应用No-touch技术分离静脉减轻动静脉内瘘手术后早期近吻合口静脉缺氧及内膜增生的机制及研究进展

The mechanism and research advances in the use of no-touch technique to dissect veins during surgery to alleviate early postoperative juxta-anastomotic venous hypoxia and intimal hyperplasia of the arteriovenous fistula

自体动静脉内瘘(autologous arteriovenous fistula,AVF)构建过程中近吻合口静脉分离所造成的滋养血管(vasa vasorum,VV)损伤及AVF手术后的血流动力学改变均可导致手术后早期近吻合口静脉缺氧,激活低氧诱导因子(hypoxia inducible factors,HIFs)以调节其下游信号通路促进血管壁的细胞增殖和胶原沉积,导致近吻合口静脉内膜增生(intimal hyperplasia,IH)与狭窄。冠状动脉旁路手术时,用于大隐静脉分离的No-touch技术(no-touch technique,NTT)能够减轻静脉分离过程中所造成的静脉VV损伤,且保留的静脉周围组织具有外支撑作用,能够减轻手术后移植静脉的血流动力学改变,从而减轻近移植静脉的缺氧及IH。近年来,该技术亦开始应用于AVF构建过程中的静脉分离,并取得了良好的临床效果。本文将对应用该技术分离静脉构建AVF减轻手术后近吻合口静脉缺氧及IH的机制及研究进展进行综述。

The damage to vasa vasorum caused by dissection of juxta-anastomotic veins during autologous arteriovenous fistula(AVF)surgery and the changes of hemodynamics after AVF construction can lead to early postoperative hypoxia of the juxta-anastomotic venous wall.As a result,hypoxia inducible factors(HIFs)and its downstream signal pathway are activated to induce cell proliferation and collagen deposition in juxta-anastomotic venous wall,and intimal hyperplasia and stenosis are thus produced.During coronary artery bypass surgery,the no-touch technique used for great saphenous vein dissection can reduce the damage to venous vasa vasorum in the venous dissection operation,and the preserved perivenous tissue has external supporting effects to reduce the hemodynamic changes of the vein graft.Therefore,the no-touch technique can alleviate hypoxia and intimal hyperplasia of the vein graft.In recent years,this technology has been applied to vein dissection during AVF surgery,and achieved better clinical results.In this review,we summarize the mechanism and research advances in the use of no touch technique to dissect veins during surgery to alleviate early postoperative juxta-anastomotic venous hypoxia and intimal hyperplasia of the arteriovenous fistula.