B超引导下经皮血管腔内血管成形术治疗自体动静脉内瘘狭窄12例

Ultrasound-guided percutaneous transluminal angioplasty for treatment of stenosis of native arteriovenous fistula:analysis of 12 cases

目的探讨B超引导下经皮血管腔内血管成形术(percutaneous transluminal angioplasty,PTA)治疗自体动静脉内瘘狭窄的临床体会。方法 2012年4月至2015年4月我院收治维持性血液透析自体动静脉内瘘狭窄致内瘘失功患者12例,B超引导下行PTA,对比手术前后狭窄部位血管直径、透析时血流量变化,定期随访观察动静脉内瘘远期通畅率。结果 12例内瘘失功患者B超检查发现狭窄部位在吻合口及其附近5例,在内瘘静脉透析用穿刺段7例。B超引导下在狭窄部位近心端8 cm处穿刺行PTA,术后B超显示11例血管再通,狭窄<30%,透析中血流量良好;1例术后透析中血流量间断<200 mL/min,静脉压高,血管造影显示上腔静脉狭窄,改为CT血管成像下行PTA。术后随访6个月,11例患者内瘘血流量满足透析所需;1例患者术后3个月再次出现血流量下降,B超显示狭窄部位有纤维环形成,再次行B超引导下PTA治疗,术后透析时血流量>250 mL/min。结论 B超引导PTA无需特殊设备和场地,操作简单,适合内瘘失功处理要求快的特点,同时避免造影剂应用和放射线暴露损伤,具有较好疗效,可作为外周放射介入的替代治疗方法。

Objective To summarize the clinical experience with B-ultrasound-guided percutaneous transluminal angioplasty（ PTA） in the treatment of stenosis of native arteriovenous fistula（ AVF）. Methods Between April, 2012 and April, 2015, 12 patients on maintenance hemodialysis underwent B-mode ultrasound-guided PTA at our hospital for treatment of stenosis of native AVF. The changes in the diameter of the vessel at the narrowed segment and the blood flow volume were evaluated after the procedure,and the patients were followed up regularly to assess the long-term patency rate of the AVF. Results Among the 12 patients,5 were found to have stenosis of the native AVF at or near the anastomosis site and 7 had stenosis in the puncture segment. Under guidance by B-mode ultrasound,PTA was performed at 8 cm proximal to the narrowed region. After the procedure,revascularization with stenosis of less than 30% was achieved in 11 patients as shown by B-mode ultrasound,and the blood flow was optimal during dialysis. One patient developed high venous pressure after the procedure,and the blood flow was intermittently below 200 mL/min during hemodialysis; angiography revealed the presence of superior vena cava stenosis,for which PTA under guidance by digital substraction angiography（ DSA） was performed. All the patients were followed up for 6months,and the blood flow in the internal fistula was optimal in 11 patients to meet the requirement of hemodialysis. Reduced blood flow occurred in one case at 3 months after the procedure,and ultrasound examination showed the formation of anulus fibrosus at the narrowed segment,for which a second PTA was performed and the blood flow in the AVF exceeded 250 mL/min after the procedure. Conclusion B-mode ultrasound-guided PTA,which avoids the use of contrast agents or radiation exposure,is convenient and produces favorable results for management of native AVF stenosis, and can be a good alternative to radiographic interventional therapy.