Burdick J F, Maley W R
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, USA.
Adv Surg. 1996;30:223-32.
Dialysis as a therapy has become nearly universally available and the ability to provide dialysis and dialysis access over long periods of time has become well established. Unfortunately, technology has yet to provide the perfect dialysis access conduit, one which will not stenose, thrombose, or be prone to infection. Native cephalic vein remains the superior dialysis conduit even 30 years after it was first described. At present, the emphasis in constructing dialysis access must be to attempt to reserve native vein, both in the arm and centrally. The most important decisions remain the ones made at the initiation of dialysis: avoiding subclavian catheters that may lead to subclavian vein stenosis and loss of that extremity for later access; nephrologists making every effort to shelter one extremity for later access formation in the patient who presents with signs of eventual need for dialysis; and if at all possible constructing a native fistula, either forearm or upper arm, which will serve the patient better in the long term, rather than the simpler course of placing a prosthetic graft. Dialysis access planning may need to look 15 to 20 years into the future for the patient who, if not a potential transplant candidate, may remain on dialysis for a very long time. The ability to keep dialysis access functional has improved markedly with the evolution of radiologic methods for thrombolysis and intervention. However, as in other areas of surgery performing the best operation first and avoiding complications is the path that best serves the patient.
透析作为一种治疗方法已几乎普及，并且长期提供透析及建立透析通路的能力也已得到充分确立。不幸的是，技术尚未提供出完美的透析通路管道，即一种不会狭窄、形成血栓或易于感染的管道。自首次被描述以来，即使过去了30年，自体头静脉仍是较好的透析管道。目前，构建透析通路时的重点必须是尽量保留上肢及中心部位的自体静脉。最重要的决策仍是在开始透析时做出的那些决策：避免使用可能导致锁骨下静脉狭窄并使该肢体日后无法用于通路建立的锁骨下导管；肾病学家应尽力为那些已出现最终需要透析迹象的患者保留一个肢体，以便日后建立通路；并且如果可能的话，构建一个自体动静脉内瘘，无论是前臂还是上臂的，从长远来看，这对患者的服务效果会更好，而不是选择放置人工血管这种更简单的做法。对于那些若不是潜在移植候选人可能需要长期接受透析的患者，透析通路规划可能需要展望未来15至20年的情况。随着放射溶栓和介入方法的发展，保持透析通路功能的能力已显著提高。然而，与外科手术的其他领域一样，首先进行最佳手术并避免并发症才是最有利于患者的途径。
