Aggressive treatment of early fistula failure
Aggressive treatment of early fistula failure
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DOI：
10.1046/j.1523-1755.2003.00210.x
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发表时间：
2003-10-01
影响因子：
19.6
通讯作者：
Litchfield, T
中科院分区：
文献类型：
--
作者：
Beathard, GA;Arnold, P;Litchfield, T
背景瘘管失败分为早期和晚期。早期失败是指动静脉（AV）瘘从未发展到可以使用的程度或在使用的前3个月内失败的病例。通常的做法是放弃这些早期失败;然而，早期瘘失败的积极评价和治疗已被证明可以挽救很大比例的瘘。目前最常见的两种失败原因是吻合口附近狭窄（JAS）和副静脉的存在。这两种情况都可以通过体检来诊断。本研究报告的结果早期瘘失败积极管理，试图挽救。这些研究在美国不同地区的6家独立门诊介入机构进行。除由介入放射科医生操作的机构外，所有这些机构都雇用了介入肾脏科医生。首先对每例患者进行血管造影评价，以确定其动静脉瘘的解剖结构并检测可能存在的异常。狭窄的病变，然后用血管成形术和辅助静脉被认为是显着的闭塞。然后对所有患者进行随访，以确定瘘管是否可用于透析。确定了100例符合早期失败定义的患者。78%的病例存在静脉狭窄。在43%的病例中，病变位于JAS位置。在15%的患者中，这是唯一存在的病变。在24%的患者中，它与副静脉相关，6%与近端狭窄相关，4%与两者相关。36%的瘘中存在近端狭窄病变。在6%的患者中，它与副静脉相关，在6%的患者中与JAS相关，在4%的患者中与两者相关。38%的病例符合动脉吻合口狭窄的定义。这一直与JAS有关。在4例病例中，吻合口上方的动脉存在狭窄病变。46%的病例存在副静脉。在12%的病例中，这是唯一存在的病变。在24%的病例中，这种异常与JAS相关，6%与近端狭窄相关，4%与两者均相关。72%的病例采用血管成形术治疗静脉狭窄，成功率为98%。38例行动脉吻合口成形术，成功率100%。46%的患者进行了副静脉闭塞，成功率为100%。该系列的总体并发症发生率为4%，其中3%为轻微并发症，1%为严重并发症。在92%的病例中，可以使用瘘管开始透析。精算寿命表分析显示，84%的功能在3个月，72%在6个月，68%在12个月。如果在早期瘘管失败的患者中检测到可纠正的病理，则可纠正病变的发生率相对较高，并且可以预期积极的治疗方法具有较高的产率。
Background. Fistula failure has been classified as early and late. Early failure refers to those cases in which the arteriovenous ( AV) fistula never develops to the point that it can be used or fails within the first 3 months of usage. It has been common practice to abandon these early failures; however, aggressive evaluation and treatment of early fistula failures has been shown to result in the salvage of a large percentage. The two most common causes of the failure seen at this time are juxta-anastomotic stenosis (JAS) and the presence of accessory veins. Both of these can be easily diagnosed by physical examination. This study reports the results of early fistula failure managed aggressively in an attempt at salvage.Methods. These studies were conducted in six freestanding outpatient interventional facilities in different regions of the United States. Interventional nephrologists are employed at all of these facilities except one that is operated by an interventional radiologist. Each patient was first evaluated angiographically to identify the anatomy of their AV fistula and detect abnormalities that might be present. Stenotic lesions were then treated with angioplasty and accessory veins thought to be significant were obliterated. All patients were then followed to determine if the fistula was usable for dialysis.Results. One hundred patients were identified that met the definition of early failure. Venous stenosis was present in 78% of these cases. In 43% of the cases, the lesion was in the JAS location. In 15%, this was the only lesion present. In 24%, it was associated with an accessory vein, in 6% with a proximal stenosis, and in 4% with both. A proximal stenosis lesion was present in the fistula in 36%. In 6%, it was associated with an accessory vein, in 6% with a JAS, and in 4% with both. The definition of arterial anastomosis stenosis was met in 38% of the cases. This was always in association with JAS. In four cases, a stenotic lesion was present in the artery above the anastomosis. An accessory vein was present in 46% of the cases. In 12% of the cases, this was the only lesion present. In 24% of the cases, this anomaly was associated with JAS, in 6% with proximal stenosis, and in 4% with both. Angioplasty was performed to treat venous stenosis in 72% of the cases with a 98% success rate. Angioplasty of the arterial anastomosis was performed in 38 cases with a 100% success rate. Accessory vein obliteration was performed in 46% of the patients with a 100% success rate. The overall complication rate in this series was 4%, of these 3% were minor and 1% were major. It was possible to initiate dialysis using the fistula in 92% of the cases. Actuarial life-table analysis showed that 84% were functional at 3 months, 72% at 6 months, and 68% at 12 months.Conclusion. If correctable pathology is detected in patients with early fistula failure, the incidence of correctable lesions is relatively high and an aggressive therapeutic approach can be expected to have a high yield.