下肢人工血管移植物内瘘的应用及中远期效果观察

Application of prosthetic arteriovenous grafts in lower extremity and its mid-and long-term efficaccy

背景与目的:终末期肾病(ESRD)是各种原因导致的慢性肾脏疾病进展到终末期阶段,大部分ESRD患者选择血液透析肾脏替代治疗,而功能良好且通畅率令人满意的血管通路对其至关重要。上肢是患者构建血液透析通路的首选位置,但部分患者因各种原因存在上肢血管或中心静脉资源耗竭等问题,无法构建上肢血管通路。对此,可以考虑构建下肢人工血管移植物内瘘(AVG)作为患者长期血液透析的通路,本研究回顾性分析构建下肢AVG患者的临床资料与中远期随访结果,以期为此提供经验证据。方法:回顾2014年3月—2018年11月南方医科大学南方医院血管外科32例构建下肢AVG的ESRD患者临床资料与随访资料,分析患者的相关临床指标,用Kaplan-Meier法计算患者术后的初级通畅率和次级通畅率。结果:全组患者术后均能触及AVG震颤,围术期1例患者出现慢性心功能不全急性发作,予药物、加强透析治疗后未见明显好转后死亡;2例患者出现移植物血栓形成,切开导管取栓后造影未见吻合口及流出道静脉狭窄,术后AVG恢复通畅,顺利透析。所有患者围术期间无感染、透析通路相关性肢端缺血综合征(HAIDI)、假性动脉瘤等并发症发生。术后随访1~60个月,中位随访时间14.1个月。随访期间出现AVG狭窄13例(40.6%),闭塞10例(31.3%),经外科手术或腔内手术修复后恢复AVG通畅;人工血管移植物感染3例(9.4%),其中1例患者移植物局段感染,行人工血管移植物感染段切除,自体静脉移植术后顺利保留AVG并用于透析,2例患者因移植物全段感染予全段切除。期间未出现假性动脉瘤、HAIDI等并发症。患者术后初级通畅时间为(20.4±3.32)个月,1、2、3年初级通畅率为64.6%、44.7%、19.6%;次级通畅时间为(38.7±5.52)个月,1、2、3年次级通畅率为79.6%、79.6%、54.6%。结论:下肢AVG经修复后可达到较满意的次级通畅率,对于无法建立上肢血管通路患者而言,是安全、有效的通路选择。规范的术前评估、手术及穿刺中严格的无菌操作以及规律的随访是保证其远期通畅的重要因素。

Background and Aims:End stage renal disease(ESRD)is the final stage of the progression of chronic kidney disease caused by various etiologies.Most patients with ESRD choose hemodialysis as a renal replacement therapy,for which maintaining the good function and satisfactory patency of the vascular access is extraordinarily critical.The upper extremity is the first choice for patients to construct hemodialysis access.However,some patients with problems such as exhaustion of upper extremity vascular or central venous resources due to various reasons,are unsuitable for upper limb vascular access creation.Therefore,creation of a lower extremity arteriovenous grafts(AVG)can be considered as a long-term hemodialysis access for patients.This study was conducted to review the clinical data and follow-up results of patients with AVG creation in lower extremity,so as to provide empirical evidence for this field.Methods:The clinical and follow-up data of 32 ESRD patients undergoing construction of lower extremity AVG in Nanfang Hospital of Southern Medical University from March 2014 to November 2018 were reviewed.The relevant clinical variables of the patients were analyzed,and the postoperative primary and secondary patency rates were determined by Kaplan-Meier method.Results:AVG tremor was palpable in all patients after the operation.One patient developed an acute attack of chronic cardiac insufficiency during the perioperative period,and then died due to no obvious improvement after drug administration and intensive dialysis treatment.Two patients developed graft thrombosis,and underwent incision of the catheter and thrombus removal.After that,no stenosis in the anastomotic stoma or in the outflow venous was observed in the angiography.The patency of the AVG was resumed and the dialysis was maintained.During the perioperative period,no complications such as infection,hemodialysis access-induced distal ischemia(HAIDI),or pseudoaneurysm occurred in all patients.Postoperative follow-up was conducted for 1 month to 6 months,with a median time of 14.1 months.During the follow-up period,AVG stenosis occurred in 13 patients(40.6%),and AVG occlusion occurred in 10 patients(31.3%),and AVG patency was restored after surgical or endovascular repair.Prosthetic vascular graft infection occurred in 3 patients(9.4%),of whom,one case had a local graft infection,and AVG was successfully retained for dialysis after removal of the infected part and transplantation of autologous vein;2 patients underwent completely resection of the graft due to whole graft infection.No complications such as pseudoaneurysm and HAIDI occurred during this period.The average primary patency time was(20.4±3.32)months,and the 1-,2-and 3-year primary patency rates were 64.6%,44.7%and 19.6%,respectively.The average secondary patency time was(38.7±5.52)months,and the 1-,2-and 3-year secondary patency rates were79.6%,79.6%and 54.6%,respectively.Conclusion:The lower extremity AVG can achieve a satisfactory secondary patency rate after repairment,and is a feasible alternative for patients with exhausted options for creating an upper extremity vascular access.Standard preoperative evaluation,strict aseptic operating during surgery and puncture,and regular follow-up are important factors to ensure long-term patency.