Hemodialysis vascular access monitoring: current concepts.
Hemodialysis vascular access monitoring: current concepts.
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DOI：
10.1111/j.1542-4758.2009.00359.x
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发表时间：
2009-04
期刊：
影响因子：
--
通讯作者：
Robbin ML
中科院分区：
文献类型：
--
作者：
Allon M;Robbin ML
大多数动静脉移植物由于不可逆的血栓形成而失败，并且大多数凝结的移植物具有潜在的狭窄病变。这些观察结果提出了一个合理的假设，即早期发现移植物狭窄，预先血管成形术将减少移植物血栓形成的可能性。许多非侵入性方法可用于检测血流动力学显着的移植物狭窄，具有较高的阳性预测值。这些测试包括临床监测，以及通过静态透析静脉压、流量监测或双工超声进行的监测。然而，在没有预先血管成形术的情况下，这些监测试验对移植物血栓形成的阳性预测值要低得多。换句话说，目前可用的监测测试都不能可靠地区分注定要凝块的狭窄移植物和那些在没有干预的情况下保持通畅的移植物。因此，任何移植物监测计划都必然导致相当大比例的不必要的血管成形术。此外，尽管前期监测试验正常，但仍有相当比例的移植物血栓形成。许多观察性研究发现，实施狭窄监测计划后，移植物血栓形成显著减少。相比之下，6项随机临床试验中有5项未能显示与仅接受临床监测的患者相比，接受移植物监测的患者移植物血栓形成减少。缺乏监测的益处主要是由于血管成形术后狭窄的快速复发。因此，不能推荐通过预先血管成形术对移植物狭窄进行常规监测来减少移植物血栓形成。未来的研究应针对药物干预，以防止移植物狭窄。
Most arteriovenous grafts fail due to irreversible thrombosis, and most clotted grafts have an underlying stenotic lesion. These observations raise the plausible hypothesis that, early detection of graft stenosis with preemptive angioplasty will reduce the likelihood of graft thrombosis. A number of noninvasive methods can be used to detect hemodynamically significant graft stenosis with a high positive predictive value. These tests include clinical monitoring, as well as surveillance by static dialysis venous pressures, flow monitoring, or duplex ultrasound. However, these surveillance tests have a much lower positive predictive value for graft thrombosis in the absence of preemptive angioplasty. In other words, none of the currently available surveillance tests can reliably distinguish between stenosed grafts destined to clot, and those that will remain patent without intervention. As a consequence, any program of graft surveillance necessarily results in a substantial proportion of unnecessary angioplasties. Moreover, a substantial proportion of grafts thrombose despite a normal antecedent surveillance test. Numerous observational studies have found an impressive reduction of graft thrombosis after implementation of a stenosis surveillance program. In contrast, 5 of 6 randomized clinical trials failed to show a reduction of graft thrombosis in patients undergoing graft surveillance, as compared with those receiving only clinical monitoring. The lack of benefit of surveillance is largely attributable to the rapid recurrence of stenosis after angioplasty. Thus, routine surveillance for graft stenosis, with preemptive angioplasty, cannot be recommended for reduction of graft thrombosis. Future research should be directed at pharmacologic interventions to prevent graft stenosis.
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