动静脉移植物内瘘通畅率及危险因素分析

Patency rates and risk factors of arteriovenous graft

目的探讨动静脉移植物内瘘(arteriovenous graft,AVG)的通畅率及其危险因素,为进一步优化血管通路选择、提高透析质量提供临床依据。方法本研究为回顾性研究,分析郑州大学第一附属医院血液净化中心2017年1月1日至2021年12月31日期间新建AVG患者的临床及随访资料。采用Kaplan-Meier生存曲线分析AVG通畅率,使用Cox回归模型分析AVG通畅的影响因素。结果共纳入AVG 381例次,年龄为(55.5±11.8)岁,男性154例次(40.4%),糖尿病140例次(36.7%)。AVG中位一期通畅时间为377.00(95%CI 314.26~439.74)d,术后1年、2年和3年一期通畅率分别为51.0%、30.7%和15.4%。中位一期辅助通畅时间为839.00(95%CI 668.89~1009.11)d,术后1年、2年和3年一期辅助通畅率分别为78.3%、56.4%和39.1%。术后1年、2年和3年二期通畅率分别为96.7%、90.1%和78.5%。多因素Cox回归分析结果显示,吻合静脉为贵要静脉和头静脉(以肘正中静脉为参照,HR=1.869,95%CI 1.124~3.107,P=0.016;HR=2.110,95%CI 1.176~3.786,P=0.012)及吻合静脉术前内径<3.5 mm(HR=1.411,95%CI 1.020~1.952,P=0.037)为AVG一期通畅异常的独立影响因素,男性(HR=1.680,95%CI 1.127~2.503,P=0.011)、平均动脉压<70 mmHg(HR=3.228,95%CI 1.109~9.394,P=0.032)、Acuseal移植物类型(以Intering为参照,HR=1.884,95%CI 1.185~2.994,P=0.007)、吻合静脉为头静脉(以肘正中静脉为参照,HR=2.817,95%CI 1.328~5.977,P=0.007)、吻合静脉术前内径<3.5 mm(HR=1.555,95%CI 1.048~2.306,P=0.028)、血磷≤1.78 mmol/L(血磷1.13~1.78 mmol/L/>1.78 mmol/L,HR=1.737,95%CI 1.111~2.716,P=0.015;血磷<1.13 mmol/L/>1.78 mmol/L,HR=2.162,95%CI 1.072~4.362,P=0.031)以及铁蛋白<200μg/L(HR=1.850,95%CI 1.231~2.780,P=0.003)为AVG一期辅助通畅异常的独立影响因素。血清白蛋白<40 g/L(HR=2.165,95%CI 1.096~4.275,P=0.026)为AVG二期通畅异常的独立影响因素。结论AVG术后1年、2年和3年一期通畅率分别为51.0%、30.7%和15.4%。AVG术后1年、2年和3年二期通畅率分别为96.7%、90.1%和78.5%。吻合静脉为头静脉和贵要静脉及内径<3.5 mm是AVG一期通畅异常的独立危险因素,吻合静脉为头静脉及内径<3.5 mm是一期辅助通畅异常的独立危险因素。血清白蛋白<40 g/L为二期通畅异常的独立危险因素。术前系统评估以及患者良好的营养状态对于维持AVG的长期通畅具有重要作用。

Objective To investigate the patency rates and risk factors of arteriovenous graft(AVG),and provide a clinical guidance for further optimization of vascular access selection and improvement of dialysis quality.Methods This was a retrospective study.The clinical and follow-up data of patients who received AVG in the Blood Purification Center,First Affiliated Hospital of Zhengzhou University from January 1,2017 to December 31,2021 were selected.Kaplan-Meier curve and Cox regression model were used to analyze the patency rates and risk factors of AVG.Results A total of 381 cases with AVG were included,with 154 cases(40.4%)of males,age of(55.5±11.8)years old,and 140 cases(36.7%)of diabetes.The median time of primary patency was 377.00(95%CI 314.26-439.74)days,and the primary patency rates at 1,2,and 3 years were 51.0%,30.7%,and 15.4%,respectively.The median time of primary assisted patency was 839.00(95%CI 668.89-1009.11)days,and the primary assisted patency rates at 1,2,and 3 years were 78.3%,56.4%,and 39.1%,respectively.The secondary patency rates at 1,2,and 3 years were 96.7%,90.1%,and 78.5%,respectively.Multivariate Cox regression analysis results showed that anastomotic vein types of basilic vein and cephalic vein(median cubital vein as a reference,HR=1.869,95%CI 1.124-3.107,P=0.016;HR=2.110,95%CI 1.176-3.786,P=0.012)and the diameter of anastomotic vein<3.5 mm(HR=1.411,95%CI 1.020-1.952,P=0.037)were the independent influencing factors for abnormal primary patency of AVG.Males(HR=1.680,95%CI 1.127-2.503,P=0.011),mean arterial pressure<70 mmHg(HR=3.228,95%CI 1.109-9.394,P=0.032),Acuseal graft type(Intering as a reference,HR=1.884,95%CI 1.185-2.994,P=0.007),anastomotic vein type of cephalic vein(median cubital vein as a reference,HR=2.817,95%CI 1.328-5.977,P=0.007),the diameter of anastomotic vein<3.5 mm(HR=1.555,95%CI 1.048-2.306,P=0.028),serum phosphorus≤1.78 mmol/L(1.13-1.78 mmol/L/>1.78 mmol/L,HR=1.737,95%CI 1.111-2.716,P=0.015;<1.13 mmol/L/>1.78 mmol/L,HR=2.162,95%CI 1.072-4.362,P=0.031),and ferritin<200μg/L(HR=1.850,95%CI 1.231-2.780,P=0.003)were the independent influencing factors for abnormal primary assisted patency of AVG.Serum albumin<40 g/L(HR=2.165,95%CI 1.096-4.275,P=0.026)was an independent influencing factor for abnormal secondary patency of AVG.Conclusions The primary patency rates of AVG at 1,2,and 3 years were 51.0%,30.7%,and 15.4%,respectively.The secondary patency rates of AVG at 1,2,and 3 years were 96.7%,90.1%,and 78.5%,respectively.Anastomotic vein types of cephalic vein and basilic vein,and internal diameter<3.5 mm are the independent risk factors for abnormal primary patency of AVG.Anastomotic vein type of cephalic vein and internal diameter<3.5 mm are the independent risk factors for abnormal assisted primary patency of AVG.Serum albumin<40 g/L is an independent risk factor for abnormal secondary patency of AVG.It is suggested that systematic preoperative evaluation and good nutritional status of patients are important to maintain long-term patency of the AVG.