Division of Vascular and Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), University of California San Diego, San Diego, CA.
Division of Vascular and Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), University of California San Diego, San Diego, CA.
Ann Vasc Surg. 2023 Oct;96:308-315. doi: 10.1016/j.avsg.2023.03.020. Epub 2023 Mar 31.
Traditionally, arteriovenous fistulas (AVF) involving the basilic vein (BV) have been created in 1 or 2 stages to allow time for the vein to enlarge before superficialization for potential better fistula maturation. Previous single institution studies and meta-analyses have found conflicting outcomes between single-stage and 2-stage procedures. Our study aims to use a large national database to assess the difference in outcomes between single-stage and 2-stage procedures for dialysis access.
We studied all patients undergoing BV AVF creation in the Vascular Quality Initiative (VQI) from 2011 to 2021. Patients were split into single-stage or a planned 2-stage procedure for dialysis access. Primary outcomes included dialysis use with index fistula, maturity rate, and number of days from surgery to fistula use. Secondary outcomes included patency (defined by physical exam or imaging on follow-up), 30-day mortality, and postoperative complications (bleeding, steal syndrome, thrombosis, or neuropathy). Logistic regression models were used to assess the association between staged dialysis access procedures and primary outcomes of interest.
The cohort consisted of 22,910 individuals of which 7,077 (30.9%) had a 2-staged dialysis access procedure and 15,833 (69.1%) had a single-staged procedure. Average follow-up was 345 days in the single stage and 420 days for 2-stage. Baseline characteristics were significantly different between the 2 groups in terms of medical comorbidities. Primary outcomes were significant for more patients in the 2-stage group undergoing dialysis with the index fistula compared to single stage (31.5% vs. 22.2%, P < 0.0001), significant decrease in days to use in current dialysis patients (103.9 days single stage versus 141.0 days 2-stage, P < 0.0001), and no difference in maturity at follow-up (19.3% single-stage and 17.4% 2-stage, P = 0.354). Secondary outcomes revealed no difference in 30-day mortality or patency (89.8% single-stage and 89.1% 2-stage, P = 0.383), but a significant difference in postoperative complications with a 2-stage procedure compared to 1-stage (1.6% vs. 1.1%, P = 0.026). Finally, a spline model was used to determine that a preoperative vein of 3 mm or less could be a cutoff in which a 2-stage procedure might be beneficial.
This study demonstrates that when dialysis access fistulas are created using the BV, there is no difference in maturity rate or 1-year patency when assessing single-stage versus 2-stage procedures. However, 2-stage procedures significantly delay the time of first use of the fistula and increase postoperative complications. Therefore, we suggest performing single stage procedures when the vein is of appropriate diameter to minimize multiple procedures, complications and expedite time to maturity.
传统上，为了使静脉有足够的时间扩大，以便在可能更好地成熟之前进行浅表化，动静脉瘘（AVF）通常分 1 期或 2 期进行。以前的单机构研究和荟萃分析发现，1 期和 2 期手术之间的结果存在矛盾。我们的研究旨在使用大型国家数据库评估用于透析通路的单期和 2 期手术之间的结果差异。
我们研究了 2011 年至 2021 年期间血管质量倡议（VQI）中所有接受 BV AVF 手术的患者。患者分为单期或计划的 2 期手术用于透析通路。主要结局包括使用指数瘘进行透析、成熟率以及从手术到瘘使用的天数。次要结局包括通畅（通过随访时的体格检查或影像学检查定义）、30 天死亡率和术后并发症（出血、盗血综合征、血栓形成或神经病）。使用逻辑回归模型评估分期透析通路手术与主要研究结果之间的关联。
该队列包括 22910 名患者，其中 7077 名（30.9%）接受了 2 期透析通路手术，15833 名（69.1%）接受了单期手术。单期的平均随访时间为 345 天，2 期为 420 天。2 期组的基线特征在医疗合并症方面与单期组有显著差异。主要结局是 2 期组接受指数瘘透析的患者比例明显高于单期组（31.5%比 22.2%，P < 0.0001），目前接受透析的患者达到透析使用的天数显著减少（单期 103.9 天，2 期 141.0 天，P < 0.0001），但随访时成熟度无差异（单期 19.3%，2 期 17.4%，P = 0.354）。次要结局显示 30 天死亡率或通畅率无差异（单期 89.8%和 2 期 89.1%，P = 0.383），但 2 期手术与 1 期手术相比，术后并发症有显著差异（1.6%比 1.1%，P = 0.026）。最后，使用样条模型确定术前静脉直径为 3mm 或更小可能是 2 期手术可能有益的截止值。
本研究表明，当使用 BV 进行透析通路瘘管手术时，评估单期与 2 期手术时，瘘管成熟率或 1 年通畅率无差异。然而，2 期手术显著延迟了瘘管首次使用的时间，并增加了术后并发症。因此，当静脉直径合适时，我们建议进行单期手术，以尽量减少多次手术、并发症并加快成熟时间。
