Can blood flow surveillance and pre-emptive repair of subclinical stenosis prolong the useful life of arteriovenous fistulae? A randomized controlled study
Can blood flow surveillance and pre-emptive repair of subclinical stenosis prolong the useful life of arteriovenous fistulae? A randomized controlled study
复制标题
DOI：
10.1093/ndt/gfh316
复制
发表时间：
2004-09-01
影响因子：
6.1
通讯作者：
Lupo, A
中科院分区：
文献类型：
--
作者：
Tessitore, N;Lipari, G;Lupo, A
背景狭窄是动静脉内瘘（AVF）失败的主要原因。然而，目前尚不清楚狭窄的监测是否能提高AVF的功能和寿命，以及是否存在理想的介入时间。在一项为期5年的随机、对照、开放性试验中，我们比较了血流监测和亚临床狭窄（血管成形术和开放性手术中的一种或两种）的抢先修复与仅基于临床标准的标准监测和干预，以确定前者是否延长了成熟前臂AVF的寿命。在透析过程中通过血泵流量（Qb）监测和每季度分流血流量（Qa）或再循环测量确定了79例血管造影证实的显著（>50%）狭窄的AVF。AVF被随机分配到对照组（针对输送透析剂量下降或血栓形成进行干预; n=36）或预先治疗组（n=43）。为了评估结果与入路血流动力学状态之间的可能关系，根据Qa值高于或低于350 ml/min或存在或不存在再循环，将AVF分为功能性和衰竭性亚组。Kaplan-Meier分析显示，预先治疗降低了失败率（P=0.003），考克斯风险模型将治疗（P=0.009）和较高的基线Qa（P=0.001）确定为与有利结局相关的唯一变量。在功能性（P=0.021）和失败亚组（P=0.005）中，治疗组的一期通畅率均高于对照组AVF。在两个对照组中，它们的功能性也高于失败的AVF（P <350 ml/min预示着AVF中具有先发制人作用的上级结局。
Background. Stenosis is the main cause of arteriovenous fistula (AVF) failure. It is unclear, however, if surveillance for stenosis enhances AVF function and longevity and if there is an ideal time for intervention.Methods. In a 5-year randomized, controlled, open trial we compared blood flow surveillance and preemptive repair of subclinical stenoses (one or both of angioplasty and open surgery) with standard monitoring and intervention based upon clinical criteria alone to determine if the former prolonged the longevity of mature forearm AVFs. Surveillance with blood pump flow (Qb) monitoring during dialysis sessions and quarterly shunt blood flow (Qa) or recirculation measurements identified 79 AVFs with angiographically proven, significant (>50%) stenosis. The AVFs were randomized to either a control group (intervention done in response to a decline in the delivered dialysis dose or thrombosis; n=36) or to a pre-emptive treatment group (n=43). To evaluate a possible relationship between outcome and haemodynamic status of the access, AVFs were divided into functional and failing subgroups, according to Qa values higher or lower than 350 ml/min or the absence or presence of recirculation.Results. A Kaplan-Meier analysis showed that preemptive treatment reduced failure rate (P=0.003) and the Cox hazards model identified treatment (P=0.009) and higher baseline Qa (P=0.001) as the only variables associated with favourable outcome. Primary patency rates were higher in treatment than in control AVFs in both functional (P=0.021) and failing subgroups (P=0.005). They were also higher in functional than in failing AVFs in both control (P350ml/min portends a superior outcome with pre-emptive action in AVFs.