Vascular access stenosis: Comparison of arteriovenous grafts and fistulas
Vascular access stenosis: Comparison of arteriovenous grafts and fistulas
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DOI：
10.1053/j.ajkd.2004.07.011
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发表时间：
2004-11-01
影响因子：
13.2
通讯作者：
Allon, M
中科院分区：
文献类型：
--
作者：
Maya, ID;Oser, R;Allon, M
血管通路狭窄是血液透析患者的常见问题。比较动静脉瘘和移植物的狭窄特点、选择性血管成形术的相对结果以及预测血管成形术后通路通畅的临床因素，目前发表的文献很少。方法前瞻性资料收集所有2年内因怀疑通道狭窄而转诊的瘘道造影患者。如果狭窄超过50%，则行血管成形术。对于每个手术，我们记录了狭窄病变的数量和位置，狭窄程度（1到4级），以及进入全身收缩压的比例。所有后续的准入程序都进行前瞻性跟踪，以计算无干预的准入生存期。采用多变量分析评价影响血管成形术后通路通畅的临床因素。结果：共获得543张瘘图，其中移植物358张，瘘管185张。瘘管发现明显狭窄的可能性明显低于移植物（39.4%比68.7%;P < 0.001）。在明显狭窄的患者中，有瘘管的患者不太可能有2个或更多的狭窄病变（12.5%比33.1%;P < 0.001）。血管成形术后，瘘管和移植物的狭窄程度（1.35 +/- 0.70 vs 1.23 +/- 0.52）和全身压力比（0.34 +/- 0.15 vs 0.32 +/- 0.14）相似。瘘管和移植物的无干预生存期相似（中位生存期，7.5个月对6.2个月；P = 0.36）。采用多变量逐步比例风险回归分析，只有女性、剩余通道狭窄和血管成形术后通道压力比大于0.4显著预测通道生存（P = 0.0006）。结论：临床评价对瘘道狭窄的阳性预测值明显低于移植物。对于瘘管和移植物，血管成形术的技术成功和随后的初级通畅是相似的。最后，女性、残留狭窄和术后高通道压力比都预示着择期血管成形术后通道通畅时间较短。
Background Vascular access stenosis is a frequent problem in hemodialysis patients. There is little published literature comparing the features of stenosis between arteriovenous fistulas and grafts, relative outcomes of elective angioplasty, and clinical factors predictive of access patency after angioplasty. Methods Prospective data were collected for all patients referred for a fistulogram during a 2-year period because of suspected access stenosis. Angioplasty was performed if there was greater than 50% stenosis. For each procedure, we recorded the number and location of stenotic lesions, degree of stenosis (on a scale of 1 to 4), and ratio of access to systemic systolic pressure. All subsequent access procedures were tracked prospectively to calculate intervention-free access survival. Multivariable analysis was used to evaluate clinical factors affecting access patency after angioplasty. Results: Five hundred forty-three fistulograms were obtained: 358 in grafts and 185 in fistulas. The likelihood of finding a significant stenosis was substantially lower in fistulas than grafts (39.4% versus 68.7%; P < 0.001). Among patients with a significant stenosis, those with fistulas were less likely to have 2 or more stenotic lesions (12.5% versus 33.1%; P < 0.001). After angioplasty, degree of stenosis (1.35 +/- 0.70 versus 1.23 +/- 0.52) and access to systemic pressure ratio (0.34 +/- 0.15 versus 0.32 +/- 0.14) were similar between fistulas and grafts. Intervention-free survival was similar for fistulas and grafts (median survival, 7.5 versus 6.2 months; P = 0.36). Using multivariable stepwise proportional hazard regression analysis, only female sex, residual access stenosis, and postangioplasty access pressure ratio greater than 0.4 significantly predicted access survival (P = 0.0006). Conclusion:The positive predictive value of clinical evaluation for access stenosis is substantially lower for fistulas than grafts. The technical success of angioplasty and subsequent primary patency are similar for fistulas and grafts. Finally, female sex, residual stenosis, and high postprocedure access pressure ratio are each predictive of shorter access patency after elective angioplasty.