自体动静脉内瘘动脉瘤血管玻璃样变是血管扩张和动脉瘤部分切除术后复发的主要病理基础

Autologous Arteriovenous Fistula Aneurysm Hyaline Degeneration Is the Main Pathological Basis of Vascular Dilation and Recurrence after Partial Aneurysmectomy

背景2019年中国已有60万维持性血液透析(MHD)患者登记在册,其中80%以上患者的透析"生命线"为自体动静脉内瘘(AVF)。而自体动静脉内瘘动脉瘤(AVFAs)是AVF最常见并发症之一,对AVFAs的研究有助于其防控。目的通过研究AVFAs部分切除术中切除的病变血管组织学,追踪患者AVFAs复发情况,探索AVFAs组织病理与AVFAs复发相关机制,制定相应可行防治措施。方法选择2016年4月—2019年10月在海南省人民医院进行以AVFAs部分切除术为主的修复手术的13例复杂型AVFAs患者,取切除动脉瘤血管组织(5~10)mm×(5~10)mm做病理分析;追踪AVFAs变化。结果13例患者手术均成功;术后追踪3~39个月,平均(22.4±11.9)个月;其中7例患者术后3~6个月AVFAs复发;12例患者内瘘通畅。病理:血管内皮细胞(ECs)明显减少或消失;内中膜成纤维细胞及胶原组织增生、排列紊乱,内外弹力层不完整或完全消失,网状纤维和弹力纤维减少;平滑肌细胞(SMAs)减少或完全消失。13例患者瘤壁存在既往从未报道的大范围玻璃样变性,其中10例累及血管壁全程,同时散在黏液样变性、局灶性钙化混合或单独存在;玻璃样变性累及管壁全程者追踪期间6例复发。结论AVFAs瘤体部分切除术对预防血管破裂、保留血管资源有效;术中利用的内瘘血管存在严重玻璃样变、散在黏液样变、局灶性钙化多种变性,使AVFAs容易复发,尤其是在修复部位继续穿刺;扣眼穿刺可能降低AVFAs患病率和修复术后复发率;瘤体早期局部加压可以延缓病情发展、减少干预;更大样本AVFAs组织学研究、不同AVF穿刺方法对AVFAs患病率影响的对照研究、AVFAs患病相关基因谱研究需进行。

Background By 2019,there have been 600000 patients with maintenance hemodialysis(MHD)registered in China,and more than 80%of them had autologous arteriovenous fistula(AVF).As aterial-venouse fistula aneurysm(AVFA)is one of the most common complications of AVF,the study of AVFAs is helpful for its prevention and control.Objective To track the AVFAs recurrence in AVF patients and to explore its association with AVFAs histopathology based on studying the histology of the diseased blood vessels removed during partial aneurysmectomy of AVFAs,to formulate corresponding feasible prevention and control measures.Methods A total of 13 cases of complex AVFAs were reconstructed with partial aneurysmectomy from April 2016 to October 2019 in Hainan Genenral Hospital.The resected vascular tissue〔with a size of(5-10)mm×(5-10)mm〕was used for pathological analysis.The changes of the AVFAs were followed up.Results The surgeries were successful for all 13 patients.During the follow-up of 3-39〔average(22.4±11.9)〕months,seven were found with AVFAs relapse within 3-6 months after surgery,but 12 had a patent fistula.Pathology results:vascular endothelial cells were significantly reduced or absent;fibroblasts and collagen tissue of the vascular intima and media showed proliferation and were disordered,the inner and outer elastic layers were incomplete or absent,and few reticular and elastic fibers were present;and few or no smooth muscle cells were present.The aneurysm wall showed large-scale hyaline degeneration in all 13 patients,which has never been reported before.In particular,the whole section of the vascular wall was involved in 10 patients,with scattered mucoid degeneration and focal calcification mixed or alone.AVFAs recurred during follow-up in 6 patients with hyaline degeneration involving the entire cross section of the resected blood vessel.Conclusion Partial aneurysmectomy for AVFAs is effective at preventing vascular rupture and preserving vascular resources.Diverse degeneration patterns,including severe hyaline degeneration,mucoid degeneration,and focal calcification of intraoperative use of AVF vessels,especially continued cannulation in the reconstructed area,may easily induce AVFAs to relapse.Buttonhole cannulation may reduce the incidence of AVFAs and reccurence ratio after partial aneurysmectomy.Early local compression of the aneurysm can delay the development of AVFAs and reduce the need for invasive surgery.Larger-scale studies of AVFAs histology,comparison studies of the effects of different AVF cannulation methods on the incidence of AVFAs,and studies on the profile of AVFAs disease-related genes are needed.