静脉内膜剥脱术重建动静脉内瘘的通畅率及静脉病理学改变

Primary patency rate of native arteriovenous fistulas reconstructed by vascular stripping and pathologic changes of vein in hemodialysis patients with venous neointimal hyperplasia

目的比较静脉内膜剥脱术与经皮球囊扩张术（percutaneous transluminal angioplasty,PTA）治疗血液透析患者动静脉内瘘（ateriovenous fistulas,AVF）功能不良的通畅率,并观察内膜剥脱前、后静脉的病理学特点。方法回顾性分析2012年1月1日至2014年1月1日期间在肾内科行静脉内膜剥脱术重建AVF（A组,17例）或行PTA术（B组,12例）的患者的临床资料。分别统计两组患者的内瘘初级通畅率及内瘘生存率。并留取内膜剥脱术患者的剥脱前、后的血管,行苏木精-伊红（hematoxylin and Eosin,HE）染色及IV型胶原（collagen-IV,COL-IV）、平滑肌肌动蛋白（smooth muscle actin,SMA）及CD34免疫组化染色,观察静脉血管的病理改变。结果 6个月、12个月、24个月时初级通畅率A组明显高于B组（A组分别为94.1%,88.2%,41.2%,B组分别为41.7%,8.3%,0,P值分别为P=0.003,P=0.008,P=0.012）。3个月、6个月、12个月、24个月及36个月时内瘘生存率A组分别为100.0%,93.8%,87.5%,87.5%及29.2%;B组分别为75.0%,45.0%,15.0%,0,0。内瘘生存率A组也明显高于B组（χ~2=15.064,P〈0.001）。两组术后24小时均可用于透析穿刺。病理检查见撕脱下来的内膜组织由大量的肌成纤维细胞、平滑肌细胞及增生的纤维组织构成。撕脱前的静脉血管可见血管内膜及中膜明显增厚,大量结缔组织增生,SMA及COL-IV染色阳性,中膜可见SMA染色阳性的平滑肌细胞成束排列。剥脱后的静脉血管壁实际是由中膜及外膜构成。结论内膜剥脱术重建动静脉内瘘能最大限度地节约血管资源,对于部分尿毒症患者而言,是有效的治疗方法。

Objective To compare primary patency rate of native arteriovenous fistulas （AVF） restored by vascular stripping or by percutaneous transluminal angioplasty （PTA） in hemodialysis patients with venous neointimal hyperplasia （VNH）, and to study pathological changes of the stripped veins. Methods Clinical data of 17 patients who underwent AVF reconstruction by VNH stripping （group A） and 12 patients who underwent PTA （group B） from Jan 1, 2012 to Jan 1, 2014 were retrospectively studied. Primary patency rate and survival rate of the two groups were compared. Pathological changes of the vein before and after vascular stripping were studied by hematoxylin and eosin （HE） staining and immunohistochemical staining. Results Primary patency rate of group A were 100%, 94.1%, 88.2%, 41.2% and 11.8% after 3 months, 6 months, 12 months, 24 months and 36 months respectively, better than that of group B after 6 months, 12 months and 24 months （41.7%, 8.3% and 0% respectively, P〈0.05）. AVF survival rate of group A was also better than that of group B （P〈0.001）. Restored AVFs could be used for hemodialysis after the operation for 24h. Pathological examination of the VNH specimens revealed the proliferation of myofibroblasts, smooth muscle cells and fibrous tissue. The line of venous endothelial cells was destroyed. Immunohistochemical staining revealed a disordered growth pattern of cells with positive staining of SAM and COL-IV in VNH specimens. The veins after vascular stripping were only left with medial membrane and adventitia. Conclusions AVF reconstruction by VNH stripping is an effective technique for some hemodialysis patients, with the advantages of maximal preservation of blood vessels and higher primary patency rate within 24 months.