支架植入治疗血液透析动静脉瘘中心静脉阻塞的价值分析

Stent implantation for the treatment of central venous obstruction in hemodialysis patients with arteriovenous fistula: analysis of its clinical value

目的探讨经皮血管支架植入术(PTS)治疗自体动静脉内瘘(AVF)透析患者中心静脉阻塞(CVO)可行性及临床应用价值。方法回顾性分析10例AVF伴CVO患者,临床均表现为手肿胀综合征。术前或术中均接受DSA检查明确阻塞部位,根据不同病情采用合适手术入路,伴有血栓形成患者先行导管接触溶栓(CDT),严重狭窄或闭塞患者先以小直径球囊预扩张遂行PTS,其余患者直接行PTS。结果 DSA显示5例有颈内静脉置管史患者为头臂静脉闭塞或/和锁骨下静脉、颈内静脉、上腔静脉闭塞或狭窄,5例无颈内静脉置管史患者均表现为内瘘侧锁骨下静脉内侧段局限性严重狭窄。10例PTS技术成功率为100%,植入支架19枚,1例(锁骨下静脉狭窄)术后7个月支架内再狭窄再行PTS术。一期通畅率在术后6个月为8/8,术后1年为3/4。结论 AVF透析患者CVO多为闭塞性或严重狭窄病变,PTS治疗成功率高、近中期效果满意、并发症轻微,安全有效、可行,可作为首选治疗方法。

Objective To discuss the feasibility and clinical value of percutaneous transluminal stenting （PTS） for the treatment of central venous obstruction （CVO） in hemodialysis patients with arteriovenous fistula （AVF）. Methods The clinical data of 10 hemodialysis patients with AVF complicated by CVO were retrospectively analyzed. Clinically, all patients presented as swollen hand syndrome. Preoperative or intraoperative digital subtraction angiography （DSA） was performed to deternline the obstruction site, and based on the disease condition the appropriate surgical approach was employed. For patients having thrombus formation, catheter-directed thrombolysis （CDT） was carried out first. For patients having severe stenosis or occlusion of veins, pre- expansion with small diameter balloon was employed before PTS. For the remaining patients, PTS was directly performed. All patients were regularly followed up after operation. Results DSA showed that brachiocephalic vein occlusion and/or occlusion or stenosis of subclavian vein, internal jugular vein and superior vena cava were observed in 5 patients who had history of internal jugular vein catheterization, while localized severe stenosis of medial segment of AVF-side subclavian vein was detected in the other 5 patients who had no history of internal jugular vein catheterization. The technical success rate of PTS was 100% （10/10）. A total of 19 stents were implanted in the 10 patients. Seven months after the treatment, one patient developed in-stent re-stenosis, and PTS had to be carried out again. Primary patency rates at 6 months and 12 months after the treatment were 100% （8/8） and 75% （3/4） respectively. Conclusion In hemodialysis patients with AVF, CVO is mainly characterized by obstructive or severely stenotic lesions. PTS carries higher success rate with satisfactory short-term and mid-term effect, its complications are slight and mild, and the technique is safe and feasible. Tberefore, PTS can be used as the preferred treatment method.（J Intervent Radiol, 2017, 26： 744-748）