吻合口动脉端狭窄致自体动静脉内瘘早期失功的初步研究

Study on early failure of autologous arteriovenous fistula due to artery stenosis at anastomosis site

目的 对内瘘功能不良行内瘘血管造影的病例进行回顾性分析,寻找狭窄位置和临床特点的相关性,提高临床对动静脉内瘘吻合手术关键的认识。方法 对2011年1月1日至2014年12月31期间在河北医科大学第三医院肾内科因内瘘功能不良行血管造影的患者进行回顾性分析。均为前臂自体动静脉内瘘,静脉动脉端-侧吻合,病史及影像资料完整。由两名专门从事血管通路建立及维护工作的肾内科医生复习所有内瘘血管造影影像,独立界定内瘘狭窄类型,分析其临床特点并进行统计学分析。结果共64例患者在我院完成81例次内瘘血管造影,其中女性患者29例39例次,男性患者35例42例次。所有64例患者平均年龄（55.52±1.71）26-80岁,平均透析龄（31.22±3.67）月。其中有明确吻合口动脉端狭窄（狭窄组）的患者27例40例次,27例患者中,吻合口动脉近端狭窄患者23例,其中吻合口动脉近端狭窄伴吻合口后静脉局限性狭窄患者10例,吻合口动脉近端狭窄伴吻合口后静脉长段狭窄患者13例。吻合口动脉远端狭窄患者2例,吻合口动脉远近端均狭窄患者2例。无吻合口动脉端狭窄（对照组）的患者37例41例次。狭窄组患者内瘘平均成熟时间（59.94±4.36）天,对照组患者内瘘平均成熟时间（37.83±3.59）天,两组间比较差异有统计学意义（t=3.918,P〈0.001）。狭窄组患者内瘘平均使用时间（27.12±5.45）w,对照组患者内瘘平均使用时间（129.44±19.77）w,两组间比较差异有统计学意义（t=-4.990,P〈0.001）。结论 吻合口动脉端狭窄会导致自体动静脉内瘘成熟时间过长,并可能短期内即发生内瘘功能不良,手术缝合失误可能是导致该类狭窄的原因。

Object To retrospectively study the clinical and radiological features of stenosis in autologous arteriovenous fistula （AVF）, and the relationship between clinical features and stenosis site in order to improve the autologous AVF surgery. Method We retrospectively analyzed the clinical and radiological data of the patients who were examined with angiography due to AVF stenosis in the Third Hospital of Hebei Medical University during the period from Jan. 1st, 2011 to Dec. 31st, 2014. Patients had complete disease history and radiological records, and their autologous AVFs adopted end-to-side anastomosis technique in forearms. Two nephrologists responsible for construction and care of AVFs reviewed the radiological images, identified the stenosis type, analyzed their clinical characteristics, and performed statistical analyses. Result A total of 64 patients having 81 angiography examinations were involved in this study, including 39 angiography examinations for 29 females and 42 angiography examinations for 35 males. Their average age was 55.52± 1.71 （26- 80） years old, and their average dialysis duration was 31.22±3.67 months. Twenty-seven cases （having 40 angiography examinations） were found to have defined stenosis at arterial site, including artery stenosis proximal to anastomosis site 23 cases （10 cases had stenosis proximal to anastomosis site combined with partial vein stenosis, and 13 cases had stenosis proximal to anastomosis site combined with a long length of vein stenosis）. Two cases had distal artery stenosis, and two cases had artery stenosis proximal and distal to the anastomosis site. The average maturation period of the AFVs was 59.94±4.36 days in patients with stenosis, and was 37.83 ±3.59 days in patients without stenosis （t=3.918, P〈 0.001）. The average period for blood access of the AVFs was 27.12±5.45 weeks in patients with stenosis, and was 129.44±19.77 weeks in patients without stenosis （t=-4.990, P〈0.001）. Conclusion Artery stenosis at the anastomosis site may lead to a prolonged mature period of the AVFs, and a shorter period for blood access due to early failure of the AFVs. Inappropriate surgical manipulation at the anastomosis site during the surgery may be the cause of the artery stenosis.