置管溶栓联合球囊成形术治疗血液透析动静脉内瘘闭塞

Transcatheter thrombolysis with percutaneous transluminal angioplasty for arteriovenous fistula occlusion in hemodialysis patients

目的探讨置管溶栓联合球囊成形术治疗血液透析动静脉内瘘闭塞伴血管狭窄的应用价值。方法回顾性分析经超声及血管造影证实为动静脉内瘘血栓性闭塞伴血管狭窄患者46例,其中观察组23例,行置管溶栓联合球囊形术治疗,对照组23例,行经头静脉留置针溶栓治疗。观察组：术中对闭塞段行导管导丝穿通术、给予25万U尿激酶注溶栓,术后视血栓清除情况保留导管持续泵入尿激酶1-3天,每天50万U,对于血栓溶解后瘘道血管仍狭窄者联合囊成形术进行治疗;对照组：经头静脉留置针泵入尿激酶1-3天,每天50万U。观察治疗后动静脉内瘘闭塞的开通况。比较治疗前后的血管造影表现、透析时血流量等的变化。结果观察组23例动静脉内瘘闭塞患者中,2例于治疗即刻造影显示动静脉内瘘即恢复通畅,分别有10、3、2例于治疗后24、48及72h造影复查示血栓溶解,动静脉内瘘满足者血液透析的要求,1例狼疮肾患者于24h复查造影示术中开通的闭塞段再次闭塞,予再次球囊扩张治疗后透析道血恢复,对5例行再次造瘘。对照组23例患者中仅有5例于72h内内瘘开通,余18例均行再次造瘘。两组患者治疗后管开通情况的差异具有统计学意义（χ^2=17.07,P〈0.001）。所有病例溶栓过程中均未出现肺栓塞及出血等严重并发症结论置管溶栓联合球囊成形术是治疗血液透析动静脉内瘘闭塞伴血管狭窄的微创、安全、有效的方法,尤其适用于血条件差,缺少再次造瘘血管的患者。

Objective To assess the clinical value of percutaneous transluminal angioplasty with transcatheter thrombolysis in treating arteriovenous fistula occlusion in hemodialysis patients.Methods The clinical data of 46 hemodialysis patients who were diagnosed with arteriovenous fistula occlusion by Doppler ultrasound and angiography was retrospective analyzed.Twenty-three patients（obsearve group）underwent transcatheter thrombolysis with percutaneous transluminal angioplasty.Firstly,the guide-wire was inserted and pushed forward to pass through the thrombus,then bolus injection（pulse spray）of urokinase（250 000units）through catheter was performed.If the thrombus could not be cleared away,transcatheter micropump continuous infusion of urokinase was employed for 1—3 days（500 000 units per day）until the thrombosis was completely dissolved.The other 23 patients（control group）were treated by thrombolysis（urokinase,500 000 units per day）via cephalic vein for 1—3days.The pre-and post-operative angiographic findings,the volume of blood flow and the level of venous pressure during hemodialysis were compared.Results In obsearve group,the immediate angiography showed that 2 of 23 cases of arteriovenous fistula occlusion were restored after treament,the thrombus was completely dissolved in 10,3and 2caces 24,48 and 72 hafter treatment.The blood flow of arteriovenous fistula was enough for hemodialysis.The reperfusion vessel was occluded again in a case of lupus patient with renal disease 24 hafter treatment,but it was restored with percutaneous transluminal angioplasty again,the artificial vascular remodeled again in 5cases.While the arteriovenous fistula reopened in 5cases in 72 hof the control group,the other 18 cases underwent artificial vascular remodeling again.The number of vessels which were reopened after treatment in the observation group was significantly higher than that in control group,and the difference was statistically significant（χ^2=17.07,P〈0.001）.Conclusion Percutaneous transluminal angioplasty with transcatheter thrombolysis for the treatment of arteriovenous fistula occlusion in hemodialysis patients is minimally-invasive,safe and effective treatment.Therefore,it is more valuable especially for the patients who were shortage of vessel for stoma.