Davies Mark G, Hart Joseph P
Center for Quality, Effectiveness and Outcomes in Cardiovascular Diseases, Division of Vascular and Endovascular Surgery, University of Texas Health at San Antonio, San Antonio, TX, United States.
Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States.
Front Surg. 2023 Mar 22;10:1149644. doi: 10.3389/fsurg.2023.1149644. eCollection 2023.
Central venous stenotic disease is reported in 7%-40% of patients needing a central venous catheter for dialysis and in 19%-41% of hemodialysis patients who have had a prior central venous catheter. Half of these patients will be asymptomatic. Venous Thoracic Outlet syndrome in hemodialysis (hdTOS) is part of this spectrum of disease. The extrinsic mechanical compression of the subclavian vein at the costoclavicular triangle between the clavicle and 1st rib results in an area of external compression with a predisposition to intrinsic mural disease in the vein. The enhanced flow induced by the presence of a distal arteriovenous access in all patients exacerbates the subclavian vein's response to ongoing extrinsic and intrinsic injury. Repeated endovascular interventions during the maintenance of vascular access accelerates chronic untreatable occlusion of the subclavian vein in the long term. Similar to patients with central venous stenosis, patients with hdTOS can present immediately after access formation with ipsilateral edema or longitudinally with episodes of access dysfunction. hdTOS can be treated in an escalating manner with arteriovenous access flow reduction to <1,500 ml/min, endovascular management, surgical decompression by first rib resection in healthy patients and medial clavicle resection in less healthy patients followed by secondary venous interventions, or finally, a venous bypass. hdTOS represents a complex and evolving therapeutic conundrum for the dialysis community, and additional clinical investigations to establish robust algorithms are required.
据报道，在需要中心静脉导管进行透析的患者中，中心静脉狭窄疾病的发生率为7%-40%，在既往有中心静脉导管的血液透析患者中为19%-41%。这些患者中有一半将无症状。血液透析中的静脉胸廓出口综合征（hdTOS）是这种疾病谱的一部分。锁骨下静脉在锁骨和第一肋骨之间的肋锁三角处受到外部机械压迫，导致外部压迫区域，使静脉易患内在壁层疾病。所有患者远端动静脉通路的存在所诱导的血流增加，加剧了锁骨下静脉对持续的外部和内在损伤的反应。在维持血管通路期间反复进行血管内干预，长期会加速锁骨下静脉慢性不可治疗的闭塞。与中心静脉狭窄患者类似，hdTOS患者在通路形成后可立即出现同侧水肿，或纵向出现通路功能障碍发作。hdTOS可以通过逐步降低动静脉通路血流量至<1500 ml/min、血管内治疗、健康患者通过切除第一肋骨进行手术减压、不太健康患者通过切除锁骨内侧进行手术减压，随后进行二次静脉干预，或最终进行静脉搭桥来治疗。hdTOS对透析界来说是一个复杂且不断演变的治疗难题，需要进行更多临床研究以建立可靠的算法。
