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.     

Clinical application of mid-thigh arteriovenous graft

Objective To evaluate the clinical outcomes of hemodialysis patients after superficial femoral artery-superficial femoral vein arteriovenous graft (AVG). Methods Hemodialysis patients with mid-thigh superficial femoral artery-superficial femoral vein AVG from August 2015 to March 2018 in department of vascular surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine were enrolled. Their clinical outcomes and complications after operation were analyzed retrospectively. Patency rates were measured by Kaplan-Meier survival curve. Results A total of 18 cases were enrolled. The success rate of the operation was 100% without complication. Follow-up time was (22.00±11.77) months with 100% follow-up rate. The 6 months-, 12 months-, 24 months-primary patency rates were 83.3%±8.8%, 48.5%±12.1%, 24.2%±13.5%, respectively; secondly patency rates were 100.0%, 100.0%, 87.5%±11.7%. There were 1 case of seroma, 1 case of puncture site infection, 11 cases of stenosis and 5 cases thrombosis during follow-up, while no heart failure, ischemia or pseudoaneurysm. Conclusion Mid-thigh AVG has low infection rate and high patency rate, so it can be as the first choice for the lower extremity AVG in hemodialysis patients.     

维持性血液透析患者前臂动静脉内瘘狭窄的球囊导管扩张治疗

目的：探讨球囊导管扩张（PTA）治疗维持性血液透析患者前臂动静脉内瘘（AVF）狭窄的临床效果。方法：自2006年01月～2010年06月,对5例前臂AVF的维持性血液透析患者进行了10次PTA治疗。结果：5例患者PTA术后即血流量恢复,但分别在3～24个月后复发,再次PTA治疗后血流量恢复;较短时间发生第1次复发的2例患者分别又在术后3、4个月发生第2次复发,其余患者目前尚未发生狭窄。结论：前臂AVF狭窄形成后,及时采用PTA治疗是修复失功能内瘘的一种行之有效的方法,PTA治疗后复发时间较长的患者,如发生再次复发可继续行PTA治疗。     

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。     

球囊扩张联合覆膜支架植入治疗人造血管动静脉内瘘狭窄

目的 探讨球囊扩张联合覆膜支架植入治疗人造血管动静脉内瘘(AVG)狭窄的临床疗效.方法 前瞻性选取15例经皮腔内血管成型术(PTA)疗效欠佳的AVG狭窄患者,且具备以下特点:狭窄长度不超过7 cm,狭窄程度大于50％;PTA后3个月内狭窄复发2次或以上;扩张后残余狭窄＞30％或狭窄部位立即弹性回缩.所有患者在数字减影血管造影(DSA)下行球囊扩张后植入不同内径的聚四氟乙烯覆膜支架.结果 男3例,女12例,平均年龄(66±12)岁.支架植入前内瘘平均使用时间为(19.5±15.0)个月.共植入支架16枚,技术成功率100％,植入部位为静脉吻合口9例(9/15);静脉流出道6例(6/15),其中头静脉3例,肱静脉2例,腋静脉1例.首次开通率3个月为40％,6个月为19％,12个月为13％.再次开通率3个月为93％,6个月为88％,12个月为87％.术后平均随访时间为(14.9±5.3)个月,再窄狭率为87％(13/15).术后PTA 36例次,支架内狭窄36％ (13/36);支架远端狭窄8％ (3/36);支架近端狭窄22％(8/36);与支架无关的狭窄33％ (12/36).AVG中位生存时间为25个月.结论 球囊扩张联合覆膜支架植入治疗AVG狭窄技术成功率高,并发症少,首次开通率不高,但再次开通率令人满意.     

Improvements in dialysis access survival with increasing use of arteriovenous fistulas in a Veterans Administration medical center

BACKGROUND: Native arteriovenous fistulas (AVFs) have been found to exhibit higher survival rates and lower complication rates than prosthetic grafts (AVGs). METHODS: Between August 2001 and December 2003, 93 patients with end stage renal disease (ESRD) had primary dialysis access placed at a single Veterans Administration medical center. Of these 93 patients, 67 had AVFs created and 26 patients had AVGs implanted. RESULTS: The percentage of patients who did not require additional intervention was 84% (56 of 67) for AVF and 78% (21 of 26) for AVG after 4 to 31 months of follow-up evaluation. In the AVF group, repeat interventions were as follows: collateral ligation (4), angioplasty owing to central stenosis (2), AVF ligation due to arterial steal phenomenon (1), and new AVF creation owing to clotting (1). Four AVFs were later converted to AVG. In the AVG group there were 4 venous anastomosis stenosis seen in 3 patients who required angioplasty. Two patients needed thrombectomy and revision, and 1 graft was removed because of infection. AVF prevalence in our dialysis patients was 63%, with 33% AVG and 4% temporary catheter. CONCLUSIONS: The National Kidney Foundation-Dialysis Outcome Quality Initiative (NKF-DOQI) guidelines for dialysis access reawakened interest in maximizing the use of renal veins for AVF. AVFs created by using the patient's native vein provides the best vascular access for dialysis when compared with prosthetic grafts. AVF has better long-term patency with fewer complications.     

血液透析动-静脉造瘘术后并发症的处理

目的 总结血液透析（血透）患者动静脉造瘘手术后并发症的处理经验。方法 收集我院120例患者,造瘘手术144例次,其中行内瘘134例次,人工血管瘘10例次。结果 术后扩要并发症：（1）血栓形成,AVF：17%、AVG：60%。内瘘血栓形成多发生于6周以内,治疗以重建新瘘道为主,或改建人工血管瘘;人工血管瘘血栓以取栓治疗为主,同时尽可能修复静脉流出道。（2）感染,AVG感染率为10%,行引流行移植物切除手术。（3）充血性心功能衰竭：3.5%,超滤、强心治疗。（4）窃血：1.4%,行血管成型和旁路架桥手术治疗。结论 积极预防和正确处理造瘘术后并发症可延长瘘道的通畅时间。     

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。     

Short- and long-term functional effects of percutaneous transluminal angioplasty in hemodialysis vascular access

The efficacy of percutaneous transluminal angioplasty (PTA) is usually expressed as the angiographic result. Access flow (Qa) measurements offer a means to quantify the functional effects. This study was performed to evaluate the short-term functional and angiographic effects of PTA and to determine the longevity of the functional effects during the follow-up period. Patients with an arteriovenous graft (AVG) or an arteriovenous fistula (AVF) who were eligible for PTA (Qa values of <600 ml/min) were included. Ultrasound-dilution Qa measurements were obtained shortly before PTA and periodically after PTA, beginning 1 wk after the procedure. The short-term effects were expressed as the increase in Qa and the reduction of stenosis. The long-term effects were expressed as patency and the decrease in Qa after PTA. Ninety-eight PTA procedures for 60 patients (65 AVG and 33 AVF) were analyzed. Qa improved from 371 +/- 17 to 674 +/- 30 ml/min for AVG and from 304 +/- 24 to 638 +/- 51 ml/min for AVF (both P < 0.0001). In 66% (AVG) and 50% (AVF) of cases, Qa increased to levels of >600 ml/min. The degree of stenosis decreased from 65 +/- 3 to 17 +/- 2% for AVG and from 72 +/- 5 to 23 +/- 7% for AVF (both P < 0.005). The reduction of stenosis was not correlated with DeltaQa (r(2) = 0.066). Six-month unassisted patency rates after PTA were 25% for AVG and 50% for AVF. The decreases in Qa were 3.7 +/- 0.8 ml/min per d for AVG and 1.8 +/- 0.9 ml/min per d for AVF. Qa values before PTA and DeltaQa were correlated with the subsequent decrease in Qa (P < 0.005). In conclusion, Qa increases after PTA but, in a substantial percentage of cases, not to levels of >600 ml/min. Qa values before PTA and the increase in Qa were correlated with long-term outcomes, whereas angiographic results were not. These data, combined with literature data, suggest that there is optimal timing for PTA.     

Treatment of failed native arteriovenous fistulae for hemodialysis by interventional radiology

BACKGROUND: We studied the feasibility, technical problems, safety, and effectiveness of percutaneous declotting of thrombosed native arteriovenous fistulae for hemodialysis. METHODS: Between 1992 and 1998, 93 declotting procedures were performed in 73 consecutive upper limb native fistulae (forearm 56 and upper arm 17), and 162 procedures were performed in 78 prosthetic grafts using manual catheter-directed thrombo-aspiration, with or without previous urokinase infusion. Detection of restenosis by clinical surveillance led to redilation or stent placement. Rethrombosis in four forearm and six upper arm fistulae were treated by 20 further declottings by aspiration. RESULTS: The initial success was 93% in the forearm and 76% in the upper arm (99% in grafts). The complications included one pulmonary embolism, one acute pseudoaneurysm, and one blood depletion requiring transfusion. Primary patency rates at one year were 49% in the forearm and 9% in the upper arm (14% in grafts). Secondary patency rates were 81 and 50% at one year, respectively (83% in grafts). Reinterventions were necessary every 19.6 months in the forearm and every 5.7 months in the upper arm (every 6.4 months in grafts, P < 0.05). Stents were placed in 11% of forearm fistulae and in 41% of upper arm fistulae (45% of grafts) for treatment of acute rupture (5 out of 19), stenosis recoil (6 out of 19), and early (< 6 months) recurring stenosis (8 out of 19). CONCLUSIONS: The percutaneous declotting of forearm fistulae by manual catheter-directed thrombo-aspiration was effective in more than 90% of cases and yielded 50% primary and 80% secondary patency rates at one year. The results were poorer in upper arm fistulae. The need for maintenance reinterventions was three times smaller in forearm fistulae than in upper arm fistulae and grafts.     

Effect of Secondary Interventions on Patency of Vascular Access Sites for Hemodialysis

PURPOSE: To determine the impact of secondary procedures performed to maintain arteriovenous fistula (AVF) and arteriovenous graft (AVG) patency. METHODS: There hundred and eighty six vascular access procedures were retrospectively evaluated. 156 (40.4%) patients required radiological interventions to treat acute thrombosis, swelling of the extremity with the access site, insufficient hemodialysis, or stenosis at an anastomotic site. RESULTS: The 386 cases comprised 106 AVGs and 280 AVFs. In 138 of the 156 cases, which required a radiological intervention, the treatment was successful and saved the vascular access site. The unassisted post-intervention patency time for these 138 successful cases was 13.1 +/- 12 months (range, 1-65 months). Twenty-nine (63%) of the 46 access sites treated with surgical thrombectomy were saved. CONCLUSIONS: Frequent, regular follow-up of hemodialysis patients with vascular access sites is the best way to diagnose problems early and allow the best chance of long-term function.     

Relation between autogenous arteriovenous fistula diameter and hemodynamic parameter

Objective To analyze the relationship between the least diameter of autogenous arteriovenous fistula and other parameters like flow rate and artery diameter. To identify an appropriate way in defining fistula stenosis. Methods Physical examination and Doppler ultrasound were used to examine the autogenous arteriovenous fistula of maintenance hemodialysis patients. Well-used wrist arteriovenous fistula was included. The least diameter of the fistula vein was found and marked by ultrasound, and the diameter and the distance between the point and the anastomotic stoma were measured. Diameters of different places along the cephalic vein of the fistula, including the forearm place, the place close to elbow and the upper arm place were measured by ultrasound. Meanwhile, diameter as well as flow velocity and flow rate of brachial artery, radial artery and ulnar artery were also measured. Result Sixty-eight patients were enrolled in the study. The average age of those patients was 52.56±2.00 years old. Thirty-one patients were female. Forty-nine fistula were located on the left arm. The average diameter and flow rate of brachial artery were 5.72(5.34, 6.33) mm and 821.50(540.50, 1075.00) ml/min, respectively. The average diameters of radial artery and ulnar artery were 3.95±0.10mm and 3.17(2.73,3.75) mm, respectively. The least diameter of cephalic vein was 3.34±0.11mm in average. The distance between the least place to the anastomotic stoma was 3.76±0.14cm in average. The diameter of forearm cephalic vein was averaged 5.36(4.52, 6.45) mm. Diameter of place close to elbow and the upper arm place in the cephalic vein were (5.57±0.12) mm and (5.80±0.14) mm, respectively. The least diameter of cephalic vein was positively and statistically associated with the diameter and flow rate of brachial artery as well as radial artery. The least diameter was also positively and statistically associated with the diameter of each place in the cephalic vein. Statistical inter-group difference was found when the division was based on the value of the least diameter. Conclusion sThe least diameter of the wrist autogenous arteriovenous fistula vein will indeed affect the whole diameter and flow rate of the fistula. The value of the least diameter is more closely associated with the fistula function rather than narrow rate.     

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.     

Minimal diameter of the fistula vein defines a significant stenosis in an autologous arteriovenous fistula

Objective To define a parameter of autologous arteriovenous fistula stenosis that limits the fistula function for hemodialysis in our country. Methods Retrospectively study the doppler ultrasound of patients who accepted the percutaneous transluminal angioplasty (PTA) therapy due to autogenous arteriovenous fistula dysfunction; identify the least diameter of the fistula vein and compare it with the corresponding data of well-functioned fistula. Determine which absolute diameter constitutes a hemodynamically significant stenosis in a radiocephalic autologous arteriovenous fistula by receiver operating characteristic curve (ROC curve). Result Forty-two patients were enrolled in the study. The average age of those patients was 54.63±2.44 years old. Twenty-one patients were female. Twenty-six fistula located on the left arm. The minimal diameter of the dysfunction fistula averaged 1.57±0.07 mm, while the average forearm fistula vein diameter was 4.04±0.23 mm, significantly smaller than those in the compare group - an average minimal fistula vein diameter of 3.34±0.11 mm and a forearm vein diameter of 5.36(4.52, 6.45) mm (P﹤0.05). The control group contained sixty-eight patients. The average age of those patients was 52.56±2.00 years old. Thirty-one patients were female. Forty-nine fistula located on the left arm. It was quiet appropriate in using minimal diameter of the fistula vein to indicate the dysfunction istula with an under-curve area of 0.979, 95%CI 0.959-0.998. The under-curve area would be at the largest level when meeting the cutoff point at 2.40mm, in which it could achieve the area of 0.853. Conclusions The minimal diameter of the dysfunction wrist autogenous arteriovenous fistula was much smaller than the functioned ones. Minimal diameter of the fistula vein may serve as an effective parameter in detecting dysfunction fistula.     

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。     

50例球囊扩张下动静脉内瘘术的临床效果评价

目的：探讨球囊扩张下血液净化用前臂动静脉内瘘术的手术方法以及临床效果。方法：总结暨南大学附属第一医院肾内科2005年7月～2012年1月收治的50例诊断明确的尿毒症患者因需要长期透析以及血管条件差而行球囊辅助下前臂动静脉内瘘术。手术选择病人的非主力手,分别游离头静脉和桡动脉,结扎头静脉的远端向头静脉和桡动脉的近端分别插入动脉取栓导管并用2ml注射器向导管内注入适量肝素生理盐水,充起球囊,根据需要持续均匀的扩张头静脉和桡动脉的狭窄段,再以7-0的血管逢线端侧吻合血管。结果：术后即时、1、2、3h、术后连续7d均能听到血管杂音以及扪及到血管震颤平均随访60个月手术的成功率90%以上。已有30例病人内瘘成熟并已使用超过3年以上,内瘘的血流量均大于250ml/min,完全能满足各种血液净化治疗的需要。结论：球囊辅助下前臂动静脉内瘘术手术成功率高,可以纠正动静脉血管条件差伴有部分狭窄的患者,内瘘成熟快,血流量大,临床效果好。     

Periodic Duplex Ultrasonography Screening Together with Elective Percutaneous Transluminal Angioplasty in the Management of Graft Arteriovenous Fistulas for Hemodialysis

Purpose To evaluate the effectiveness of regular duplex ultrasonography in the management of graft arteriovenous fistulas for hemodialysis. Methods Between March 1997 and December 2004, we prospectively studied consecutive patients who underwent polytetrafluoroethylene graft arteriovenous (AV) fistulae in the upper extremity with a subsequent regular duplex ultrasound examination for the identification of stenosis. The main ultrasound-guided indication for percutaneous transluminal angioplasty (PTA) was the identification of 50% or more venous stenosis. The assisted primary and secondary patency rates of vascular access were calculated in these 36 patients and were then compared with those in 19 patients who had undergone graft AV fistula before the start of regular ultrasonographic screening. Results The mean follow-up lasted 25 months. PTA procedures were performed in 24 patients, of which 13 patients received multiple PTAs. The half survival time (secondary patency) of the graft was 49 ± 3.8 months in patients who had undergone ultrasound screening followed by elective PTA, which was significantly (P < 0.01) longer than the 22 ± 7.1 months observed in patients who had not undergone regular duplex ultrasound screening. Conclusion The prospective monitoring of AV fistula with ultrasound is a simple and reliable technique for detecting graft AV outflow stenosis. Elective PTA is therefore considered to be an effective therapy for the maintenance of hemodialysis access.     

Arteriovenous fistula aneurysmorrhaphy is associated with improved patency and decreased vascular access abandonment

BackgroundUpper extremity hemodialysis arteriovenous fistulas (AVFs) can become aneurysmal over time due to repeated cannulation and/or outflow steno-occlusive disease. The optimal surgical management of aneurysmal AVFs (aneurysmorrhaphy vs interposition graft) has remained unclear.MethodsWe performed a retrospective review in which current procedural terminology codes were used to screen for patients who had undergone surgical treatment of aneurysmal AVFs between 2016 and 2021 at a single hospital system. The patients were included after a review of the operative reports. The cases were divided by surgical procedure (aneurysmorrhaphy vs interposition graft placement). The patients who had undergone primary AVF ligation or other types of repair were excluded. The primary outcomes were primary assisted and secondary patency, and the secondary outcome was dialysis access abandonment. Multivariable Cox proportional hazards regression was used to test the association between the type of AVF aneurysm repair and the primary and secondary outcomes.ResultsFrom 2016 to 2021, 6951 patients had undergone 16,190 dialysis access procedures. Of these procedures, 381 (2.4%) were related to surgical treatment of an aneurysmal AVF. We excluded 58 primary AVF ligation cases and 20 cases involving other types of repair, leaving 303 cases for analysis. These were divided into two groups: aneurysmorrhaphy (n = 123; 41%) and interposition graft (n = 180; 59%). No differences were found between the groups in male gender (68% vs 63%), hypertension (98% vs 98%), or central stenosis (14% vs 22%). The patients who had undergone aneurysmorrhaphy were younger (median age, 54 years vs 59 years); had had a lower rate of diabetes (41% vs 59%), coronary artery disease (41% vs 58%), and congestive heart failure (41% vs 55%); and were less likely to have undergone upper arm access (72% vs 92%). The median follow-up was 11.1 months (interquartile range, 3.6-25.2 months). No differences were found in the incidence of 30-day wound complications (1% vs 3%) or surgical site infections (4% vs 6%). On multivariable Cox regression, interposition graft placement was associated with the loss of primary assisted patency (adjusted hazard ratio [aHR], 2.42; 95% confidence interval [CI], 1.18-4.95), loss of secondary patency (aHR, 3.10; 95% CI, 1.21-7.94), and abandonment of dialysis access (aHR, 3.07; 95% CI, 1.61-5.87; P < .05 for all) at 2 years.ConclusionsAVF aneurysmorrhaphy was associated with improved primary assisted and secondary patency and decreased abandonment of dialysis access. We suggest using aneurysmorrhaphy when AVF aneurysms are indicated for repair. However, individual factors such as patient comorbidities, AVF anatomy, remaining dialysis access options, and patient preference should be considered when planning the surgical approach.     

Evaluation of the efficacy of the transposed upper arm arteriovenous fistula: a single institutional review of 190 basilic and cephalic vein transposition procedures

INTRODUCTION: Although autogenous brachial-basilic upper arm transpositions (BVT) have been extensively utilized, there has been significant disparity in published patency rates. Very little is known about the efficacy of autogenous brachial-cephalic upper arm transpositions (CVT). We evaluated our experience with transposed upper arm arteriovenous fistulas (tAVF) in order to assess patency and identify factors that affect efficacy. We then compared our tAVF patients with a cohort of upper arm arteriovenous grafts (AVG). METHODS: A retrospective review was conducted of tAVF performed at our institution from 1998 to 2004. The tAVF group consisted of 119 BVT and 71 CVT procedures. We compared these with 164 AVG. tAVF were placed only for veins >/=2.5 mm in diameter by duplex ultrasonography. RESULTS: Mean follow-up was 28 months. With the exception of mean vein diameter, the patients in the BVT and CVT groups had similar demographic parameters and complication rates. Primary and secondary patency rates were 52% and 62% at 5 years for BVT and 40% and 46% at 5 years for CVT, respectively (P = NS). Multivariate analysis revealed that hemodialysis dependence at the time of fistula placement and history of previous upper arm access independently affected primary patency. History of upper torso dialysis catheters independently affected secondary patency. Comparison of the tAVF and AVG groups revealed that tAVF patients were significantly younger, more likely to be male, less likely to be African American (AA) and less likely to have a history of previous AV access. The primary patency rate for tAVF was significantly higher than for AVG: 48% vs 14% at 5 years (P < .001). The secondary patency rate for tAVF was also significantly higher than for AVG: 57% vs 17% at 5 years (P < .001). Among the tAVF procedures, 9% required one or more revisions to maintain secondary patency, compared to 51% with the AVG group (P < .001). Multivariate analysis revealed that presence of AVG and a history of previous upper arm access negatively affected primary and secondary patency. CONCLUSIONS: Autogenous BVT and CVT have similar, high patency rates. Transposed upper arm arteriovenous fistulas have higher patency rates than upper arm AVG and require significantly fewer revisions. Our data strongly support the contention that as long as the patient is a candidate for an upper arm tAVF, based on anatomical criteria, a tAVF should always be considered before an AVG.     

下肢人工血管移植物内瘘的应用及中远期效果观察

背景与目的：终末期肾病（ESRD）是各种原因导致的慢性肾脏疾病进展到终末期阶段,大部分ESRD患者选择血液透析肾脏替代治疗,而功能良好且通畅率令人满意的血管通路对其至关重要。上肢是患者构建血液透析通路的首选位置,但部分患者因各种原因存在上肢血管或中心静脉资源耗竭等问题,无法构建上肢血管通路。对此,可以考虑构建下肢人工血管移植物内瘘（AVG）作为患者长期血液透析的通路,本研究回顾性分析构建下肢AVG患者的临床资料与中远期随访结果,以期为此提供经验证据。 方法：回顾2014年3月—2018年11月南方医科大学南方医院血管外科32例构建下肢AVG的ESRD患者临床资料与随访资料,分析患者的相关临床指标,用Kaplan-Meier法计算患者术后的初级通畅率和次级通畅率。 结果：全组患者术后均能触及AVG震颤,围术期1例患者出现慢性心功能不全急性发作,予药物、加强透析治疗后未见明显好转后死亡;2例患者出现移植物血栓形成,切开导管取栓后造影未见吻合口及流出道静脉狭窄,术后AVG恢复通畅,顺利透析。所有患者围术期间无感染、透析通路相关性肢端缺血综合征（HAIDI）、假性动脉瘤等并发症发生。术后随访1~60个月,中位随访时间14.1个月。随访期间出现AVG狭窄13例（40.6%）,闭塞10例（31.3%）,经外科手术或腔内手术修复后恢复AVG通畅;人工血管移植物感染3例（9.4%）,其中1例患者移植物局段感染,行人工血管移植物感染段切除,自体静脉移植术后顺利保留AVG并用于透析,2例患者因移植物全段感染予全段切除。期间未出现假性动脉瘤、HAIDI等并发症。患者术后初级通畅时间为（20.4±3.32）个月,1、2、3年初级通畅率为64.6%、44.7%、19.6%;次级通畅时间为（38.7±5.52）个月,1、2、3年次级通畅率为79.6%、79.6%、54.6%。 结论：下肢AVG经修复后可达到较满意的次级通畅率,对于无法建立上肢血管通路患者而言,是安全、有效的通路选择。规范的术前评估、手术及穿刺中严格的无菌操作以及规律的随访是保证其远期通畅的重要因素。