动静脉内瘘功能不良行经皮血管腔内治疗后2年随访效果评价

Effect evaluation of 2⁃year follow⁃up for dysfunction of arteriovenous fistula after percutaneous endovascular treatment

目的:探讨经皮腔内血管成形术、手术取栓和经皮腔内尿激酶溶栓治疗动静脉内瘘(AVF)功能不良后2年次级通畅率。方法:采用回顾性队列研究设计,收集2016年1月1日—2017年6月1日在广东省人民医院血液净化中心行维持性血液透析的所有病人资料。根据病人动静脉内瘘首次出现功能不良(血栓闭塞或血管狭窄伴有内瘘流量不足)时干预方法分为3组:单纯尿激酶溶栓组、经皮腔内血管成形术组和外科手术取栓组。观察不同干预治疗后2年内瘘次级通畅率、干预成功率和动静脉内瘘干预失功影响因素。结果:动静脉内瘘首次出现功能不良病人133例(血栓闭塞99例,血管狭窄伴有内瘘流量不足34例),干预成功112例(84.2%);动静脉内瘘功能不良干预治疗后2年,单纯尿激酶溶栓组内瘘失功31例(45.6%),经皮腔内血管成形术组内瘘失功10例(25.6%),外科手术取栓组内瘘失功6例(23.1%),3组比较差异有统计学意义(P=0.040);经皮腔内血管成形术组内瘘使用中位时间为[1.24(0.50,2.00)]年,单纯尿激酶溶栓组内瘘的使用中位时间为[0.59(0.32,0.96)]年,外科手术取栓组内瘘使用中位时间为[1.18(0.63,2.00)]年,3组比较差异有统计学意义(P=0.008)。Kaplan-Meier生存分析(Log-rank检验)显示:3组间动静脉内瘘2年次级通畅率差异无统计学意义。通过Cox比例风险模型并经过动静脉内瘘使用时间、血钙、血磷和钙磷乘积校正后,外科手术取栓组动静脉内瘘2年次级通畅率[HR(95%CI)为0.31(0.11,0.82),P=0.02]、经皮腔内血管成形术组[HR(95%CI)为0.60(0.26,1.38),P=0.23]均高于单纯尿激酶溶栓组。多因素分析显示,内瘘使用时间≥3年和钙磷乘积≥66 mg^(2)/d L^(2)与内瘘干预后2年失功率相关。结论:经皮腔内血管成形术、手术取栓治疗可以改善动静脉内瘘功能不良后2年通畅率,术后需加强钙磷管理,有助于改进干预效果。

Objective:To discuss the secondary patency rate at 2⁃year after treatment through percutaneous transluminal angioplasty,surgical thrombectomy,and percutaneous intraluminal urokinase thrombolysis for arteriovenous fistula(AVF).Methods:A retrospective cohort study design was used to collect data of all patients who underwent maintenance hemodialysis at the Blood Purification Center of Guangdong Provincial People's Hospital from January 1,2016 to June 1,2017.According to the intervention method,when the patient's AVF first appeared(thrombotic occlusion or vascular stenosis accompanied by insufficient flow of the internal fistula),the patients were divided into 3 groups:simple urokinase thrombolysis group,percutaneous transluminal angioplasty group,and surgical operation suppository group.Observe the secondary patency rate of fistula,the success rate of intervention,and the influencing factors of AVF intervention failure within 2 years after different interventions.Results:Among the 133 patients with internal AVF for the first time(99 cases of thrombotic occlusion,34 cases of vascular stenosis accompanied by insufficient flow of internal fistula),112 cases(84.2%)successed with the intervention.After the 2⁃year intervention,31 cases(45.6%)of AVF failure occurred in the urokinase thrombolysis group,10 cases(25.6%)of AVF failure occurred in the percutaneous transluminal angioplasty group,and 6 cases(23.1%)of AVF failure occurred in the surgical thrombectomy group,the difference between the three groups was statistically significant(P=0.040).The median time of using different methods was 1.24(0.50,2.00)years in the percutaneous transluminal angioplasty group,0.59(0.32,0.96)years in the urokinase thrombolytic group,and 1.18(0.63,2.00)years in the surgical thrombus removal group;the difference was statistically significant(P=0.008).Kaplan⁃Meier survival analysis(log⁃rank test)showed no significant difference in the 2⁃year secondary patency rate of AVF between the 3 groups.After the Cox proportional hazard model was corrected for the use time of the AVF,blood calcium,blood phosphorus,and calcium-phosphorus product,the 2⁃year secondary patency rate of the AVF in the surgical thrombectomy group was higher than that in the urokinase thrombolytic group,HR(95%CI)=0.31(0.11,0.82),P=0.02,and percutaneous transluminal angioplasty group,HR(95%CI)=0.60(0.26,1.38),P=0.23.Multivariate analysis showed that the use time of internal fistula≥3 years and the product of calcium and phosphorus greater than 66 mg^(2)/dL^(2) were related to the AVF failure at 2 years after the intervention of internal fistula.Conclusions:Percutaneous transluminal angioplasty and surgical thrombectomy could improve the patency rate of AVF after 2 years.Postoperative calcium and phosphorus management should be strengthened to help improve the intervention effect.