经皮与手术动静脉瘘的早期临床经验和比较。
Early clinical experience and comparison between percutaneous and surgical arteriovenous fistula.
机构信息
Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
School of Medicine, University of Pittsburgh, Pittsburgh, PA.
出版信息
J Vasc Surg. 2023 Sep;78(3):766-773. doi: 10.1016/j.jvs.2023.05.030. Epub 2023 May 24.
BACKGROUND
Percutaneous arteriovenous fistula (pAVF) has been recently developed as an alternative to surgical AVF (sAVF). We report our experience with pAVF in comparison with a contemporaneous sAVF group.
METHODS
Charts of all 51 patients with pAVF performed at our institution were analyzed retrospectively, in addition to 51 randomly selected contemporaneous patients with sAVF (2018-2022) with available follow-up. Outcomes of interest were (i) procedural success rate, (ii) number of maturation procedures required, (iii) fistula maturation rates, and (iv) rates of tunneled dialysis catheter (TDC) removal. For patients on hemodialysis (HD), sAVF and pAVF were considered mature when the AVF was used for HD. For patients not on HD, pAVF were considered mature if flow rates of ≥500 mL/min were documented in superficial venous outflow; for sAVF, documentation of maturity based on clinical criteria was required.
RESULTS
Compared patients with sAVF, patients with pAVF were more likely to be male (78% vs 57%; P = .033) and less likely to have congestive heart failure (10% vs 43%; P < .001) and coronary artery disease (18% vs 43%; P = .009). Procedural success was achieved in 50 patients with pAVF (98%). Fistula angioplasties (60% vs 29%; P = .002) and ligation (24% vs 2%; P = .001) or embolization (22% vs 2%; P = .002) of competing outflow veins were more frequently performed on patients with pAVF. The surgical cohort had more planned transpositions (39% vs 6%; P < .001). When all maturation interventions were combined, pAVF required more maturation procedures, but this was not statistically significant (76% vs 53%; P = .692). When planned second-stage transpositions were excluded, pAVF had a statistically significant higher rate of maturation procedures (74% vs 24%; P < .001). Overall, 36 pAVF (72%) and 29 sAVF (57%) developed mature fistulas. This difference, however, was not statistically significant (P = .112). At the time of AVF creation, 26 patients with pAVF and 40 patients with sAVF were on HD, all through use of a TDC. Catheter removal was recorded in 15 patients with pAVF (58%) and 18 patients with sAVF (45%) (P = .314). The mean time until TDC removal in pAVF group was 146 ± 74 days, compared with 175 ± 99 in the sAVF group (P = .341).
CONCLUSIONS
Compared with sAVF, rates of maturation after pAVF seem to be similar, but this result may be related to the higher intensity of maturation procedures and patient selection. An analysis of appropriately matched patients will assist in elucidating the possible role of pAVF vis-a-vis sAVF.
背景
经皮动静脉瘘（pAVF）最近已被开发为外科动静脉瘘（sAVF）的替代方法。我们报告了我们在与同期 sAVF 组比较时使用 pAVF 的经验。
方法
回顾性分析了我院 51 例 pAVF 患者的病历，另外还随机选择了 51 例同期具有可随访的 sAVF 患者（2018-2022 年）。感兴趣的结果包括：（i）手术成功率，（ii）所需的成熟程序数量，（iii）瘘管成熟率，以及（iv）隧道透析导管（TDC）去除率。对于血液透析（HD）患者，当 AVF 用于 HD 时，sAVF 和 pAVF 被认为是成熟的。对于未进行 HD 的患者，如果记录到浅表静脉流出的流量≥500mL/min，则认为 pAVF 是成熟的；对于 sAVF，则需要根据临床标准记录成熟度。
结果
与 sAVF 患者相比，pAVF 患者更可能为男性（78% vs 57%；P=.033），不太可能患有充血性心力衰竭（10% vs 43%；P<.001）和冠心病（18% vs 43%；P=.009）。50 例 pAVF 患者（98%）手术成功。pAVF 患者更常进行瘘管血管成形术（60% vs 29%；P=.002）、竞争流出静脉结扎（24% vs 2%；P=.001）或栓塞（22% vs 2%；P=.002）。手术组更常进行计划的转位（39% vs 6%；P<.001）。当所有成熟干预措施合并时，pAVF 需要更多的成熟程序，但这没有统计学意义（76% vs 53%；P=.692）。当排除计划的二期转位时，pAVF 的成熟程序有统计学上更高的发生率（74% vs 24%；P<.001）。总的来说，36 例 pAVF（72%）和 29 例 sAVF（57%）发展为成熟瘘管。然而，这一差异没有统计学意义（P=.112）。在创建 AVF 时，26 例 pAVF 和 40 例 sAVF 患者正在接受 HD，均通过使用 TDC。记录了 15 例 pAVF 患者（58%）和 18 例 sAVF 患者（45%）的 TDC 去除情况（P=.314）。pAVF 组 TDC 去除的平均时间为 146±74 天，而 sAVF 组为 175±99 天（P=.341）。
结论
与 sAVF 相比，pAVF 成熟后的成熟率似乎相似，但这一结果可能与成熟程序的强度和患者选择有关。对匹配良好的患者进行分析将有助于阐明 pAVF 相对于 sAVF 的可能作用。
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