局域直接穿刺改善血液透析动静脉内瘘狭窄的临床观察

The clinical observation of the local directly punctures to improve the arteriovenous internal fistula stenosis in the blood dialysis

目的:探讨穿刺方法扩张动静脉内瘘狭窄部位是否可防治动静脉内瘘狭窄,改善内瘘功能不良或失功。方法:选择2012年1月至2016年1月在温州医科大学附属第一医院接诊的内瘘狭窄的血液透析患者39例。血透时采用16G内瘘穿刺针在狭窄部位进行穿刺,穿刺前对内瘘进行评估及触摸,以内瘘最狭窄处为进针点,分离局部组织,伴有血栓者给予溶栓。每次透析时视患者内瘘情况,重复上述操作,观察内瘘狭窄改善情况。结果:39例患者中,27例治疗有效,12例无效,内瘘狭窄≤2处及狭窄内瘘长度≤1 cm患者治疗效果较好,差异有统计学意义(χ~2=14.745、8.269,P<0.01)。治疗有效者穿刺治疗后较治疗前透析血流量增加,静脉压减少,差异有统计学意义(t=-9.251、8.628,P<0.01)。治疗有效者平均穿刺次数为(8.6±3.8)次。27例有效病例中,有9例伴1处狭窄穿刺后血管扩张、狭窄消失;13例伴有2处狭窄,穿刺法处理后血流量升高、内瘘静脉压下降;5例3处狭窄者经治疗后静脉压下降,其中有1例伴血栓形成,经过溶栓及反复狭窄处穿刺,狭窄基本消失。27例中动脉瘤明显缩小的有9例,5例局部胀痛消失,3例胀痛减轻。12例无效患者改行内瘘再建术或经皮球囊扩张术。结论:短期狭窄处局域穿刺能扩张狭窄内瘘局部血管,预防和治疗动静脉内瘘血管狭窄,减少患者痛苦和经济负担,方便易行。

Objective： To investigate the effects of local puncture in treatment of arteriovenous internal fistula stenosis in hemodialysis patients. Methods： Thirty nine arteriovenous fistula stenosis cases from January 2012 to January 2016 in the First Affiliated Hospital of Wenzhou Medical University were included. In order to expand blood vessels, 16 g needles were used to puncture in the narrowest site of the fistula and separate blood vessels within the organization, with thrombolysis being used on thrombosis patients. Every time before puncture, the fistula was evaluated and touched. Whenever hemodialysis was conducted, the above puncture procedures would be repeated and internal fistula stenosis was observed. Results： Twenty-seven of 39 cases were effective treatment, and 12 cases were invalid. The treatment was more effective with patients whose narrow fistula sites were less than two and those whose stenosis length was shorter than 1 cm （χ^2=14.745, 8.269, P〈0.01）. The blood flow increased and venous pressure decreased in patients of effective treatment after puncture （t=-9.251, 8.628, P〈0.01）. That the time of puncture on those patients was 8.6±3.8. Nine of the 27 effective cases showed vascu- lar expansion and disappearance of stenosis after the puncture; another 13 cases with two narrow sites showed increased blood flow and deereading of the venous pressure that 5 cases with three narrow sites, including one thrombosis patient whose stenosis almost disappeared after thrombolysis and repeated punctures, showed dropping of the venous pressure. Nine of the 27 cases were seen noticeable shrinking aneurysm; 5 cases were reported disappearance of local sites pains and 3 cases reported pain relief. Twelve patients with invalid treatment turned to fistula rebuild or balloon expansion. Conclusion： Local puncture in short-term fistula within narrow place can expand local blood vessels, prevent and treat arteriovenous fistula in vascular stenosis, reduce the patients pain and economic burden, be convenient and feasible.