前臂近端自体动静脉内瘘在老年血液透析病人中的应用

目的探讨老年血液透析病人在前臂近端建立自体动静脉内瘘的优劣性及临床转归。方法选取在我院进行首次自体动静脉内瘘建立的老年病人,分为近端组(桡动脉起始段与正中静脉或头静脉吻合)和远端组(桡动脉与头静脉吻合),观察2组病人内瘘术后的手术并发症以及内瘘血流量、成熟情况及预后等。结果所有内瘘手术术后即刻成功率为100%。术后6~8周进行内瘘超声评估,近端组和远端组的血流量分别为(1328.5±234.4)mL/min和(1125.6±198.1)mL/min(P<0.05),首次穿刺时间分别为(56±15)d和(62±13)d(P=0.03),首次穿刺成功率分别为87.8%和78.9%(P<0.05)。2组术后总体并发症发生率差异无统计学意义(P>0.05);所有手术6个月的总体通畅率为92.41%,1年的总体通畅率为81.01%。2组病人1年的内瘘存活率差异无统计学意义(85.2%比74.1%,P=0.32),但在第2年时,近端组的存活率为74.3%,明显高于远端组的48.3%(P<0.05);同时近端组由于血栓形成而导致的内瘘闭塞率及再次手术干预次数也低于远端组(P<0.05)。结论前臂近端自体动静脉内瘘具有成熟快、流量充足、通畅率高等优点,对于前臂远端血管条件不佳、需建立内瘘的老年人,尤其是高龄病人可以优先考虑。

Application of proximal forearm autogenous arteriovenous fistula in elderly patients receiving hemodialysis

Objective To investigate the advantages and disadvantages and clinical outcome of autologous arteriovenous fistula in proximal forearm of the elderly patients receiving hemodialysis.Methods The elderly patients who established autologous arteriovenous fistula in our hospital for the first time were divided into proximal group(anastomosis between radial artery and median vein or cephalic vein)and distal group(anastomosis between radial artery and cephalic vein)according to the methods of surgery.The postoperative complications,fistula blood flow,maturity and prognosis of internal fistula were observed and compared between the two groups.Results The immediate success rate of all fistula operations was 100%.Ultrasound evaluation of fistula was performed 6-8 weeks after operation.The blood flow volume of proximal group and distal group was 1328±234 mL/min and 1125.6±198.1 mL/min(P=0.03),and the first puncture time was 56±15 d and 62±13 d(P<0.05),the success rate of first puncture was 87.8%and 78.9%(P<0.05),respectively.There was no significant difference in postoperative complications between the two groups(P>0.05).The overall patency rate of all operations for 6 months was 92.41%,and the overall patency rate for 1 year was 81.01%.The 1-year survival rate of the internal fistula in the two groups was 85.2%and 74.1%(P=0.32).The survival rate of the proximal group in the second year was 74.3%,which was significantly higher than that of the distal group(P<0.05).At the same time,the incidence rate of internal fistula occlusion and the times of surgical intervention caused by thrombosis in the proximal group were also lower than those in the distal group(P<0.05).Conclusions The proximal forearm autogenous arteriovenous fistula has the advantages of rapid maturity,sufficient flow and high patency rate,which can be given priority to the elderly patients who need to establish internal fistula because of poor vascular condition of the distal forearm.