获得性动-静脉瘘的介入微创治疗

目的 评价用介入微创技术治疗获得性动一静脉瘘(AVF)的安全性和疗效。方法 对10例不适宜传统外科治疗的AVF患者进行介入治疗,包括肾动-静脉瘘4例、髂动-静脉瘘3例、锁骨下动-静脉瘘3例。致病原因为穿通性损伤5例、医源性损伤3例、恶性肿瘤和小肠Crohn病各1例。就诊时临床表现有肢体肿胀-静脉显露6例、局部血管杂音10例、心脏负荷增加10例、右心功能衰竭2例、血尿4例。3例用经导管超选择性栓塞,7例用被覆膜支架置人封闭瘘口。结果 10例患者均治疗成功,治疗结束时复查血管造影显示瘘口被封闭。轻微并发症3例,无严重并发症。术后患者局部肿胀、静脉充血、心脏负荷过度等症状迅速改善,血管杂音消失;肾脏AVF患者,术后肾功能测定属于正常,其中2例肾动脉被覆膜支架置入患者同位素肾扫描显示患侧肾脏形态-功能正常。术后随访6个月至6年。3例患者分别于术后6、9、14个月死于与AVF无关的疾病;2例于术后3周、2个月因AVF复发,在原支架区再次置入一个被覆膜支架后残留瘘口闭塞;2例于术后6、8个月复查造影显示支架区存在轻度狭窄。7例患者仍然生存,未再针对AVF进行外科或介人治疗。结论 介入微创技术,包括超选择性栓塞和被覆膜支架置入术,是治疗获得性、复杂型AVF安全有效的方法。

Treatment of acquired arteriovenous fistulas with interventional minimally invasive techniques

OBJECTIVE: To evaluate the efficacy and safety of the interventional techniques for treatment of acquired arteriovenous fistulas (AVF). METHODS: Ten patients with acquired AVFs, including 4 with renal AVF, 3 with iliac AVF, and 3 with subclavian AVF, were treated with interventional procedures. The etiological factors of the AVFs were penetrating trauma in 5 cases, iatrogenic injury in 3, malignancy in 1, and intestine Crohn's disease in 1. The patients presented with peripheral venous hypertension (n = 6), local bruit (n = 10), cardiac overload (n = 10), the right cardiac failure (n = 2), and hematuria (n = 4). Three patients underwent transcatheter super-selective coils embolization and 7 underwent stent-graft placement in the involved arteries. RESULTS: The technical success was achieved in all cases. Completion angiography documented complete exclusion of the fistulas. Minor complications occurred in 3 patients, but without significant consequences. The patients experienced immediate relief of the limb swelling, peripheral venous hyperemia, and tachycardia. The local bruit was disappeared. The cardiac overload conditions were improved significantly, which was confirmed by ultrasound scan. Renal function tests in patients with renal AVF were stable. Radioactive isotopic scan revealed that the function was preserved in the treated kidney in two patients using stent-graft placement in the renal arteries. Follow-up time ranged from 6 months to 6 years. Three patients respectively died of unrelated AVF diseases in 6, 9, and 14 months after the treatment. Re-intervention with an another stent-graft placement was performed on 2 patients with recurrence of the AVF respectively at 3 weeks and two months after the procedures. The minor stenosis was found in stent-graft 2 of patients on the follow-up angiography respectively at 6 and 8 months after the treatment. Seven patients are still alive and in good condition without further intervention. CONCLUSIONS: Minimally invasive interventional procedures, including super-selective embolization and stent-graft exclusion, are safe and effective in the treatment of acquired arteriovenous fistulas.