瘤壁部分切除术治疗自体动静脉内瘘瘤样扩张的临床研究

Clinical study of partial aneurysmectomy for salvage of aneurysmal dilatation of autogenous arteriovenous fistula

目的探讨瘤壁部分切除术治疗自体动静脉内瘘瘤样扩张的临床疗效。方法选择2012年7月至2016年6月就诊于本科的自体动静脉内瘘瘤样扩张患者共39例,其中男性27例(69.2%),女性12例(30.8%),年龄(40.6±13.3)岁,不包括假性动脉瘤和吻合口处瘤样扩张病例。采用超声多普勒评估血管(肱动脉血流量,桡动脉管径,吻合口管径,瘘静脉管径,瘤样扩张最大直径)。采用瘤壁部分切除术治疗该组病例,观察手术前后瘤样扩张血管直径及肱动脉血流量变化,两组间比较行t检验,随访术后并发症。结果 39例患者均为上肢动静脉内瘘,包括鼻咽窝内瘘12例(桡动脉-头静脉),腕部/前臂内瘘25例(桡动脉-头静脉),肘部内瘘2例(肱动脉-头静脉)。其中只有1个瘤体的15例,2个瘤体的19例,3个瘤体的4例,4个瘤体的1例。内瘘建立的时间为(41.05±14.45)个月。瘤壁部分切除术成功率为100%,随访时间为(27.73±8.59)个月。瘤样扩张段的直径缩小为(10.39±1.83)mm,较术前[(43.79±4.74)mm]下降约76.27%,差异有统计学意义(t=41.08,P<0.01)。术后肱动脉血流量为(770.59±130.10)m L/min,较术前肱动脉血流量[(1 647.39±250.33)m L/min]下降约53.22%(t=19.41,P<0.01)。术后随访(27.73±8.59)个月,2例患者死亡,1例死于严重脑出血,1例死于急性心肌梗死;7例患者发现瘘静脉狭窄,在超声引导下行球囊扩张术后可继续使用。结论瘤壁部分切除术治疗自体动静脉内瘘瘤样扩张可保留内瘘的功能和穿刺的长度,延长动静脉内瘘使用时间,临床疗效显著。

Objective To investigate the clinical effect of partial aneurysmectomy for salvage of autogenous arteriovenous fistula with aneurysmal dilatation. Methods A total of 39 patients with aneurysmal dilatation of autogenous arteriovenous fistula admitted in our department from July 2012 to June 2016 were included in this study. They were 27 males （69.2%） and 12 females （30.8%）, and at a mean age of 40.6± 13. 3 years. The aneurysmal dilatation of autogenous arteriovenous fistula that occurred in the anastomosis and pseudoaneurysms were excluded. All patients underwent color Doppler ultrasound examination to determine the braehial arterial blood flow, radial artery diameter, anastomotic diameter, fistula vein diameter, and maximum diameter of aneurysmal dilatation. All cases were treated with partial aneurysmectomy. The changes of the diameter of dilated blood vessels and flow of brachial artery were observed before and after the operation, and these changes were compared between the 2 groups by student＇ s t test. The incidences of postoperative complications were observed during follow-up. Results All the patients had an upper arm arteriovenous fistula, including 12 cases of radioeephalic fistula （radial artery to cephalic vein） , 25 cases of braehiocephalic fistula （ radial artery to cephalic vein） and 2 cases of elbow fistula（brachial artery to cephalic vein）. There were only 15 cases of 1 tumor body, 19 cases of 2 tumor bodies, 4 cases of 3 tumor bodies and 1 case of 4 tumor bodies. The arteriovenous fistulas were for a mean duration of 41.05 ±14.45 months. The operation was succeeded in all cases. During the mean follow-up period of 27.73 ±8.59 months, the diameter of the dilated section was reduced by 76.27%, from 43.79 ±4.74 mm preoperatively to 10.39 ± 1.82 mm postoperatively （t = 41.08, P 〈 0. 01 ）. Blood flow of the brachial artery was also decreased by 53.22% （from 1 647.39 ±250.33 to 770.59 ± 130. 10 ml/min, t = 19.41, P 〈0. 01 ）. Two patients died during follow-up, one due to severe cerebral hemorrhage and the other to acute myocardial infarction. Fistula stenosis was found in 7 patients, and the condition was relieved after balloon expansion under the guidance of color Doppler ultrasound. Conclusion Partial aneurysmectomy can retain the function of autogenous arteriovenous fistula and length of the puncture, and extend the service life of arteriovenous fistula with distinct clinical effect in the treatment of aneurysmal dilatation of autogenous arteriovenous fistula.