UTILITY OF INTRA-ACCESS PRESSURE MONITORING IN DETECTING AND CORRECTING VENOUS OUTLET STENOSES PRIOR TO THROMBOSIS
UTILITY OF INTRA-ACCESS PRESSURE MONITORING IN DETECTING AND CORRECTING VENOUS OUTLET STENOSES PRIOR TO THROMBOSIS
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DOI：
10.1038/ki.1995.192
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发表时间：
1995-05-01
影响因子：
19.6
通讯作者：
MORITZ, MJ
中科院分区：
文献类型：
--
作者：
BESARAB, A;SULLIVAN, KL;MORITZ, MJ
血管通路血栓形成是血液透析患者的主要问题。在7.75年的时间里，我们在零透析器血流量（VP 0）下进行了通路内静脉压监测，将VP 0与血管造影的通路解剖结构相关联，并检查了两个狭窄水平（50%和>65%管腔直径减小（%D））的影响，作为转诊和择期血管成形术或手术翻修的选择标准。构建绝对入路内压（VP 0）和针对体循环压标准化的入路内压（VP 0/收缩压）的总结受试者结局曲线，以评价灵敏度和特异性，并与再循环和双功彩色血流多普勒进行比较。入路结局包括每100患者年（100患者年）标准化的血栓形成、翻修、置换和血管成形术发生率。在长达7.75年的研究期间，共计832个患者访问年的风险，假体桥移植物的百分比从65%增加到80%。SROC对移植物中标准化（VP 0/收缩压）的敏感性优于绝对入路内压（VP 0）。与VP 0相比，再循环在假体桥移植物中的预测能力较差。在自体动静脉内瘘中，再循环的预测能力上级于VP 0。血管成形术率与管腔缩小程度呈负相关，管腔缩小程度可作为血管成形术或手术翻修的选择标准。血栓形成率与血管成形术率之间存在强负相关关系（R（2）= 0.99），但血栓形成率与血管造影次数之间不存在强负相关关系（R（2）= 0.39）。一个一致的，但不断发展的，密集的移植物维护方案产生了70%的血栓形成率下降，79%的接入更换率下降，并在专利可用的血管通路的平均年龄从1.97年增加到2.98年，这与血管成形术率增加了13倍。我们的结论是，血管通路监测与VP 0/收缩压提供了良好的选择标准，血管造影转诊。对于狭窄病变>50%D，采用血管成形术或外科翻修术进行干预可显著降低血栓形成和通路置换率。
Vascular access thrombosis is a major problem for hemodialysis patients. Over 7.75 years, we performed intra-access venous pressure monitoring at zero dialyzer blood flow (VP0), correlated VP0 with access anatomy angiographically, and examined the effect of two levels of stenosis, 50% and >65% luminal diameter reduction (%D) as selection criteria for referral and elective angioplasty or surgical revision upon access outcomes. Summary receiver outcome curves for absolute intra-access pressure (VP0) and intra-access pressure normalized for systemic pressure (VP0/systolic BP) were constructed to evaluate sensitivity and specificity and compared to recirculation and duplex color-flow Doppler. Access outcomes included thrombosis, revision, replacement, and angioplasty rates that were normalized per 100 patient years (100 pt-yrs). During the 7.75 year long study period totaling 832 patient-access years of risk, the percentage of prosthetic bridge grafts increased from, 65% to 80%. SROC showed better sensitivity for normalized (VP0/systolic BP) than absolute intra-access pressure (VP0) in grafts. Recirculation had poor predictive power in prosthetic bridge grafts compared to VP0. Predictive power of recirculation was superior to VP0 in native arteriovenous fistulae. The angioplasty rate correlated inversely with the degree of luminal reduction used as selection criterion for referral for angioplasty or surgical revision. A strong inverse relationship between thrombosis rate and the angioplasty rate (R(2) = 0.99) but not between thrombosis rate and the number of angiograms performed (R(2) = 0.39) was noted. A consistent, yet evolving, intensive graft maintenance protocol produced a 70% decrease in the thrombosis rate, a 79% decrease in the access replacement rate, and an increase in the average age of patent usable vascular accesses from 1.97 to 2.98 years that was associated with a 13-fold increase in the angioplasty rate. We conclude that vascular access monitoring with VP0/systolic BP provides excellent selection criteria for angiographic referral. Intervention for stenotic lesions >50%D using angioplasty or surgical revision markedly reduces thrombosis and access replacement rates.