二次PTA术后穿刺部位选择对内瘘功能的影响

The selection of puncture site after secondary percutaneous transluminal angioplasty on the function of autologous arteriovenous fistula

目的探讨二次经皮腔内血管成形术后(percutaneous translumin angioplasty,PTA)选择不同部位的血管穿刺行透析治疗对自体动静脉内瘘(autogenous arteriovenous fistula,AVF)功能的影响。方法前瞻性纳入桂林医学院附属医院行AVF II类狭窄、二次PTA术后60例患者,随机分为试验组(手术后长期避开内瘘流出道动脉端的扩张段血管穿刺)、对照组(手术后2周穿刺内瘘流出道动脉端的扩张段血管)。收集2组患者临床资料并随访12个月,比较2组患者手术后1、3、6、9个月AVF泵控血流量、肱动脉血流量、扩张段血管内径及血流量有无差异,手术后内瘘生存时长。结果随访12个月,试验组在手术后6、9个月泵控血流量(t=4.026、4.317,P均<0.001)、肱动脉血流量(t=2.361、3.247,P=0.022、0.002)、扩张段血管内径(t=2.714、2.245,P=0.009、0.031)及血流量(t=3.274、2.625,P=0.002、0.012)明显高于对照组;随访期内2组的中位通畅时间无统计学差异(χ^(2)=2.316,P=0.128)。结论对于行PTA术内瘘的患者,选择长期避开扩张段血管的穿刺,有利于内皮细胞的修复,可维持长期良好的内瘘功能,并有可能延长二次PTA术后内瘘寿命,改善其远期通畅率。

Objective To investigate the selection of puncture site after secondary percutaneous transluminal angioplasty(PTA)on the function of autologous arteriovenous fistula(AVF).Methods A total of 60 patients who underwent secondary PTA for AVF class II stenosis in our hospital were prospectively reviewed.They were randomly divided into experimental group,in which the puncture site was far from the dilated arterial end of the AVF outflow tract after PTA,and control group,in which the puncture site located at the dilated arterial end of the AVF outflow tract after PTA for 2 weeks.They were followed up for 12 months,and their clinical data were collected.AVF pump-controlled blood flow,brachial artery blood flow,diameter of dilated vessel and blood flow in dilated vessel after PTA for 1,3,6 and 9 months as well as the survival time of the AVF after PTA were compared between the two groups.Results In experimental group and control group after PTA for 1,3,6 and 9 months,AVF pump-controlled blood flow was 230.22±12.29 vs.227.26±11.28(t=0.971,P=0.335)after one month,230.36±21.69 vs.220.32±20.37(t=1.800,P=0.077)after 3 months,231.32±19.31 vs.210.42±13.32(t=4.026,P<0.001)after 6 months,and 231.32±18.21 vs.206.18±16.22(t=4.317,P<0.001)after 9 months;brachial artery blood flow was 1260.62±210.23 vs.1235.56±218.26(t=0.452,P=0.652)after one month,1132.25±213.28 vs.1028.34±217.25(t=1.822,P=0.074)after 3 months,1088.45±221.18 vs.936.37±219.36(t=2.361,P=0.022)after 6 months,and 967.39±219.22 vs.729.61±217.18(t=3.247,P=0.002)after 9 months;diameter of dilated vessel was 5.55±1.28 vs.5.33±1.23(t=0.678,P=0.499)after one month,5.12±1.36 vs.4.67±1.02(t=1.409,P=0.164)after 3 months,5.06±1.37 vs.3.90±1.56(t=2.714,P=0.009)after 6 months,and 4.86±1.29 vs.3.83±1.46(t=2.245,P=0.031)after 9 months;blood flow in dilated vessel was 680.26±38.66 vs.678.14±36.56(t=0.218,P=0.828)after one month,672.11±137.63 vs.623.23±135.51(t=1.351,P=0.182)after 3 months,638.21±135.24 vs.510.37±131.62(t=3.274,P=0.002)after 6 months,and 621.27±136.23 vs.502.87±132.12(t=2.625,P=0.012)after 9 months.The AVF pump-controlled flow,brachial blood flow,diameter of dilated vessel,and blood flow in dilated vessel in the two groups had no differences after PTA for one and 3 months,but were significantly different after PTA for 6 and 9 months;The median patency period was similar between the two groups during the follow-up period(9.40 vs.9.00,χ^(2)=2.316,P=0.128),but had a trend of longer period in experimental group than in control group.Conclusion In patients undergoing secondary PTA for AVF,the puncture site should always be far from the dilated vessel segment to facilitate the repair of endothelial cells and the preservation of function,patency and survival period of the AVF.