原位动静脉内瘘重建术用于血液透析患者内瘘闭塞的临床研究

背景　长期血液透析患者动静脉内瘘失功能不可避免，为最大限度地节约血管资源，现有研究多以Fogarty球囊导管取栓加吻合口扩张手术在原血管基础上重建动静脉内瘘，该方法再通率高，但长期通畅率不佳，寻找一种既能节约血管资源，又可延长内瘘使用周期的方法十分必要。目的　探讨血液透析患者内瘘闭塞后原位动静脉内瘘重建术的应用价值。方法　选取2015年3月—2017年3月浙江省台州市恩泽医疗中心（集团）恩泽医院收治的维持血液透析动静脉内瘘失功能患者92例为研究对象，采用随机数字表法将患者分为研究组和对照组，每组各46例。对照组采用Fogarty球囊导管取栓加吻合口扩张手术修复内瘘，研究组采用原位动静脉内瘘重建术。对比两组患者手术情况，并分别于动静脉内瘘重建前后取患者外周静脉血测定肾功能、炎性因子、血脂、蛋白指标水平。记录手术并发症发生率。结果　两组患者术中出血量和手术成功率比较，差异无统计学意义（P>0.05）。研究组手术时间短于对照组，切口长度长于对照组，手术费用低于对照组，术后6个月及1年通畅率、内瘘血流量高于对照组（P<0.05）。重建前，两组患者血肌酐（Scr）、尿氮素（BUN）、超敏C反应蛋白（hs-CRP）、白介素6（IL-6）、肿瘤坏死因子α（TNF-α）、总胆固醇、三酰甘油、总蛋白、清蛋白、β2微球蛋白水平比较，差异均无统计学意义（P>0.05）。重建后，两组患者Scr、BUN、总蛋白、清蛋白、β2微球蛋白水平比较，差异均无统计学意义（P>0.05）；研究组hs-CRP、IL-6、TNF-α、总胆固醇、三酰甘油水平低于对照组（P<0.05）。两组患者重建后血清Scr、BUN、hs-CRP、IL-6、TNF-α、总胆固醇、三酰甘油、β2微球蛋白水平低于重建前，总蛋白、清蛋白水平高于重建前（P<0.05）。研究组总并发症发生率为15.2%（7/46），对照组为10.9%（5/46），两组比较差异无统计学意义（χ2=0.383，P=0.536）。结论　血液透析患者内瘘闭塞后原位动静脉内瘘重建术成功率高、疗效稳定，且操作简便、经济适用，具有较高的临床推广价值。

Clinical Study of in Situ Arteriovenous Fistula Reconstruction for Occlusion of Internal Arteriovenous Fistulas in Hemodialysis Patients

Background　Loss of arteriovenous fistula function is inevitable for patients undergoing long-term hemodialysis.In order to save vascular resources，current studies mostly focus on reconstructing arteriovenous internal fistula on the basis of original blood vessels by Fogarty balloon catheter extraction and anastomotic dilation.Although its recanalization rate is high，its long-term recanalization rate is not satisfied.It is necessary to find a method that can not only save vascular resources but also prolong the service life of internal fistula.Objective　To explore the value of in situ arteriovenous fistula reconstruction applied to the treatment of internal arteriovenous fistula occlusion in hemodialysis patients.Methods　Totaled 92 maintenance hemodialysis patients with arteriovenous fistula occlusion were recruited from Taizhou Enze Medical Center of Zhejiang Province from March 2015 to March 2017.They were equally divided into the study group and control group by using a random number table，receiving in situ arteriovenous fistula reconstruction，fistula embolectomy and angioplasty with Fogarty balloon embolectomy catheter，respectively.Data concerning surgery，inflammatory factors，indicators of renal function，blood lipid，protein and so on before and after treatment（obtained by measuring peripheral venous blood） were compared between the groups.The incidence of surgical complications was recorded.Results　The study group demonstrated shorter mean duration of surgery and mean incision length，lower mean surgery cost，and higher 6-month and 12-month patency rates of the arteriovenous fistula and more blood flow through the arteriovenous fistula compared with the control group（P<0.05） although mean intraoperative blood loss and success rate of surgery were similar in the two groups（P>0.05）.Similar mean serum levels of Scr，BUN，hs-CRP，IL-6，TNF-α，total cholesterol，triacylglycerol，total protein，albumin and β2 microglobulin were found in both groups before treatment（P>0.05）.After treatment，all of them decreased except total protein and albumin increased significantly in both groups（P<0.05）.Pairwise comparison showed hs-CRP，IL-6，TNF-α，total cholesterol and triacylglycerol were obviously lower in the study group than in the control group（P<0.05） but other 5 indicators were still similar in both groups（P>0.05）.Two groups showed no significant difference in the incidence of complications 〔15.2%（7/46） vs 10.9%（5/46）〕（χ2=0.383，P=0.536）.Conclusion　In situ arteriovenous fistula reconstruction is strongly recommended for clinical use，for it is easy to operate and inexpensive，and has high success rate and can achieve a stable and favorable outcome.