甲状旁腺全切除加前臂移植术后动静脉内瘘早期失功的临床分析

Early dysfunction of arteriovenous fistula after total parathyroidectomy and autotransplantation in uremic patients with secondary hyperparathyroidism

目的回顾性分析甲状旁腺全切除加前臂移植术后动静脉内瘘早期失功的原因及影响因素。方法选择2011年9月~2015年5月在南京医科大学第一附属医院接受甲状旁腺全切除加前臂移植的497例尿毒症继发性甲状旁腺功能亢进患者。其中14例患者在术后24h内发生动静脉内瘘失功。选择同期手术的28例内瘘功能正常的患者(对照组),进行1:2匹配,比较内瘘失功组与对照组的一般情况、手术前后的血压以及生化参数等的变化。结果14例患者中有2例在术后透析过程中发生内瘘穿刺处血肿,1例患者术中发现甲状腺癌而同时行甲状腺癌根治术,2例术中出现血压明显下降;1例在既往7年中内瘘失功6次,本次在术后12h出现内瘘失功。动静脉内瘘失功组的手术前后收缩压下降值(20.28±17.72)mmHg较对照组的(3.11±17.58)mmHg存在明显差异(t=2.978,P=0.005);收缩压的降低与手术前后血钙水平的降低相关(r=0.385,P=0.012)。回归分析提示手术前后收缩压的下降是术后动静脉内瘘早期失功的危险因素(HR=1.053,95%CI1.012~1.095,P=0.010)。结论甲状旁腺全切除加前臂移植术后可能发生动静脉内瘘早期失功。手术前后收缩压的下降是术后动静脉内瘘早期失功的危险因素,术后透析过程中血肿的发生也需要密切关注。

Objective To retrospectively analyze the causes and risk factors for the early dysfunction of arteriovenous fistula (AVF) after total parathyroidectomy (PTX) and autotransplantation surgery (PTX + AT). Methods In our hospital, 14 of 497 patients undergoing total PTX+AT during the period from September 2011 to May 2015 lost patency of AVFs within 24 hours after the surgery. In this retrospective study, we analyzed the potential risk factors for early AVF dysfunction in the 14 patients. Simultaneously, 28 patients with functional AVFs after PTX were also included as a matched group. Patient characteristics and biochemical parameters associated with increased risk for AVF failure were analyzed. Results Of the 14 patients in AVF dysfunction group, 2 had hematoma during the postoperative dialysis, and one patient had thyroid cancer and received thyroidectomy at the same time. Two patients had a significant decrease of blood pressure during the procedure. One case lost her AVF function 6 times in the past 7 years due to poor cardiac function. The decrease of systolic blood pressure after PTX+AT was greater in AVF dysfunction group (20.28±17.72mmHg) than in control group (3.11±17.58mmHg;t=2.978, P=0.005). The decrease of systolic blood pressure correlated to the decrease of serum calcium level after the surgery (r=0.385, P=0.012). Regression analysis suggested that the decrease of systolic blood pressure after PTX+AT was a risk factor for early AVF dysfunction (HR= 1.053, 95% CI 1.012~1.095, P=0.010). Conclusions Early AVF dysfunction may occur in patients undergoing PTX+AT. The decrease of systolic blood pressure after PTX+AT is a risk factor for early AVF dysfunction. The presence of hematoma during postoperative dialysis also needs to be closely monitored.