血液透析患者中心静脉狭窄的血管腔内治疗费用与生存分析

Cost- effect analysis of endovascular intervention to central vein stenosis in hemodialysis population

目的评估血液透析患者中心静脉狭窄（CVS）的临床特点，并比较血管腔内治疗与其他治疗方法的医疗费用以及患者的生存获益。方法以2011年1月1日至2012年12月31日期间在本院肾内科为解决长期血管通路且符合静脉造影指征的高危血液透析患者共116例为研究对象。采用血管彩超及静脉造影结合的方法评估患者双侧中心静脉。将有CVS的患者分为3组：有症状未行血管腔内治疗组（17例）、有症状行血管腔内治疗组（6例）及无症状未行血管腔内治疗组（24例）。记录不同治疗方案的单疗程费用，并用Kaplan—Meier法对患者行生存分析。结果在116例患者中，有47例患者诊断为CVS，从症状出现到临床确诊的平均时间间隔大于10个月。与无CVS患者相比，CVS患者中有中心静脉导管插管史的患者比例较高（87．2％比14．5％，P＜0．01）。在需要处理的36例患者中，只有6例患者接受血管腔内治疗以维护其血液透析通路，30例患者因担心再狭窄风险及增加治疗费用均采取非血管腔内治疗，其中28例患者改换其他透析通路。有症状未行血管腔内治疗组、有症状行血管腔内治疗组及无症状未行血管腔内治疗组12个月生存率分别为84．6％、88．9％及87．0％，24个月生存率分别为38．5％、61．0％及53．9％，各组间生存率差异无统计学意义。结论考虑到患者的生存获益及相对高昂的医疗费用，血管腔内治疗不是中国血液透析患者CVS治疗的首选方案，而仅仅是其中一种治疗方案。

Objective To evaluate the clinical features and the survival benefits of Chinese hemodialysis （HD） patients with central vein stenosis （CVS） undergoing different treatments. Methods From January 1, 2011 to Dec 31, 2012, 116 HD patients at high risk of CVS in Wuhan Central Hospital had their bilateral central veins assessed by vascular ultrasound and conventional venography. The clinical outcomes of 24 non-treated asymptomatic CVS patients, 17 non-treated symptomatic CVS patients and 6 treated symptomatic CVS patients were compared. Treatment costs of CVS were recorded and patients′ survival rates were estimated by Kaplan-Meier analysis. Results Among 116 patients, 47 were diagnosed with CVS. The time span between symptomatic presentation and the diagnosis of CVS was more than 10 months averagely. Compared with non-CVS patients, the duration of HD in CVS patients was longer [（33.8±14.5） months vs （1.1±0.7） months, P〈0.01] and the rate of central venous catheter （CVC） insertion was higher （87.2% vs 14.5%, P〈0.01）. Only 6 patients tried to maintain vascular access by endovascular intervention which costed ￥33 500 per person, much higher than other treatment options. While 30 patients refused endovascular intervention for fear of re-stenosis riskand high treatment costs, among whom 28 patients lost their initial vascular access. The 12- month survival rates of non-treated symptomatic CVS patients, treated symptomatic CVS patients and nontreated asymptomatic CVS patients were 84.6%, 88.9% and 87.0%, respectively, and the 24-month survival rates were 38.5%, 61% and 53.9%, respectively. No significant difference was found among the three groups. Conclusions Endovascular intervention may not be the first choice, but an alternative choice for Chinese HD patients with CVS, considering the long term survival benefit and the high treatment cost.