Alnahhal Khaled I, Rowse Jarrad, Kirksey Lee
Department of Vascular Surgery, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
Cardiovasc Diagn Ther. 2023 Feb 28;13(1):162-172. doi: 10.21037/cdt-22-560. Epub 2023 Feb 13.
With the increasing life expectancy of patients with end-stage kidney disease, the creation and maintenance of hemodialysis vascular access are becoming more challenging. A comprehensive patient evaluation including a complete history, physical examination, and ultrasonographic vessel assessment is the foundation of the clinical evaluation. A patient-centered approach acknowledges the myriad of factors that impact the selection of optimal access for the distinct clinical and social circumstance of each patient. An interdisciplinary team approach involving various healthcare providers in all stages of hemodialysis access creation is important and associated with better outcomes. While patency is considered the most important parameter in most vascular reconstructive scenarios, the ultimate determinant of success in vascular access for hemodialysis is a circuit that allows consistent and uninterrupted delivery of the prescribed hemodialysis. The best conduit is one that is superficial, easily identified, straight, and of a large caliber. Individual patient factors and skill level of the cannulating technician also play a crucial role in the initial success and maintenance of vascular access. Special attention should be considered in dealing with more challenging groups such as the elderly population where the newest vascular access guidance from The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative will be transformative. The current guidelines recommend monitoring the vascular access by regular physical and clinical assessments, however, inadequate evidence is available to support routine ultrasonographic surveillance for improving access patency.
随着终末期肾病患者预期寿命的增加，建立和维护血液透析血管通路变得更具挑战性。全面的患者评估，包括完整的病史、体格检查和超声血管评估，是临床评估的基础。以患者为中心的方法认识到影响为每个患者独特的临床和社会情况选择最佳通路的众多因素。在血液透析通路建立的各个阶段采用跨学科团队方法，由各种医疗保健提供者参与，这很重要且与更好的结果相关。虽然在大多数血管重建情况下通畅性被认为是最重要的参数，但血液透析血管通路成功的最终决定因素是一个能够持续、不间断地进行规定血液透析的回路。最佳的血管通路是浅表、易于识别、笔直且口径较大的通路。个体患者因素和插管技术人员的技能水平在血管通路的初始成功和维护中也起着关键作用。在处理更具挑战性的群体时应给予特别关注，例如老年人群体，美国国家肾脏基金会的肾脏病预后质量倡议发布的最新血管通路指南将带来变革。目前的指南建议通过定期的体格和临床评估来监测血管通路，然而，尚无足够证据支持常规超声监测以改善通路通畅性。
