锁边缝合在内瘘血管吻合中的应用对动静脉内瘘通畅性的影响

Effect of overlock stitch for vascular anastomosis during internal fistula surgery on patency of the arteriovenous fistula

目的探讨锁边缝合在内瘘血管吻合中的应用对动静脉内瘘通畅性的影响。方法回顾性分析2020年7月─2023年6月于贵州航天医院接受内瘘血管吻合手术的患者(n=256)。根据缝合方式分为2组:传统的手工缝合为手工缝合组(n=178),锁边缝合(用缝合器)的为锁边缝合组(n=78)。通过倾向性评分匹配(propensity score matching,PSM)法按照1:1匹配后2组各64例,比较2组患者治疗后疗效和并发症情况。根据治疗后6个月动静脉内瘘通畅情况将128例患者分为通畅组(n=81)和通畅不良组(n=47),采用单因素和多因素Logistic回归分析筛选患者动静脉内瘘通畅不良的独立影响因素,构建风险评估量表、危险分层及评估量表的预测价值及验证。结果匹配后锁边缝合组手术后1、6个月的吻合口直径(t=22.936、24.078,均P<0.001)、内瘘血流量(t=12.990、14.009,均P<0.001)、瘘管通畅率(χ^(2)=5.489、6.646,P=0.019、0.010)均优于手工缝合组,手术后并发症发生率低于手工缝合组(χ^(2)=19.384,P<0.001)。多因素Logistic回归分析显示平均动脉压≥70 mmHg(OR=3.355,95%CI:1.502~7.492,P=0.003)、吻合动脉手术前内径<3.5 mm(OR=2.344,95%CI:1.124~4.888,P=0.023)和吻合静脉手术前内径<3.5 mm(OR=2.177,95%CI:1.048~4.525,P=0.037)是患者动静脉内瘘通畅不良的独立危险因素,高血压史(OR=0.114,95%CI:0.049~0.265,P<0.001)、糖尿病史(OR=0.357,95%CI:0.168~0.759,P=0.007)和血磷≤1.78 mmol/L(OR=0.501,95%CI:0.239~1.047,P=0.006)是其保护因素。选取风险评估量表中3分作为最佳诊断界值,其灵敏度和特异性分别为79.8%和73.2%,得分≤2.5分通畅不良率风险为低危,3.0~4.0分为中危,≥4.5分为高危。用2022年7月─2023年6月的120例患者进行验证,其预测通畅不良的灵敏度为79.6%,特异性为78.9%,阳性预测值为70.6%,阴性预测值为85.6%。结论锁边缝合技术在动静脉内瘘血管吻合中的应用可以改善手术后的内瘘通畅性。其优势在于提供更稳固和可靠的吻合,减少手术后并发症的风险。

Objective To investigate the effect of overlock suture for vascular anastomosis during internal fistula surgery on postoperative patency of the internal arteriovenous fistula(AVF).Methods A retrospective analysis was performed on 256 patients who received vascular anastomosis surgery for AVF construction in our hospital from July 2020 to June 2023.They were divided into two groups according to the stitch method:the traditional manual stitch group using manual stitch(n=178),and the overlock stitch group using a stitch instrument for stitch(n=78).The two groups were matched 1:1 with 64 patients in each group by propensity score matching(PSM)method.The efficacy and complications after the treatment were compared between the two groups.According to the patency of AVF after the surgery for 6 months,the 128 patients were divided into patency group(n=81)and poor patency group(n=47).Univariate and multivariate logistic regression were used to analyze the independent influencing factors for poor AVF patency.A risk assessment scale and risk stratification were conducted,and the predictive value of the risk assessment scale were verified.Results After the surgery for one month and 6 months,anastomotic diameter(t=22.936 and 24.078,P<0.001),blood flow in AVF(t=12.990 and 14.009,P<0.001)and AVF patency rate(χ^(2)=5.489 and 6.646,P=0.019 and 0.010)were better in the matched overlock stitch group than in the matched traditional manual stitch group.Postoperative complication rate was lower in the matched overlock stitch group than in the matched traditional manual stitch group(χ^(2)=19.384,P<0.001).Multivariate logistic regression showed that mean arterial pressure≥70mmHg(OR=3.355,95%CI:1.502~7.492,P=0.003),preoperative internal diameter of the anastomotic artery<3.5mm(OR=2.344,95%CI:1.124~4.888,P=0.023)and preoperative internal diameter of anastomotic vein<3.5mm(OR=2.177,95%CI:1.048~4.525,P=0.037)were the independent risk factors for poor postoperative patency of AVF,while hypertension history(OR=0.114,95%CI:0.049~0.265,P<0.001),diabetes history(OR=0.357,95%CI:0.168~0.759,P=0.007)and blood phosphorus≤1.78mmol/L(OR=0.501,95%CI:0.239~1.047,P=0.006)were the protective factors for postoperative AVF patency.Using scores of 3 points in the risk assessment scale as the optimal cutoff value for diagnosis,the sensitivity and specificity were 79.8% and 73.2% respectively;scores of≤2.5 points were classified as low risk,3.0~4.0 points as medium risk,and≥4.5 points as high risk of poor patency.Using the 120 patients treated between July 2022 to June 2023 to verify the diagnostic value of the assessment scale and showed that the sensitivity,specificity,positive predictive value,and negative predictive value of poor patency were 79.6%,78.9%,70.6%,and 85.6% respectively.Conclusion The overlock suture technique for vascular anastomosis in the surgery of AVF construction can significantly improve the postoperative patency of the AVF.Overlock stitch technique provides a stable and reliable anastomosis and reduces the risk of postoperative complications.