球囊扩张成形术处理透析用动静脉内瘘狭窄性病变及短中期结果

目的:探讨球囊扩张成形技术在治疗血液透析用动静脉内瘘(AVF)狭窄的临床效果。方法:回顾性分析2014年5月—2015年12月间采用球囊扩张成形技术治疗的31例血液透析用AVF狭窄性病变患者的临床资料。结果:31例患者中,男18例,女13例;桡动脉-头静脉内瘘27例,桡动脉-贵要静脉内瘘2例,尺动脉-贵要静脉内瘘2例;均接受球囊扩张技术治疗。28例(90.3%)获得技术上的成功,围手术期无患者死亡。1例患者术后出现动脉穿刺处假性动脉瘤,1例患者术后出现AVF血栓形成,1例患者出现前臂皮下血肿,其他所有患者AVF恢复通畅并能够以正常流量进行血液透析治疗。术后随访3~12个月,3、6、12个月初次通畅率分别为92.9%,75.0%,50.0%。结论:球囊扩张成形术处理AVF狭窄性病变微创、安全,是AVF狭窄性病变的合理治疗方法,但其中长期疗效仍有待于进一步改善。     

超声引导下腔内血管成形术治疗动静脉内瘘狭窄早期疗效评估

目的探讨超声引导下腔内血管成形术在治疗血液透析动静脉内瘘(AVF)狭窄的早期疗效。方法回顾性分析接受超声引导下经皮腔内血管成形术(PTA)治疗的24例前臂AVF狭窄的透析患者的临床资料,比较术前及术后即刻狭窄处内径,对通畅率采用Kaplan-Meier生存分析。结果 24例患者均获得技术成功,成功率为100%(24/24)。无穿刺部位假性动脉瘤及皮下血肿等并发症发生,除1例术后AVF血栓形成,围术期无患者死亡。术后随访3、6、9、12个月的初级通畅率分别为87.50%(21/24)、83.33%(20/24)、79.17%(19/24)、58.33%(14/24)。结论超声引导下PTA治疗AVF狭窄性病变微创、安全,是AVF狭窄性病变的合理治疗方法,近期效果明显。     

经桡动脉行自体动静脉内瘘功能不良的介入治疗

目的探讨经桡动脉行自体动静脉瘘(AVF)腔内成形和(或)溶栓治疗的可行性。方法于因AVF狭窄或血栓闭塞而需行介入治疗的患者中,选取经桡动脉入路介入治疗的8例患者进行回顾性分析。结果首次造影证实6例患者为AVF重度狭窄,即刻行腔内球囊成形术,术后狭窄程度改善;对2例急性血栓形成患者行动脉内溶栓治疗,次日复查造影示血栓溶解,其中1例溶栓后造影显示吻合口附近静脉狭窄严重,行PTA治疗,另1例狭窄程度较轻者未进一步PTA治疗。对8例患者随访2~13个月,其中7例可正常行AVF透析,1例单纯PTA治疗患者2个月后再次行PTA治疗,4个月后因AVF功能不良而改行颈内静脉插管透析。结论经桡动脉行AVF功能不良的介入治疗有一定的可行性。     

活血化瘀药防治动静脉内瘘并发症的研究进展

<正>动静脉内瘘(arteriovenous fistula,AVF)是维持性血液透析患者的生命线,内瘘狭窄和血栓形成是AVF最常见的并发症,常直接导致AVF丧失功能[1,2]。无论是新建立的内瘘,还是在使用过程中,血液透析患者终身都笼罩在内瘘无法正常使用的阴影中,给患者造成巨大的心理影响和经济损失。据相关报道:新建立的AVF有50%的内瘘狭窄或血栓形成发生在透析前,84%发生在透析第1年[3];在AVF使用的6个月、1年、2年、3和4年中,AVF通畅率分别为79. 5%,70. 0%,65. 0%,60. 5%,48. 0%[4]。内瘘失功后主要治疗措施是重新建立内瘘,这会极大地减少患者有效血管供给,反复重建会耗竭血管通路,而预防内瘘狭窄和血栓形成的措施有限,效果不佳。随     

中药贴敷配合温和灸促进血液透析患者动静脉内瘘成熟研究

目的探讨中药贴敷配合温和灸对促进维持性血液透析患者自体动静脉内瘘(AVF)成熟的作用。方法将60例首次行AVF成形术患者,随机分为对照组和观察组各30例,对照组实施AVF围手术期常规护理,观察组在常规护理基础上术后1周实施中药贴敷配合温和灸,连续3周后评价效果。结果干预后观察组AVF血流量显著优于对照组(P<0.05),AVF均成熟;对照组4例AVF未成熟重新手术;两组瘘口狭窄、血栓发生率比较,差异无统计学意义(均P>0.05)。结论 AVF成形术后1周增加中药贴敷配合温和灸干预,能有效增加AVF血流量,促进AVF成熟。     

动静脉内瘘和起搏器同侧所致肿胀手综合征及腔内治疗效果观察

目的观察自体动静脉内瘘(arteriovenous fistula,AVF)和起搏器位于患者手臂同侧时是否容易出现肿胀手综合征以及腔内治疗效果。方法试验组:起搏器同侧建立AVF的患者10例;对照组:起搏器对侧建立AVF的患者10例。观察内容:(1)内瘘侧颈静脉或锁骨下静脉有无透析导管置入史;(2)存在起搏器导线的情况下AVF术后或者存在AVF的情况下同侧安装起搏器术后出现内瘘侧肢体肿胀时间;(3)中心静脉狭窄或者闭塞部位;(4)腔内治疗方法;(5)腔内治疗后复发时间;(6)经皮腔内血管成形术(percutaneous transluminal angioplasty,PTA)对起搏器导线功能有无影响。结果试验组:8例患者内瘘、起搏器同侧共存17.0(2.6,30.0)个月后开始出现肢体肿胀;1例患者内瘘、起搏器同侧共存3.5年后内瘘闭塞,闭塞前内瘘侧肢体仅有轻度肿胀,无需干预;1例患者内瘘、起搏器同侧共存4.5年内瘘侧肢体无肿胀。治疗上,2例患者对侧上肢重新建立内瘘,新的内瘘成熟后关闭患侧内瘘。6例患者行单纯PTA治疗,共10例次,单纯PTA术后至肿胀复发时间为(6.0±4.9)个月,所有患者均未置入支架。PTA术后起搏器功能无异常。对照组:截止到观察终点所有患者均未出现内瘘侧肢体肿胀。结论动静脉内瘘和起搏器位于同侧时相对容易出现肿胀手综合征,中心静脉病变单纯PTA效果相对较差,不建议放置支架。短期观察球囊扩张对起搏器导线功能无明显影响。     

介入手术联合口服培哚普利治疗血液透析患者动静脉瘘功能不良的疗效

目的 探讨经皮血管成形术(percutaneous transluminal angioplasty,PTA)治疗血液透析动静脉内瘘狭窄的有效性,比较介入手术后联合培哚普利对再次狭窄率的影响.方法 对17例自体血管动静脉内瘘狭窄患者行血管造影,其中15例行PTA.7例患者PTA术后每日口服培哚普利8 mg,7例患者未服用任何血管紧张素转换酶抑制剂(angiotensin converting enzyme inhibitor,ACEI)和血管紧张素Ⅱ受体拮抗剂(angiotensin receptor blocker,ARB).术后对患者进行随访,观察球囊扩张术的并发症、技术成功率、临床成功率和半年通畅率.结果 17例患者均在动静脉内瘘成熟并使用3个月以上发生功能不良,造影见狭窄多位于动静脉吻合口附近及头静脉透析用穿刺段.经PTA治疗后,造影显示狭窄段血管扩张、再通,治疗技术成功率达86.7％ (13/15),临床成功率达93.3％(14/15).2例患者因为导丝无法通过近乎闭塞段血管而选择其他手术方式.穿刺部位血肿2例,无医源性血管破裂,无继发血栓形成.随访6个月,14例获得临床成功的患者内瘘半年通畅率为64.3％,其中培哚普利组发生再次狭窄1例,对照组发生再次狭窄4例.结论 PTA是治疗动静脉内瘘狭窄安全、有效及微创的方法,联合口服培哚普利可能有助于降低术后再次狭窄率.     

前臂非常规自体动静脉瘘在血液透析患者中的应用及护理

目的：探讨前臂非常规自体动静脉瘘在维持性血液透析患者中的临床应用和护理方法。方法2007年12月至2013年12月对119例维持性透析患者进行前臂非常规自体动静脉瘘手术,其中,81例为原桡动脉-头静脉内瘘失功,38例为初次行血管内瘘手术。所有患者均有针对性地采用系统化护理干预。结果在119例患者中,109例患者手术一次取得成功（92％）,术后血流量200～350 ml/min。对患者的心功能未造成不良影响,未出现严重并发症。结论有针对性的系统化护理干预能够有效提高前臂非常规自体动静脉手术的成功、成熟和使用。     

动静脉内瘘闭塞的原因探讨及防治

目的：探讨血液透析患者动静脉内瘘（AVF）闭塞的原因及如何预防、治疗。方法：对91例建立永久性AVF并行维持性血液透析患者进行回顾性分析。发生栓塞者分别行内瘘动脉端注入尿激酶或肝素及导管介入下溶栓。结果：发现21例AVF闭塞,其中原发病为糖尿病患者10例,穿刺不当及压迫时间过长者5例,低血压者4例,心动过缓1例,促红素未及时减量者1例。其中8例发现栓塞〈12 h,予溶栓治疗后5例再通。结论：AVF闭塞与糖尿病,瘘口压迫时间过长,内瘘穿刺不当,血液黏滞度增加,透析中低血压等因素有关,尽早发现内瘘闭塞及尽早行溶栓治疗是再通的关键。     

超声引导下经皮血管成形术治疗血透患者动静脉内瘘狭窄的临床效果研究

目的研究分析超声引导下行PTA治疗AVF狭窄的整体疗效。方法选取2019年6月至2020年6月本院收治的AVF狭窄患者共97例,治疗医师根据入院先后顺序将97例患者分为两组。其中对照组48例,行DSA引导下PTA手术治疗;观察组49例,行超声引导下PTA手术治疗。结果观察组患者的单次穿刺完成率及手术成功率均明显高于对照组患者(P0.05),术后观察组的透析血流量、狭窄血管内径值均明显大于对照组(P0.05);观察组患者术后AVF再次出现狭窄的平均时间明显长于对照组患者(t=13.5112,P0.05)。结论对于AVF狭窄患者,采用超声引导下PTA治疗可以获得更为满意的治疗效果,适合治疗医师选择应用。     

Cutting balloon angioplasty in hemodialysis arteriovenous fistula stenosis resistant to conventional balloon angioplasty

Objective To investigate the efficacy and safety of cutting balloon angioplasty for the treatment of hemodialysis arteriovenous fistula stenosis resistant to conventional percutaneous transluminal angioplasty (PTA). Methods The patients with arteriovenous fistula stenosis who had suboptimal results (residual stenosis ＞30%) by conventional PTA from December 2011 to February 2015 were enrolled. All the patients received cutting balloon angioplasty were rechecked every three months. Results A total of 25 patients with age of (60.7±12.9) years had suboptimal PTA results. Eleven patients with native arteriovenous fistula (AVF) and 14 patients with graft fistula (AVG) underwent cutting PTA for 30 times. The technical success rate was 86.7% and clinical success rate was 100%. The diameter stenosis pre-procedural and post-procedural of cutting PTA was (1.7±0.6) mm and (4.5±0.8) mm respectively (P＜0.05). Six patients had multiple lesions and the stenosis consisted of 21 outflow venous, 6 graft-to-vein anastomosis, 6 cephalic arch, 2 artery and 1 puncture hole stenosis. The primary access patency at 3 and 6 months for AVF group were 70.0% and 10.0%, while for AVG group the figures were 64.3% and 7.1% (P＞0.05). The secondary access patency at 3 and 6 months for AVF group were 70.0% and 30.0%, while for AVG group the figures were 85.7% and 64.3% (P＞0.05). The follow-up time was (8.1±7.3) months. The restenosis rate was 64.0%. Cutting PTA failed to achieve technical success for four times, of whom 2 patients required graft stent implantation and 2 patients required ultra-high-pressure balloons angioplasty to finally achieve technical success. The median survival time of fistula was 173 days. Conclusions Cutting balloon angioplasty have well short-term patency and safety in arteriovenous fistula stenosis resistant to conventional PTA, especially for calcified lesion or "balloon waist". Although it could provide a satisfied long patency by recurrent PTA, the use of cutting balloon would be not advocated as the first-line treatment for fistula stenosis. The efficacy superiority of cutting balloon between AVF and AVG, as well as the cost-effect comparison between cutting balloon and high-pressure balloon, remains unclear, the verification of which requires large-sampled, prospective and randomized studies.     

Restoration of acutely thrombosed arterio-venous fistulae by rTPA and percutaneous angioplasty

Acute thrombosis in native arterio-venous fistulae (AVF) results in considerable patient morbidity. Interventional radiology (IR) comprising thrombolysis and percutaneous transluminal angioplasty (PTA) is well established in the management of thrombosed polytetrafluoroethylene (PTFE) grafts. However its role in thrombosed AVF is uncertain. We looked retrospectively at the role of IR in re-establishing blood flow in acutely throm-bosed AVF. Between 1992-2000, 21 episodes of acutely thrombosed AVF in 15 patients (9 females; age range 29-80yrs) were referred for intervention. All fistulae were being used for haemodialysis at the time. Diagnosis was established by angiography and thrombolysis with recombinant tissue plasminogen activator (rTPA) was attempted in all patients. Discrete stenoses when present (n=12) were then treated with PTA and resistant or recurrent stenoses were managed by stent insertion (n=3). Patients were then heparinised for 24 hours. Technical success as defined by radiological patency was achieved in 86% cases. Clinical success i.e. the ability to reuse of the fistula for haemodialysis was achieved in 62% of the interventions, where patency rates at 3 and 6 months were 92% and 69% respectively. Five patients had recurrence of thrombosis >3 months after the primary procedure, 3 had successful reintervention. Minor local bleeding was the only complication. Our retrospective study shows rTPA and PTA is successful in the management of acutely thrombosed AVF. We advocate the routine use of IR as a valuable technique for prolonging the life of native AVF in patients on maintenance haemodialysis.     

维持性血液透析患者自体动静脉内瘘失功的影响因素分析

目的：回顾性分析维持性血液透析患者自体动静脉内瘘（AVF）失功的影响因素。方法：以我院血透中心73例首次发生自体AVF失功的患者为内瘘失功组,选取同期自体AVF功能良好的136例维持性血液透析患者为内瘘通畅组,比较两组患者各项临床及生化指标,分别进行单因素分析及logistic回归分析。结果：内瘘失功组和通畅组在年龄、糖尿病、血红蛋白、血清白蛋白、血小板、三酰甘油、血清铁、C反应蛋白（CRP）、血钾、血磷、甲状旁腺激素（PTH）等方面差异存在统计学意义（P〈0.05）;logistic回归分析显示患有糖尿病（OR=1.551）,血清白蛋白（OR=1.061）、三酰甘油（OR=1.275）、血磷（OR=1.580）水平是内瘘失功的危险因素;内瘘失功组的生存分析显示糖尿病患者内瘘的中位生存时间为7个月,非糖尿病患者为27个月,差异有统计学意义（P=0.002）;分别进行内瘘失功组和通畅组的组内比较,糖尿病患者与非糖尿病患者在血清白蛋白、三酰甘油、血磷方面差异存在统计学意义（P〈0.05）。结论：糖尿病、血清白蛋白、三酰甘油、血磷水平是内瘘失功的危险因素,糖尿病患者内瘘使用时间明显短于非糖尿病患者,其影响因素与血清白蛋白、三酰甘油、血磷水平密切相关。     

北京市单中心初始血液透析动-静脉内瘘使用情况及相关因素分析

目的调查维持性血液透析（maintenance hemodialysis,MHD）患者初始透析动一静脉内瘘使用情况,并分析其相关因素,为提高初始透析动一静脉内瘘使用率提供参考依据。方法选择2012年1～3月北京市海淀医院接受维持性血液透析患者86例,采用问卷调查方式记录患者一般情况（如年龄、性别、婚姻状况、文化程度、职业、家庭收入）;患者疾病相关情况[如原发病、透析时间、肾科专科随访时间、在预计进入透析前半年行建立透析通路告知（以下称“预先通路告知”）、告知透析医院级别、居住地与最近医院距离、居住地与透析医院距离];对上述指标进行量化后Logistic回归分析。结果北京市海淀区单中心初始血液透析动一静脉内瘘使用率约为30．2％（26／86）,肾科专科随访1年以上（OR值4．825,P=0．02）、预先通路告知（0R值22．15,P=0．006）是主要影响因素。结论早期肾科专科随访、预先通路告知是影响维持性血液透析患者首次透析动一静脉内瘘使用的重要因素,慢性肾脏病患者早期肾科专科就诊、告知患者选择合适时机建立动一静脉内瘘可以提高初始血液透析动一静脉内瘘使用率。     

Percutaneous treatment of symptomatic central venous stenosis [corrected

OBJECTIVES: The increased use of central venous access primarily for hemodialysis has led to a significant increase in clinically relevant central venous occlusive disease (CVOD). The magnitude of and the optimal therapy for CVOD are not clearly established. The purpose of this study is to define the problem of CVOD and determine the success of percutaneous therapy for relieving symptoms and maintaining central venous patency. METHODS: Patients presenting with disabling upper-extremity edema suggestive of central venous stenosis or occlusion during a 3-year period were evaluated by venography of the upper extremity and central veins. Percutaneous venous angioplasty (PTA) and/or stent placement was performed as clinically indicated. The success of therapy was assessed, and the patients were observed to determine the incidence of recurrence and additional procedures. Recurrent lesions underwent similar evaluation and treatment. RESULTS: A total of 32 sides were treated in 29 patients with a mean of 1.9 interventions per side treated. Hemodialysis-related lesions were the underlying cause in 87% with the remaining 13% related to previous central venous catheterization. The lesions involved the axillary, subclavian, and innominate veins with complete venous occlusion in six (19%) cases. Percutaneous angioplasty was followed by stent placement in six (19%) cases. The procedure was a technical success and was performed without complications in all cases (100%). Mean follow-up was 16.5 months (range, 4-36 months). On average, patient symptoms were controlled for 6.5 months after the initial intervention. Recurrent edema led to additional PTA in 20 (63%) cases. Fifty percent (n = 14) of patients with an arteriovenous fistula (AVF) experienced recurrent symptoms after initial and/or repeat PTA and required AVF ligation. Complete resolution after the initial PTA was predictive of long-term success. CONCLUSIONS: Central venous occlusive disease has emerged as a significant clinical problem. Percutaneous venous angioplasty can provide temporary symptomatic relief; however, multiple procedures are often required and long-term relief is rarely achieved.     

单中心血液透析患者血管通路使用情况分析

目的 探讨维持性血液透析患者血管通路的使用情况,为进一步规范化选择建立和使用维护血液透析血管通路提供依据.方法 采用单中心横断面调查及回顾性分析的研究方法,统计分析2012年1月至2012年12月兰州军区兰州总医院血液净化中心新入血液透析患者156例与维持性血液透析患者120例人口统计学资料、血管通路类型,并对自体动静脉内瘘与长期血液透析导管患者原发病种类进行对比分析.结果①首次血液透析血管通路为临时血液透析导管的占84％,成熟的自体动静脉内瘘占16％,无长期血液透析导管;②长期维持性血液透析患者血管通路为自体动静脉内瘘251例（占90.9％）,长期血液透析导管14例（占5.1％）,动静脉直接穿刺及其他11例（占4.0％）,无动静脉移植血管内瘘.自体动静脉内瘘吻合血管依次为桡动脉-头静脉占96％,桡动脉-贵要静脉占2％,尺动脉-贵要静脉占2％;自体动静脉内瘘瘘管吻合方式端侧吻合占54％,端端吻合占46％,无侧侧吻合.自体动静脉内瘘发生并发症17例,血栓12例（占并发症总例数70.6％）,其余依次为缺血（占10.2％）,狭窄（占10.2％）,肿胀手（占0.9％）.长期导管年平均感染率为0.1次/1 000导管日.结论①新入血液透析患者中,选择临时血液透析导管比例较大,预先行动静脉内瘘血管通路准备的血液透析患者比率仍较低,但较前明显提高,需要积极专科宣教提高终末期肾脏疾病患者认识和依存性;②维持性血液透析患者自体动静脉内瘘使用率与文献报道接近,但尚无移植物和人造血管内瘘病例,尚有一定比例的患者直接选择穿刺;③自体动静脉内瘘术失败与年龄无关,基础疾病心血管疾病糖尿病等及反复血管穿刺是自体动静脉内瘘术失败的主要原因.     

Ultrasound evaluation and interventional therapy for peripheral vascular access stenosis in dialysis patients

Objective To investigate the patency rate and restenosis after percutaneous transluminal angioplasty (PTA) for the treatment of arteriovenous fistula (AVF) and arteriovenous graft (AVG) stenosis in dialysis patients. Methods The patients who were successfully treated by PTA for the first time in the blood purification center of the 2nd Affiliated Hospital of Nanjing Medical University from January 2016 to June 2017, including 71 cases of AVF in the forearm, 52 cases of AVF in the upper arm and 59 cases of AVG were recorded. The data of different stenosis parts were analyzed before and after treatment and followed up for 12 months. The initial patency rate and assisted-PTA patency rate were observed at 3 months, 6 months, 9 months, and 12 months after ultrasound interventional therapy, and the initial patency time for patients who needed to reintervention among all types of pathways were recorded. Results The initial patency rates at 3 months, 6 months, 9 months and 12 months after ultrasound interventional therapy were 98.59%, 90.14%, 71.93%, 54.93% respectively in forearm AVF, 90.38%, 65.38%, 42.31%, 32.69% respectively in upper arm AVF, 91.53%, 32.20%, 6.78%, 1.69% respectively in AVG, and the PTA-assisted patency rates were 98.59%, 97.18%, 95.77%, 94.37% respectively in forearm AVF, 92.31%, 86.54%, 84.62%, 80.77% respectively in upper arm AVF, 100.00%, 98.31%, 96.61%, 93.22% respectively in AVG, while the initial patency time was (8.99±3.54) months in forearm AVF, (6.33±3.01) months in upper arm AVF, (4.80±1.40) months in AVG respectively. Conclusions Ultrasound can comprehensively evaluate the function of peripheral vascular access, guide PTA treatment, and evaluate treatment outcomes. Ultrasound intervention therapy has best initial patency rate for forearm AVF stenosis. The prognosis of upper arm AVF stenosis PTA is relatively poor due to the easy cephalic stenosis. Although AVG has a short interval of restenosis, it can achieve a better long-term patency rate through regular intervention with ultrasound intervention.     

两种自体动静脉瘘术式在老年血液透析患者中的应用观察与分析

目的 观察和分析老年血液透析患者自体动静脉内瘘（AVF）的应用。方法 收集北京大学深圳医院手显微外科自2012年6月到2018年6月期间收治的血液透析患者的临床资料。按血管通路类型分为2组：头静脉-桡动脉AVF（桡-头AVF组,n=161）、尺动脉-贵要静脉AVF（尺-贵要AVF组,n=32）。通过查询住院病历、门诊记录、随访记录,通过血管通路（AV）前后的彩色多普勒超声（DUS）等检查,观察和记录记录的患者内瘘成熟、功能障碍、管腔狭窄等信息。结果 在纳入的193例中,92例（47.7%）在AV建立前使用中心静脉插管（CVC）进行血液透析,平均使用时间为134.8±66.2 d。两组在年龄、性别、血压、实验室检查、ESRD病因和伴发疾病方面没有显著差异;14例（7.4%）放弃VA,21例（10.8%）因各种原因死亡;28例（14.7%）因静脉瘘管失功不能使用VA,其中13例（6.8%）接受二次或改良手术。桡-头AVF组和尺-贵要AVF组在上述数据间的差异没有统计学意义。AVF术后并发症分别为血栓、血肿形成、感染、动脉瘤形成、管腔狭窄和静脉瘤样扩张,组间差异无统计学意义。老年患者在建立AV后的各种原因的死亡以及导致AVF失败或弃用的相关因素涉及到年龄、外周血管疾病、桡动脉直径有关,但与手术方式选择无关。结论 AVF安全有效,并发症低;医生可根据经验和患者具体情况选择手术方式。