结扎桡动脉远心端治疗透析通路相关缺血综合征

Distal radial artery ligation for dialysis access-associated ischemic syndrome

目的总结结扎桡动脉远心端治疗透析通路相关缺血综合征的方法及经验。方法选择2011年6月至2013年12月北京大学第三医院海淀院区肾内科以头静脉一桡动脉端侧吻合动静脉内瘘为透析通路，且临床表现为内瘘侧肢体缺血者16例，行彩色多普勒超声检查显示吻合口桡动脉近心端及远心端血流方向相反，行血管造影显示大动脉通畅，行Allen实验提示尺动脉功能良好，采用局部浸润麻醉结扎吻合口桡动脉远心端治疗肢体远端自体动静脉内瘘相关缺血综合征，术后观察缺血症状缓解情况、透析时内瘘泵控血流量、尿素清除指数、尿素下降率、内瘘通畅性等指标。结果共观察上肢远端自体动静脉内瘘相关缺血综合征16例（占同期因动静脉内瘘并发症住院患者的1．45％），其中男性8例，女性8例，平均年龄（66．2±11．2）岁，平均透析时间（66．32±85．26）个月，内瘘时间（57．75±88．41）个月，内瘘建立后出现缺血症状时间（39．62±58．31）个月；根据临床表现的缺血症状进行分级，其中13例（占71．40％）为Ⅲ级患者，3例（28．60％）为Ⅱ级，未出现Ⅳ级患者。结扎桡动脉远心端手术技术成功率100％，临床成功率93．70％（15／16）。术前及术后第7天、第6个月、第12个月人组患者透析泵控血流量分别为（258．63±25．44）ml／min、（246．61±24．24）ml／min、（260．42±20．83）ml／min、（254．87±22．44）ml／min，差异无统计学意义（P〉0．05）；尿素清除指数分别为（1．65±0．21）、（1．59±0．24）、（1．62±0．28）、（1．58±0．39），差异无统计学意义（P〉0．05）；尿素下降率分别为（78．43％±3．27％）、（74．46％±2．64％）、（76．85％±3．84％）、（74．21％±3．32％），差异无统计学意义（P〉0．05），术后平均随访（19．30±13．15）个月，通畅率100％。未出现严重并发症。结论结扎桡动脉远心端治疗上肢远端自体动静脉内瘘相关缺血综合征简便、安全、有效，保留宝贵血管资源，同时延长内瘘使用寿命，可作为处理缺血综合征的一种方法。

Objective To summarize the experience of treatment for dialysis access-associated ischemic steal syndrome by ligating distal radial artery of radial Cephalic fistulas （RCFs）. Methods We enrolled hemodialysis patients who used RCFs with complaint of ipsilateral limb ischemia admitted in our department. Anatomical prerequisites （side-to-end anastomosis fistula and retrograde flow in the distal radial artery） were checked by ultrasound, the patency of central artery by angiography, and the function of ulnar artery by Allen test. Division and ligation of the juxta-anastomosis distal radial artery were performed under regional anesthesia Clinical presentation, blood flow during hemodialy- sis, urea clearance index, urea reduction rate, and fistula patency were observed before and after operation. Results This study included 16 patients （8 males and 8 females, accounting for roughly 1.45% of hospitalizations of patients associated with fistula complications at the corresponding time） who underwent DRAL of RCFs with ischemia, of whom the mean age was （66. 2 ± 11.2） years, fistula age was （57. 75 ± 88. 41） months, and the ischemia was detected （39. 62 ± 58. 31） months after the construction of fistula. According to clinical presentation, 71.40% patients were grade Ⅲ, 28. 60% were grade Ⅱ , and no patients belonged to grade Ⅳ. The technique success rate was 100% and clinical sue tess rate was 93. 7% . Blood flow during hemodialysis before and 7 days, 6 months and 12 months after operation was （258.63 ± 25.44）, （246. 61 ± 24. 24）, （260. 42 ± 20. 83） and （254. 87± 22. 44） ml/ min （P〉0. 05）, and Kt/V was （1.65 ± 0. 210）, （1. 59 ± 0. 24）, （1.62 ±0. 28） and （1.58± 0. 39） （P〉0. 05）, respectively. The mean follow-up duration was （19. 30± 13. 15） months and the patency rate was 100% . Conclusions DRAL is a simple, safe, and effective technique for dialysis access-associated ischemic syndrome in RCFs.