Arteriovenous Grafts: Much Maligned But in Need of Reconsideration?
Arteriovenous Grafts: Much Maligned But in Need of Reconsideration?
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DOI：
10.1111/sdi.12567
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发表时间：
2017-03-01
影响因子：
1.6
通讯作者：
Allon, Michael
中科院分区：
文献类型：
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作者：
Allon, Michael
不同国家、美国不同地区、甚至同一大都市区不同血液透析中心的血液透析患者动静脉内瘘 (AVF) 的使用情况存在很大差异。在对患者人口统计数据和合并症进行调整后，这些差异仍然存在，表明实践模式在确定 AVF 使用频率方面发挥着重要作用。这些观察结果催生了血管通路指南，敦促肾脏病学家和外科医生增加慢性肾病患者的 AVF 形成。过去 20 年来，随着临床医生采用这些指南，血液透析患者中 AVF 的使用率大幅增加。与此同时，临床医生已经认识到坚定不移的瘘管优先方法的重要局限性。首先，即使使用常规术前血管标测，仍有相当大比例的 AVF 未能成熟，导致导管依赖时间延长。其次，某些患者亚组存在 AVF 不成熟的高风险。第三，未成熟的 AVF 经常需要干预来促进其成熟。第四，需要此类干预的 AVF 缩短了累积通畅时间。第五，动静脉移植物（AVG）与 AVF 相比有几个优点，包括较低的初次失败率、成功插管前较少的干预以及较短的导管依赖持续时间及其相关的菌血症风险。所有这些观察结果促使肾脏病学家提出一种个体化的血管通路方法，对于使用导管开始血液透析的患者，AVG 是首选，特别是如果他们处于 AVF 不成熟的高风险且预期寿命相对较短。
There are substantial variations in arteriovenous fistula (AVF) use among hemodialysis patients in different countries, in different regions of the U.S., and even in different hemodialysis units within a single metropolitan area. These variations persist after adjustment for patient demographics and comorbidities, suggesting that practice patterns play a major role in determining the frequency of AVF use. These observations led to vascular access guidelines urging nephrologists and surgeons to increase AVF creation in patients with chronic kidney disease. Over the past 20 years, as clinicians have adopted these guidelines, the prevalence of AVF use in hemodialysis patients has increased substantially. At the same time, clinicians have recognized important limitations of an unwavering Fistula First approach. First, a substantial proportion of AVFs fail to mature even when routine preoperative vascular mapping is used, leading to prolonged catheter dependence. Second, certain patient subgroups are at high risk for AVF nonmaturation. Third, nonmaturing AVFs frequently require interventions to promote their maturation. Fourth, AVFs that require such interventions have shortened cumulative patency. Fifth, arteriovenous grafts (AVG) have several advantages over AVFs, including lower primary failure rates, fewer interventions prior to successful cannulation, and shorter duration of catheter dependence with its associated risk of bacteremia. All these observations have led nephrologists to propose an individualized approach to vascular access, with AVG being preferred in patients who initiate hemodialysis with a catheter, particularly if they are at high risk for AVF nonmaturation and have a relatively short life expectancy.