Hakaim A G, Scott T E
Department of Surgery, Boston University School of Medicine, MA, USA.
J Vasc Surg. 1997 Jun;25(6):1002-5; discussion 1005-6. doi: 10.1016/s0741-5214(97)70123-x.
Initiation of hemodialysis frequently requires temporary central venous catheterization, which leads to subsequent venous stenosis in 50% of patients. These lesions severely limit upper extremity dialysis fistula creation. The present study was undertaken to determine whether early cannulation (EC) allowed omission of temporary venous catheterization without affecting perioperative morbidity and long-term graft patency.
Seventy-nine prosthetic grafts for hemodialysis were placed in 76 patients over a 40-month period. Patients who required hemodialysis between 24 and 72 hours after surgery were assigned to EC. The remaining grafts underwent late cannulation (LC) after postoperative day 14. All grafts were constructed with a 6 mm stretch-expanded polytetrafluoroethylene conduit in the brachial artery-to-axillary vein position. Statistical analysis of cumulative primary patency estimates and patient survival data were determined by Kaplan-Meier analysis and log-rank test, patient variables were compared using chi 2 and Fisher's exact test, and multivariate analysis was performed using Cox's proportional hazard model.
Forty-eight patients underwent EC and 31 underwent LC. There were no significant differences regarding age (mean, 61.5 years), history of diabetes, congestive heart failure, hematocrit level (mean, 30%), or presence of peripheral vascular disease. Thrombosis occurred before cannulation in one of 48 ECs (2.0%) and one of 31 LCs (3.2%). There were no episodes of cannulation hemorrhage or wound infection in either group. Cumulative primary patency estimates for EC were 0.89, 0.82, and 0.70 at 3, 6, and 12 months, respectively. These were not significantly different from the LC estimates of 0.86, 0.78, and 0.74 at 3, 6, and 12 months, respectively. Overall, patients who had a history of peripheral vascular disease had a significantly decreased 12-month patency rate (60% vs 74%; p = 0.05). Central venous catheters were omitted in 47 of 48 EC patients.
EC of prosthetic dialysis grafts does not increase perioperative morbidity rates or decrease 12-month cumulative primary patency rates.
开始血液透析常常需要临时中心静脉置管，这会导致50%的患者随后出现静脉狭窄。这些病变严重限制了上肢透析瘘的建立。本研究旨在确定早期插管（EC）是否能在不影响围手术期发病率和长期移植物通畅率的情况下避免临时静脉置管。
在40个月的时间里，为76例患者植入了79个用于血液透析的人工移植物。术后24至72小时需要进行血液透析的患者被分配至早期插管组。其余移植物在术后第14天之后进行晚期插管（LC）。所有移植物均采用6毫米拉伸扩张聚四氟乙烯导管，置于肱动脉至腋静脉位置。通过Kaplan-Meier分析和对数秩检验确定累积原发性通畅率估计值和患者生存数据的统计分析，使用卡方检验和Fisher精确检验比较患者变量，并使用Cox比例风险模型进行多变量分析。
48例患者接受了早期插管，31例接受了晚期插管。在年龄（平均61.5岁）、糖尿病史、充血性心力衰竭、血细胞比容水平（平均30%）或外周血管疾病的存在方面，两组之间没有显著差异。48例早期插管患者中有1例（2.0%）在插管前发生血栓形成，31例晚期插管患者中有1例（3.2%）发生血栓形成。两组均未发生插管出血或伤口感染事件。早期插管组在3、6和12个月时的累积原发性通畅率估计值分别为0.89、0.82和0.70。这些值与晚期插管组在3、6和12个月时分别为0.86、0.78和0.74的估计值没有显著差异。总体而言，有外周血管疾病史的患者12个月通畅率显著降低（60%对74%；p = 0.05）。48例早期插管患者中有47例未进行中心静脉置管。
人工透析移植物的早期插管不会增加围手术期发病率，也不会降低12个月的累积原发性通畅率。
