Division of Vascular Surgery, Kaiser Permanente, Fontana Medical Center, Fontana, CA; Division of Vascular Surgery, Arrowhead Regional Medical Center, Colton, CA.
Division of Vascular Surgery, Kaiser Permanente, Fontana Medical Center, Fontana, CA; Division of Vascular Surgery, Arrowhead Regional Medical Center, Colton, CA.
Ann Vasc Surg. 2023 Nov;97:399-404. doi: 10.1016/j.avsg.2023.05.030. Epub 2023 May 27.
Dialysis access complications and failure requiring revision are common. Understanding which methods of revision yield the optimal patency rates and lowest complications remain in evolution. Revision of native vessels is preferred, with revision using expanded polytetrafluoroethylene (ePTFE) graft as an alternative. Revision with Bovine Carotid Artery Graft (Artegraft) has historically been indicated when other options have been exhausted. While earlier studies demonstrated lower patency and higher infection rates compared to ePTFE, more recent studies have suggested otherwise. We describe our experience with patients who underwent arteriovenous access revision with Artegraft, and present this as a viable alternative.
A multicenter analysis was conducted over 6 years of 25 patients with arteriovenous access complications requiring revision. Complications included aneurysmal degeneration, bleeding, recurrent thrombosis, and sclerotic outflow. Patients were grouped into 2 groups based on the complication. The first group included aneurysm-only complication and the second group included aneurysm and all other complications. All patients underwent revision of their arteriovenous fistula with excision of diseased segment of the arteriovenous fistula and interposition placement of Artegraft. All patients were followed long term and assessed for postop complications, patency, and any reintervention.
Of 25 patients, 13 were male and 12 female. Average age was 57 (range 27-83). Sixteen of the 25 patients had follow-up. Of the 16, 10 patients had primary patency (62.5%), 3 with primary-assisted patency (18.75%), and 3 with failure of grafts (18.75%). Ten of the 16 had at least 1 year or greater follow-up (5 with primary patency, 3 primary-assisted patency, and 2 with failure both of which failed after 1 year). Those that required intervention to maintain patency were from thrombosis requiring declot or anastomotic stenosis requiring angioplasty. None of the followed patients were found to have neither postoperative surgical site nor graft infections.
This case series supports that arteriovenous access revision with Artegraft is a viable option that has acceptable patency rates (81% overall functional patency rate at 1.5 years), with an observed 0% infection rate, and is comparable to ePTFE. With more recent studies suggesting Artegraft may have superior outcomes, further study and consideration should be given to using Artegraft as a conduit for arteriovenous fistula revision.
透析通路并发症和需要修复的失败很常见。了解哪种修复方法能产生最佳的通畅率和最低的并发症仍然在不断发展。修复原生血管是首选方法，使用膨体聚四氟乙烯（ePTFE）移植物作为替代方法。当其他选择都已耗尽时，历史上一直采用牛颈动脉移植物（Artegraft）进行修复。虽然早期的研究表明与 ePTFE 相比，通畅率较低，感染率较高，但最近的研究表明并非如此。我们描述了在接受 Artegraft 动静脉通路修复的患者中的经验，并将其作为一种可行的替代方法。
对 6 年来 25 例需要修复的动静脉通路并发症患者进行了多中心分析。并发症包括动脉瘤样变性、出血、复发性血栓形成和流出道硬化。根据并发症将患者分为两组。第一组包括仅动脉瘤并发症，第二组包括动脉瘤和所有其他并发症。所有患者均接受了动静脉瘘的修复，切除动静脉瘘的病变段，并置入 Artegraft。所有患者均进行了长期随访，并评估术后并发症、通畅率和任何再次干预情况。
25 例患者中，男性 13 例，女性 12 例。平均年龄 57 岁（范围 27-83 岁）。25 例患者中有 16 例得到了随访。在 16 例患者中，10 例患者具有原发性通畅（62.5%），3 例具有原发性辅助通畅（18.75%），3 例患者移植物失败（18.75%）。在 16 例患者中，有 10 例至少随访 1 年以上（5 例原发性通畅，3 例原发性辅助通畅，2 例移植物失败，两者均在 1 年后失败）。需要干预以保持通畅的患者是由于血栓形成需要溶栓或吻合口狭窄需要血管成形术。随访的患者均未发现术后手术部位或移植物感染。
本病例系列支持使用 Artegraft 进行动静脉通路修复是一种可行的选择，其通畅率可接受（1.5 年时总功能性通畅率为 81%），观察到的感染率为 0%，与 ePTFE 相当。最近的研究表明 Artegraft 可能具有更好的结果，因此应进一步考虑将 Artegraft 用作动静脉瘘修复的移植物。
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