HD02型血透监测仪对血液透析患者内瘘的监测

目的评价应用超声稀释法的HD02型血透监测仪对血液透析患者内瘘监测的效能。方法使用HD02型血透监测仪对90例长期维持性血液透析（MHD）患者在透析期间进行内瘘再循环、流量及心输出量等监测。分析影响内瘘流量的相关因素。结果4例患者出现再循环。占4．44％。且均大于5％（非尿素稀释法异常标准）。21例患者内瘘血流量〈500mL／min，占23．33％：3例〉2000ml／min，占3．33％。影响内瘘流量的Logistic回归分析显示，年龄、性别、透析时间、内瘘使用时间、平均动脉压均与内瘘流量下降无相关；低心输出量和糖尿病与内瘘流量下降相关。33例患者心输出量〈4L／min，占36．67％，提示部分患者在透析期间处于低心输出量状态。其中低心输出量的8例患者接受心脏彩色多普勒超声检查。均发现有不同程度的室间隔肥厚、瓣膜区钙化和反流、左室舒张功能不全等心血管功能和形态学改变。结论超声稀释法是一项操作简便、非侵入及实用的内瘘监测方法。自体动静脉内瘘在有足够血流情况下．再循环率低。低心输出量和糖尿病与内瘘流量下降相关。     

肘部内瘘与腕部内瘘对维持性血液透析患者左心功能的影响

目的探讨肘部内瘘与腕部内瘘对维持性血液透析患者左心功能的影响。方法选择我院2007年1月至2010年6月维持性血液透析患者39例。血管通路为肘部内瘘者14例,为肘部内瘘组;血管通路为腕部内瘘者25例,为腕部内瘘组。比较2组左心室射血分数（EF）、短轴缩短率（FS）、左心房内径（LAD）、主动脉根部内径（AAo）、左心室舒张末期内径（LVDd）、左心室收缩末期内径（LVDs）、室间隔厚度（IVST）、左心室后壁厚度（LVPWT）、泵控血流量（Qb）及心脏舒张功能减退者比例[E／A（〈1）％]。结果肘部内瘘组LVDd较腕部内瘘组降低[（46．07±6．38）mm比（52．44±7．60）mm3（P〈0．05）,而EF、FS、LAD、AAO、LVDs、IVST、LVPWT、Qb及E／A（〈1）％无差异（P〉0．05）。结论与腕部内瘘相比,肘部内瘘并没有明显影响左心结构,并不成为高输出量性心力衰竭的高危因素。因此,在腕部内瘘不成功的情况下,可选择肘部内瘘作为长期透析的血管通路。     

超声稀释法在血液透析血管通路功能评价中的初步应用

目的：探讨超声稀释法在血液透析血管通路功能评估中的临床应用价值,并观察血管通路血流量与患者心输出量的相关性。方法：选择在我院血液净化中心透析龄为3～6月的维持性血液透析患者82例,病情稳定,已排除急性活动性疾病,均采用自体动静脉内瘘作为血管通路。使用Transonic HD02型血液透析监护仪对患者的血管通路进行检测,随访期为6个月,分别监测内瘘再循环率、内瘘通路血流量及心输出量等,并观察血管通路血流量与患者心输出量的相关性。结果：（1）观察0个月,内瘘血流量平均为（994.41±434.98）ml/min,心输出量平均为（6.38±3.14）L/min;随访6个月后复测相关指标,血液透析患者的血管通路血流量和心输出量均有所下降,内瘘血流量平均为（961.19±420.92）ml/min,心输出量平均为（6.12±4.17）L/min,但观察6个月与0个月比较,无统计学差异（P〉0.05）;4例（4.88%）患者出现再循环,均大于5%。（2）观察0个月,血管通路狭窄的发生率为9.76%;观察6个月后,血管通路狭窄的发生率为26.83%,二者比较,血管通路狭窄的发生率有统计学差异（P〈0.05）。（3）血管通路血流量与心输出量呈正相关（P〈0.05）,提示患者低心输出量可能导致血管通路血流量的下降。结论：超声稀释法操作简便、非创伤侵入性、安全实用,适用于血液透析患者血管通路的功能评估,可以前瞻性监测血管通路血流动力学意义上的狭窄,具有临床应用价值。     

180例血液透析患者自体动静脉内瘘闭塞临床分析

动静脉内瘘（AVF）是血液透析患者的生命线，其血流充足、安全、使用方便，已常规作为维持性血液透析的血管通路。AVF的好坏直接影响血透患者的生活质量及长期存活，因此维护血管通路的通畅保证足够的血流量尤为重要。为保证血液透析有充足的血流量（250～300ml／min）且能够长期使用的血流通路，临床上一般将血液透析患者桡动脉和邻近静脉做血管吻合，建立自体动静脉内瘘，但是要维持长期血管通路通畅较为困难。由于终末期肾病患者常合并严重贫血、电解质紊乱、营养不良、心功能不全、血压不稳定等，极易造成动静脉内瘘的闭塞。我们分析了我院部分血液透析患者发生动静脉内瘘闭塞的危险因素及处理，以飧读者。     

透析动静脉内瘘吻合失败及成熟不良原因分析

目的：探讨血液透析自体动静脉内瘘吻合手术失败与成熟不良的影响因素。方法：回顾性分析初次行自体动静脉内瘘术的89例慢性肾衰竭患者的病例资料，观察内瘘吻合手术的成功率与成熟不良发生率；将大于60岁的老年患者的内瘘吻合手术成功率与青壮年组比较；同时观察动静脉血管病变对内瘘吻合手术与成熟的影响。结果：所有病例的内瘘吻合手术成功率为97．7％，内瘘成熟不良发生率为9．2％；老年患者的内瘘吻合手术失败与成熟不良发生率（17.1％）明显高于青壮年（5．7％）；观察病例中由于血管因素导致手术失败与成熟不良共9例（90％，9／10）。结论：在做好充分的术前检查并熟练掌握手术方法的前提下，桡动脉头静脉标准内瘘的手术吻合成功率很高，但老年以及已有的血管病变是明显影响内瘘建立与成熟的重要因素。     

自体动静脉内瘘局部血流动力学研究

目的探讨自体动静脉内瘘局部血流动力学特点及其影响因素。方法选择维持性血液透析（maintennance hemodialysis,MHD）患者71例,横断面分析,应用彩超测量自体动静脉内瘘瘘口直径,双侧上肢桡动脉、尺动脉、肱动脉内径及血流量,分析动静脉内瘘对双侧上肢局部血流动力学的影响。结果动静脉内瘘手术后1-144个月,术侧头静脉内径（6.67±2.18）mm;术侧肱动脉内径（5.59±1.24）mm,对侧肱动脉内径（3.81±0.72）mm;术侧桡动脉吻合口近心端内径（4.12±1.13） mm,吻合口远心端（2.84±0.90）mm,对侧桡动脉内径（1.93±0.46）mm;术侧尺动脉内径（2.21±0.86）mm,对侧尺动脉内径（1.64±0.58）mm;术侧和对侧相比,有统计学差异（P〈0.01）。术侧肱动脉血流量（2164.18±1413.06）ml/min,对侧肱动脉血流量（538.90±326.90）ml/min;术侧桡动脉血流量（1172.75±718.20）ml/min,对侧桡动脉血流量（106.50±75.83）ml/min;术侧尺动脉血流量（245.95±184.09）ml/min,对侧尺动脉近心端血流量（81.34±68.80）ml/min;术侧和对侧相比,有统计学差异（P〈0.01）。结论自体动静脉内瘘建立后,术侧肢体的肱动脉、尺动脉、桡动脉内径相应增粗,血流量增大。     

动静脉内瘘术中应用硬膜外导管对内瘘功能的影响

目的探讨在动静脉内瘘术中应用硬膜外导管对内瘘功能的影响。方法将2008年6月至2009年12月行动静脉内瘘成形术97例,按手术方式不同分为,对照组（A组,46例）采用常规动静脉造瘘和治疗组（B组,51例）手术过程中采用硬膜外导管扩张及探查,测定两组患者内瘘术后4w时血流量、内瘘成熟率及1年内瘘血栓形成率。结果A组内瘘术后4w时血流量为（452．4±15．4）ml／min,内瘘成熟率为84．8％,1年内瘘血栓形成率为10．9％;B组内瘘术后4w时血流量为（480．6±16．8）ml／min,内瘘成熟率为96．1％,1年内瘘血栓形成率为13．7％。2组内瘘术后4w时血流量及内瘘成熟率差异具有统计学意义（P〈0．05）。结论在动静脉内瘘成形手术过程中,应用硬膜外导管探查及扩张,能增加内瘘术后4周时血流量,提高内瘘成熟率,且不增加1年内内瘘血栓发生率。     

球囊辅助下血透用桡动静脉内瘘术

目的 评价球囊辅助下血透用桡动静脉内瘘术的手术方法和初步疗效。方法回顾性总结2005年8～12月复旦大学附属中山医院血管外科收治的12例诊断明确的尿毒症病人行球囊辅助下桡动静脉瘘术。选择非主利手，游离头静脉和桡动脉，分别结扎头静脉和桡动脉的远端，向头静脉和（或）桡动脉近端插入Fogarty取栓导管，用1mL的注射器向球囊注入肝素盐水0．1—0．3mL，充起球囊，持续、均匀扩张头静脉和（或）桡动脉及其狭窄段，以7-0无损伤血管缝线吻合血管。结果术后即时、回病房当天、术后1d、3d和7d听诊吻合口杂音，扪及血管震颤。平均随访3个月，手术通畅率100％。已有5例病人内瘘成熟，内瘘血流量大于150mL／min，满足血透流量。结论球囊辅助下桡动静脉内瘘术成功率高，可以纠正头静脉狭窄，内瘘成熟快。短期临床效果好，中远期临床效果在进一步观察中。     

动静脉内瘘对维持性血液透析患者左心室结构及功能的影响

目的：探讨动静脉内瘘对维持性血液透析（血透）患者左心室结构及功能的影响。方法：观察44例血透患者治疗前及治疗后12个月、24个月时的血红蛋白水平、透析间期体重增长量、血压、内瘘吻合口直径、血流量、左心室结构及功能等指标。第24个月根据患者内瘘血流量的大小分为低血流量组（A组＜900ml/min)及高血流量组（B组≥900ml/min)。结论：随血透时间的延长，左心室舒张末内径（LVDd)、室间隔厚度（IVST）及左心室心肌重量指数（LVMI）逐渐增大，心胸比例提高，以血透治疗后24个月高血流量组（B组）显著，左心收缩及舒张功能以射血分数（EF）及舒张早期及晚期最大血流速度比（E／A）变化明显。A、B两组重度水钠潴留者的心胸比例、LVDd及LVMI高于同组的轻度水钠潴留者，E／A低于轻度水钠潴留者。相关分析提示，内瘘血流量与LVDd、LVMI呈明显正相关（均P＜0．05），与EF及E／A呈负相关（P＜0．05），而在左心室收缩末内径（LVDs)、短轴缩短率（FS）及等容舒张时间（IRF）无显著相关性。结论：较高的内瘘血流量与左心室结构及功能的变化有关，水钠潴留有协同作用。     

桡动脉-肘正中静脉交通支动静脉内瘘术初步疗效分析

目的:探讨桡动脉-肘正中静脉交通支动静脉内瘘术的可行性和疗效。方法:选取前臂多次动静脉内瘘失败或前臂血管条件差无法行桡动脉-头静脉动静脉内瘘术的患者共8例,经术前多普勒超声评估后,于肘关节以下通过桡动脉-肘正中静脉交通支(静脉)端(动脉)侧吻合建立动静脉内瘘。并对术前、术后6周、术后3月桡动脉及上臂头静脉行多普勒超声检查,评估血管内径、血流动力学参数变化及瘘管成熟情况。结果:8例患者术前评估血管条件均符合自体静脉动静脉内瘘手术标准,即刻手术成功率100%。术后6周和3个月,桡动脉内径(diameter of radial artery,RAD)、头静脉内径(di-ameter of forearm cephalic vein,CVD)、桡动脉收缩期峰值流速(peak systolic velocity,PSV)、头静脉平均流速(mean velocity ofcephalic vein,CVMV)、头静脉血流(blood flow,BF)均高于术前,且术后3个月高于术后6周。患者随访6～12个月平均8.6个月,术后4～6周开始血透,瘘管均满足血透流量要求,目前均仍在继续使用。结论:(1)桡动脉-肘正中静脉交通支(静脉)端(动脉)侧吻合动静脉内瘘术式是安全可行的,术后瘘管成熟良好。(2)术前常规多普勒超声评估血管条件可以提高桡动脉-肘正中静脉交通支动静脉内瘘术式的成功率。     

Fistula dysfunction: effect on rapid hemodialysis.

Rapid hemodialysis (Qb 400 to 500 ml/min) places considerable demands on hemodialysis vascular access. This six-month prospective study enrolled 52 patients and evaluated urea recirculation as a means of detecting fistula dysfunction. It evaluated the effects of fistula location and dialysis blood flow on urea recirculation during rapid hemodialysis and assessed the effect of rapid dialysis on fistula thrombosis. Urea recirculation increased as Qb increased from 300 to 400 ml/min (8 +/- 3% to 16 +/- 3%, P less than 0.05). The extent of urea recirculation was also fistula site dependent (radial fistulas 18 +/- 4%, upper arm fistulas 11 +/- 3%, Qb 400 ml/min, P less than 0.05). Site and blood flow dependent urea recirculations were an indicator of venous stenoses. When venous stenoses were corrected, urea recirculation rates improved (36 +/- 3% to 21 +/- 3%, P less than 0.05). There were no differences between methods of determining urea recirculation early in dialysis (contralateral arm venepuncture vs. stop flow technique; 30 to 60 min). However, at 120 minutes urea recirculation was significantly greater with the contralateral arm venepuncture technique. Venous dialysis pressure at Qb 400 ml/min had limited use as a predictor of venous stenoses unlike its value at lower Qb. Fistula thrombosis (0.26/patient year of dialysis) and fistula replacement (0.09/patient year of dialysis) were similar to our observations in a conventional hemodialysis facility where prospective correction of fistula dysfunction was also used.     

Effective blood flow and recirculation rates in internal jugular vein twin catheters: measurement by ultrasound velocity dilution

The ultrasound dilution technology (Transonic Systems, Ithaca, NY) is a reliable method to assess blood flow (Qb) and recirculation rates (R) in vascular access during hemodialysis. However, the information available on these parameters for central venous dialysis catheters remains scarce at this point. Real Qb and R were evaluated in 33 well-functioning TwinCath (Medcomp, Harleysville, PA) inserted as mid- or long-term hemodialysis vascular access (mean duration since insertion, 270 +/- 253 days); all were implanted into the right internal jugular vein with their multiperforated distal tips located in the superior vena cava or right atrium. Several types of dialysis machines were used (Monitral and AK100, Hospal-Gambro, Lyon, France; 2008E and 4008E, Fresenius, Bad Homburg, Germany). Real Qb was measured with the ultrasound dilution method and compared with the set Qb (indicated by the dialysis machine); R, also evaluated by ultrasound dilution, was evaluated at various Qb with nonreversed lines; therefore, a total of 121 measures were performed. Arterial and venous pressures (PA and PV) were recorded simultaneously. The 33 measures at a set Qb of 200 mL/min showed a mean effective Qb of 210 +/- 18 mL/min and a mean R of 5.3 +/- 5.3%. At a Qb of 300 mL/min, 33 repeated measures resulted in mean effective Qb of 303 +/- 21 mL/min and R of 8.5 +/- 7.0%; 28 measures performed at a set Qb of 350 mL/min showed that the effective Qb was 336 +/- 24 mL/min and that R was 7.8% +/- 6.7%. Finally, an effective Qb of 372 +/- 26 mL/min and an R of 10.9 +/- 8.6% were found for the 27 measures performed at an indicated Qb of 400 mL/min. The difference between indicated and effective Qb was particularly significant for set Qb equal to or above 350 mL/min (P < 0.001). Variable correlations were observed between obtained parameters: Qb eff and R (r = 0.34), PV and R (r = 0.36), Qb eff and PV (r = 0.78), Qb eff and PA (r = 0.71), and PV and PA (r = 0.53). In conclusion, TwinCath delivers an effective Qb of nearly 375 mL/min when Qb is set at 400 mL/min on most dialysis machines. Mean R in TwinCath varies between 5% and 11% for Qb within the range of 200 to 400 mL/min. In well-functioning TwinCath, the ratio between PV and Qb remains usually below 0.5.     

A New Approach to Evaluate Vascular Access in HemodialysisPatients

Abstract: We evaluated the importance of vascular access in hemodialysis patients using noninvasive methods with the Transonic Systems monitor in 108 patients. Most of these patients (84%) had native vein fistulas. We found that a blood flow rate of below 500 ml/min suggested the occurrence of vascular stenosis and justified confirmation by angiography. Increased recirculation could be evaluated readily and was detected in only 10% of patients. Finally, employing the evaluation of the Kt/V index, we found a good correlation between low flux through the fistula and a low Kt/V value.     

前臂远端贵要静脉转位建立自体血管内瘘手术

目的 探讨前臂远端贵要静脉转位建立自体血管内瘘的方法.方法 自2007年12月至2009年12月我们对26例维持性血液透析患者进行前臂远端贵要静脉转位建立自体血管内瘘手术治疗.26例中有17例为原桡动脉-头静脉内瘘因并发症失去功能,9例初次行血管内瘘手术.手术方式采用贵要静脉转位与肱动脉端侧吻合;贵要静脉转位与桡-动脉端端吻合;贵要动脉与尺动脉端侧或端端吻合,吻合口直径为5.0～8.0 mm.结果 26例患者中有1例因术后血肿压迫闭塞,2例因术后内瘘成熟不良,其余手术患者一次取得成功,术后血流量达200～350 ml/min.对患者的心功能未造成不良影响,也未出现严重并发症.结论 只要适应证选择合适,前臂远端贵要静脉转位建立自体血管内瘘手术,是尽量利用自身血管条件,建立内瘘的一种行之有效的方法.     

上臂人工血管移植透析内瘘的建立及应用

目的 探讨上臂人工血管移植透析内瘘的建立方法及临床应用价值. 方法参考国外文献设计了腋动脉与腋静脉建立上臂U形人工血管移植内瘘,腋动脉与肘窝贵要静脉作上臂直桥式内痿,肱动脉与腋窝腋静脉制作上臂直桥式内瘘,采用3种方法为20例长期血液透析患者建立了上臂人工血管移植透析通路.患者男9例,女11例.年龄37～64岁,平均54岁.透析时间2～15年.结果 20例手术操作均一次成功,术后6～8周用于临床穿刺透析,透析血流量220～300ml/min,血液再循环在正常范围,完全满足长期血液透析治疗的需要.结论 当前臂或上臂由于各种原因不能制作自体动静脉内瘘和前臂血管移植内瘘时,上臂腋窝制作人工血管移植血管内瘘是行之有效的方法.     

三维动态增强MR血管成像观察长期血液透析患者血管通路

目的评价三维动态增强磁共振血管成像（3D-DCE-MRA）观察长期血液透析患者自体动静脉内瘘功能不全的应用价值。方法对11例慢性肾功能不全接受长期血液透析的疑似自体内瘘功能不全患者行3D-DCE-MRA,观察血管通路。结果 11例患者均获得满意的血管图像。4例可见吻合口远端狭窄,其中3例位于流出道吻合处,1例位于距吻合口静脉端2cm处;2例可见尺动脉近段至吻合口段闭塞,桡动脉经掌弓动脉与尺动脉远段形成侧支循环后与头静脉相连;3例可见流出静脉瘤样扩张;2例可见静脉瘤形成。结论 3D-DCE-MRA可清晰显示自体动静脉内瘘及其相关血管,准确评价血管狭窄、闭塞及瘤样扩张。     

Bridging to a high flow upper arm native fistula for hemodialysis with the LifeSite Hemodialysis Access System

Permanent vascular access for chronic hemodialysis requires a reliable structure with adequate blood flow. Endogenous arteriovenous (AV) fistulas offer the best outcomes, but standard radiocephalic fistulas are not always feasible. A reliable alternative is a transposed basilic vein-brachial artery AV fistula, which offers a number of advantages over synthetic AV grafts. The transposed basilic vein fistula provides high flow rates along with low rates of infection, thrombosis, and other complications; however, longer maturation times may be nec-essary. This longer maturation time may necessitate the use of a "bridge device" for access. The new, fully subcutaneous vascular access device - the LifeSite(R) hemodialysis Access System - offers several significant advantages over a standard dialysis catheter as a bridge device: higher flow rates without recirculation, as well as lower rates of infection, thrombosis, and hospitalization. This article describes the surgical procedure for the creation of the transposed basilic vein fistula and the implantation procedure for the LifeSite System. We report on the use of this combined sequential approach to vascular access in 14 patients with excellent results. All 14 patients initially implanted with the LifeSite System were successfully bridged to a functional transposed basilic vein fistula. The mean flow rate with the LifeSite System was 450 ml/min; only one device had to be removed due to infection in an HIV-positive patient, and no other complications were observed. The mean time to maturation of the transposed basilic vein fistula was 6 months; the upper arm fistulas delivered a mean flow rate of 1100 ml/min with a 100% patency rate at 6 months. The sequential use of the LifeSite System and a transposed basilic vein fistula represents a valuable approach to increasing the usage of a high flow native AV fistula.     

Short- and long-term evaluation of arteriovenous fistulas for chronic hemodialysis.

One hundred ninety-three internal arteriovenous (A-V) fistulas were performed on patients with renal failure in the last eleven years. The A-V fistulas were divided on the basis of the following: side-to-side between the radial artery and cephalic vein (157 cases); end-to-side between the cephalic vein and radial artery (11 cases); end-to-end between the radial artery and cephalic vein (5 cases); A-V fistulas between the brachial artery and the cephalic, basilic or medial cubital vein (20 cases). The side-to-side A-V fistulas achieved an immediate patency in 88% of cases, lower than each of the other groups. However, the subsequent long-term failure rate was less than the other groups. In addition, satisfactory function was maintained at a high level (93%) during the follow-up period. The end-to-side and end-to-end A-V fistulas showed higher percentages of immediate patency (90% and 100%, respectively), although they were used more often on patients with vascular problems. Diabetic nephropathy was the main factor associated with thrombosis of A-V fistulas.