疑难血液透析通路的建立

Vascular access establishment in difficult cases

目的总结疑难血液透析通路的建立经验，为提高患者生存率提供一定的临床依据。方法回顾性分析上海交通大学医学院附属仁济医院血管外科收治的7例疑难病例的病史及血液透析通路的设计。结果收集2008年4月至2014年1月收治的7例病例，男3例，女4例，年龄46～79岁，平均年龄（66．6±13．4）岁，其共同特点是由于插管及其他原因，造成中心静脉资源的耗竭，缺乏常规血液透析通路的建立手段及后续手段匮乏，远期通畅率不高，同时部分患者还存在急诊透析通路的建立困难。最终这7例患者根据各自病情分别施行了左股静脉带隧道带涤纶套导管置管1例，右头臂静脉支架植入术1例，股动脉-股总静脉人工血管袢式动静脉内瘘术2例，股动脉-髂总静脉人工血管袢式动静脉内瘘术1例，股浅动脉-股浅动脉人工血管通路1例，肱动脉-肱动脉人工血管通路1例，以维持透析。7例患者随访时间11～56个月，维持规律性血液透析，有5例因其他原因死亡，1例随访2年后失访，1例维持透析。结论中心静脉耗竭是造成血液透析通路建立困难的主要原因，尽量减少和避免中心静脉插管，有助于保护静脉资源。下肢血管通路是维持血液透析通路的一种选择，而当所有静脉资源耗竭时，可采用动脉-动脉的血管通路。

Objective To summarize the experience of hemodialysis access establishment in the difficult cases. Methods The experience of 7 cases of difficult vascular access establishment in Renji Hospital was retrospectively reviewed. Results From Apr. 2008 to Jan. 2014, 7 cases were treated, including 3 males and 4 females with mean age of 66. 6 ± 13. 4 years. Features of these cases were lack of effective, persistent and enough methods to establish a new vascular access due to the exhaustion of central venous resources, and hard to establish an emergency access at the same time. Eventually, the procedures included left femoral vein tunneled cuffed catheter （one case）, right innominate vein stent implantation （one case）, femoral artery-femoral vein loop arteriovenous graft （2 cases）, femoral artery-lilac vein loop arteriovenous graft （one case）, superficial femoral artery graft access （one case） and hrachial artery graft access （one case）. During the follow-up period of 11 months to 56 months, all the cases maintained regular dialysis. There were 5 deaths because of other reasons. Conclusions The central venous exhaustion is the cause of difficult cases. Minimizing and avoiding central venous catheterization can help protect the vein of resources. Lower extremity vascular access is a choice to maintain the dialysis, and when all venous resources exhausted, artery to artery graft may be the choice.