacron™ patch shaped with one slit-end and saw-tooth edges (resulting in a 'Christmas-tree' pattern) to provide a ratchet mechanism to progressively constrict the fistula outflow. Real-time finger perfusion pressure monitoring allowed an accurate reduction in AVF flow whilst increasing distal arterial perfusion pressure. Baseline characteristic were recorded and Kaplan-Meier survival curves were obtained to calculate the post-intervention primary, assisted primary and secondary patency.
29 patients presented with rest pain and 11 presented with tissue loss due to distal ischemia. The post-intervention primary access patency was 100%, 98%, 78% and 61% at 30, 60 and 180 days and 1 year respectively. Complete resolution of symptoms was achieved in 74% ( = 34) of patients and a partial response needing no further intervention was achieved in 11% ( = 5) of patients. A Youden index calculation suggested that digital pressures of 41 mm Hg or lower in an open AVF were highly sensitive for symptomatic hand ischemia whereas pressures greater than 65 mm Hg ruled out distal ischemia.
'Christmas-tree' banding with on table finger systolic pressures is not only an efficacious and durable method for treating HAIDI but also preserves fistula patency.
动静脉瘘（AVF）创建后，远端动脉血流减少会导致灌注不足，称为血液透析通路诱导的远端缺血（HAIDI）。已经提出了各种技术来治疗这个难题，但成功率各不相同。我们介绍了一种新的带扎技术的长期结果。
2008 年至 2021 年期间，来自这一队列的 46 名患者接受了一种新的带扎手术，使用一块带有一个狭缝端和锯齿边缘的 Dacron 补丁（形成“圣诞树”图案），提供棘轮机制，逐渐收紧瘘管流出。实时手指灌注压监测可在增加远端动脉灌注压的同时，准确减少 AVF 流量。记录基线特征，并获得 Kaplan-Meier 生存曲线，以计算干预后的主要、辅助主要和次要通畅率。
29 名患者出现静息痛，11 名患者因远端缺血出现组织丧失。干预后的主要通路通畅率分别为 30、60、180 天和 1 年时的 100%、98%、78%和 61%。74%（34 名）的患者症状完全缓解，11%（5 名）的患者部分缓解，无需进一步干预。Youden 指数计算表明，开放 AVF 中手指收缩压为 41mmHg 或更低与手部症状性缺血高度相关，而压力大于 65mmHg 则排除了远端缺血。
“圣诞树”带扎与表压结合不仅是治疗 HAIDI 的有效且持久的方法，而且还能保持瘘管通畅。
