Shahverdyan Robert, Hussain Mohamad A
Vascular Access Center, Asklepios Clinic Barmbek, Hamburg, Germany.
Division of Vascular and Endovascular Surgery and the Center for Surgery and Public health, Brigham and Women's Hospital, Mass General Brigham, Boston.
J Vasc Surg. 2025 Jul;82(1):229-239. doi: 10.1016/j.jvs.2025.03.166. Epub 2025 Jun 4.
This study evaluates the long-term outcomes of radiocephalic arteriovenous fistulas (RCAVFs) created in the anatomical snuffbox (SB-AVF) or with the VasQ external support device (ES-RCAVF).
We conducted a single-center retrospective analysis including 394 primary AVFs created for hemodialysis access in patients with advanced kidney disease between November 2017 and October 2024. Outcomes examined included rates of access maturation, successful cannulation, patency (primary, assisted primary, and secondary), reintervention rates, and rates of juxta-anastomotic stenosis. Multivariate analyses were used to study the associations between baseline characteristics and clinical outcomes, aiming to identify variables that could inform algorithmic decision-making for optimal distal RCAVF configuration selection.
The cohort consisted of 148 SB-AVFs and 246 ES-RCAVFs. ES-RCAVFs had significantly higher rates of 4-week maturation (81.9% vs 69.7%; P = .009), successful cannulation (82.6% vs 71.6%; P = .044), and tunneled dialysis catheter (TDC) removal (62.9% vs 56.9%; P = .28) at 6 months as compared with SB-AVFs. There was no significant difference in juxta-anastomotic stenosis rates (34% in the SB-group and 32% in the ES-group; P = .734) or 5-year patency rates between the two groups (26.1% vs 26.6% for primary [P = .531]; 51.2% vs 52.4% for assisted primary [P = .778]; and 56.5% vs 57.8% for secondary [P = .1278] patency rates) for the SB-AVF vs ES-RCAVFs, respectively. The number of interventions per patient year was 0.46 for SB-AVFs and 0.57 for ES-RCAVFs (P = .998). In the multivariate analysis, the VasQ significantly (P = .001) increased the probability of maturation, and female gender (P = .007) and diabetes (P = .026) significantly reduced that probability at 4 weeks. The VasQ also significantly increased the probability of overall maturation (P = .002). Female gender (P = .003) and older age (P = .028) negatively contributed to the probability of overall maturation. Moreover, VasQ significantly increased the probability of cannulation success (P = .034) and was the only significant factor for increased likelihood of TDC removal by 6 months (P = .031). Female gender (P = .002) and older age (P = .006) were associated with a significantly decreased likelihood of TDC removal.
Our findings indicated that, although ES-RCAVFs achieve superior short-term and long-term outcomes, SB-AVFs remain a valuable option for select patients-particularly younger and nondiabetic individuals-to preserve distal access sites for future use.
本研究评估在解剖鼻烟窝创建的桡动脉-头静脉动静脉内瘘（SB-AVF）或使用VasQ外部支撑装置创建的桡动脉-头静脉动静脉内瘘（ES-RCAVF）的长期结局。
我们进行了一项单中心回顾性分析，纳入了2017年11月至2024年10月期间为晚期肾病患者创建的用于血液透析通路的394例原发性动静脉内瘘。检查的结局包括通路成熟率、成功穿刺率、通畅率（原发性、辅助原发性和继发性）、再次干预率以及吻合口近端狭窄率。采用多变量分析研究基线特征与临床结局之间的关联，旨在确定可为最佳远端桡动脉-头静脉动静脉内瘘配置选择的算法决策提供信息的变量。
该队列包括148例SB-AVF和246例ES-RCAVF。与SB-AVF相比，ES-RCAVF在4周时的成熟率（81.9%对69.7%；P = 0.009）、成功穿刺率（82.6%对71.6%；P = 0.044）以及6个月时隧道式透析导管（TDC）拔除率（62.9%对56.9%；P = 0.28）显著更高。两组之间的吻合口近端狭窄率（SB组为34%，ES组为32%；P = 0.734）或5年通畅率无显著差异（SB-AVF与ES-RCAVF的原发性通畅率分别为26.1%对26.6% [P = 0.531]；辅助原发性通畅率分别为51.2%对52.4% [P = 0.778]；继发性通畅率分别为56.5%对57.8% [P = 0.1278]）。SB-AVF的每患者年干预次数为0.46次，ES-RCAVF为0.57次（P = 0.998）。在多变量分析中，VasQ显著（P = 0.001）增加了成熟的概率，女性（P = 0.007）和糖尿病（P = 0.026）在4周时显著降低了该概率。VasQ还显著增加了总体成熟的概率（P = 0.002）。女性（P = 0.003）和高龄（P = （此处原文似乎有误，推测应为0.028））对总体成熟概率有负面影响。此外，VasQ显著增加了穿刺成功的概率（P = 0.034），并且是6个月时TDC拔除可能性增加的唯一显著因素（P = 0.031）。女性（P = 0.002）和高龄（P = 0.006）与TDC拔除可能性显著降低相关。
我们的研究结果表明，尽管ES-RCAVF取得了更好的短期和长期结局，但SB-AVF对于特定患者，尤其是年轻和非糖尿病个体，仍然是一个有价值的选择，可保留远端通路部位以供未来使用。
