Besarab A, Sullivan K L, Ross R P, Moritz M J
Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA.
Kidney Int. 1995 May;47(5):1364-73. doi: 10.1038/ki.1995.192.
Vascular access thrombosis is a major problem for hemodialysis patients. Over 7.75 years, we performed intra-access venous pressure monitoring at zero dialyzer blood flow (VP0), correlated VP0 with access anatomy angiographically, and examined the effect of two levels of stenosis, 50% and > 65% luminal diameter reduction (% D) as selection criteria for referral and elective angioplasty or surgical revision upon access outcomes. Summary receiver outcome curves for absolute intra-access pressure (VP0) and intra-access pressure normalized for systemic pressure (VP0/systolic BP) were constructed to evaluate sensitivity and specificity and compared to recirculation and duplex color-flow Doppler. Access outcomes included thrombosis, revision, replacement, and angioplasty rates that were normalized per 100 patient years (100 pt-yrs). During the 7.75 year long study period totaling 832 patient-access years of risk, the percentage of prosthetic bridge grafts increased from 65% to 80%. SROC showed better sensitivity for normalized (VP0/systolic BP) than absolute intra-access pressure (VP0) in grafts. Recirculation had poor predictive power in prosthetic bridge grafts compared to VP0. Predictive power of recirculation was superior to VP0 in native arteriovenous fistulae. The angioplasty rate correlated inversely with the degree of luminal reduction used as selection criterion for referral for angioplasty or surgical revision. A strong inverse relationship between thrombosis rate and the angioplasty rate (R2 = 0.99) but not between thrombosis rate and the number of angiograms performed (R2 = 0.39) was noted. A consistent, yet evolving, intensive graft maintenance protocol produced a 70% decrease in the thrombosis rate, a 79% decrease in the access replacement rate, and an increase in the average age of patent usable vascular accesses from 1.97 to 2.98 years that was associated with a 13-fold increase in the angioplasty rate. We conclude that vascular access monitoring with VP0/systolic BP provides excellent selection criteria for angiographic referral. Intervention for stenotic lesions > 50% D using angioplasty or surgical revision markedly reduces thrombosis and access replacement rates.
血管通路血栓形成是血液透析患者面临的一个主要问题。在7.75年的时间里，我们在透析器血流为零时进行了血管内静脉压力监测（VP0），通过血管造影将VP0与血管通路解剖结构相关联，并研究了两种狭窄程度（管腔直径减少50%和>65%，即%D）作为转诊以及择期血管成形术或外科修复选择标准时对血管通路结局的影响。构建了绝对血管内压力（VP0）和经体循环压力标准化的血管内压力（VP0/收缩压）的汇总受试者工作特征曲线，以评估敏感性和特异性，并与再循环以及双功彩色血流多普勒检查结果进行比较。血管通路结局包括每100患者年（100 pt-yrs）标准化后的血栓形成、修复、置换和血管成形术发生率。在长达7.75年的研究期间，总计有832患者-血管通路年的风险，人工搭桥移植物的比例从65%增加到了80%。汇总受试者工作特征曲线显示，对于移植物，经标准化后的（VP0/收缩压）比绝对血管内压力（VP0）具有更好的敏感性。与VP0相比，再循环在人工搭桥移植物中的预测能力较差。在自体动静脉内瘘中，再循环的预测能力优于VP0。血管成形术发生率与用作血管成形术或外科修复转诊选择标准的管腔缩小程度呈负相关。注意到血栓形成率与血管成形术发生率之间存在强烈的负相关关系（R2 = 0.99），但血栓形成率与血管造影检查次数之间不存在这种关系（R2 = 0.39）。一项持续且不断发展的强化移植物维护方案使血栓形成率降低了70%，血管通路置换率降低了79%，并且使可用的有功能血管通路的平均使用年限从1.97年增加到了2.98年，同时血管成形术发生率增加了13倍。我们得出结论，使用VP0/收缩压进行血管通路监测可为血管造影转诊提供出色的选择标准。对管腔直径减少>50%的狭窄病变进行血管成形术或外科修复干预可显著降低血栓形成率和血管通路置换率。
