导尿管在动静脉内瘘阻塞重建中的临床应用
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摘要
目的探讨外科手术联合导尿管取栓+扩张术用于治疗动静脉内瘘失功的优缺点,为治疗长期血液透析患者因内瘘血管狭窄导致血栓形成从而引起内瘘阻塞提供新的思路。方法选取因血栓形成导致前臂自体动静脉内瘘失功患者共36例纳入研究,在动静脉吻合口上方横行剪开已经动脉化的头静脉,应用导尿管逆行取栓并扩张近心端狭窄血管后吻合血管、缝合皮肤。分别观察手术临床成功率,应用超声测量术前、术后内瘘血管内径,并计算术后开通率,观察有无术后并发症等,共观察12个月。结果 34例患者术后均可触及明显震颤,术后第二天均应用内瘘进行血液透析,透析流量在200 mL/min以上,临床成功率为94.4%;血管狭窄部位的平均内径在手术前为(3.1±0.6) mm,术后为(4.5±0.8) mm,术后与术前相比较,差异有统计学意义(P<0.05),经治疗后血管狭窄情况明显改善;K-M曲线分析其12个月时开放率为79.4%;36例患者术后均未出现严重并发症,仅2例出现肿胀手综合征,经治疗后症状消失。结论外科手术联合导尿管取栓+扩张的方式适用于部分动静脉内瘘闭塞的患者,尤其对于不能开展PTA等技术的基层医疗单位而言有其特殊的优势所在,具有一定的应用前景。
Objective To explore the advantages and disadvantages of surgical operation combined with urethral catheter thrombectomy and dilation for the treatment of arteriovenous fistula failure, and to provide new ideas for the treatment of long-term hemodialysis patients with fistula vessel obstruction due to thrombosis caused by internal fistula vessel stenosis. Methods Thirty-six patients with complications of arteriovenous fistula in the forearm caused by thrombosis were enrolled in the study. The arterialized cephalic vein was incised above the arteriovenous anastomosis, and the urethral catheter was used to remove the thrombus and expand the proximal stenosis. At last,vascularanastomosis and incision closure were performed. The clinical success rate was observed, and the internal diameter of the internal fistula vessel was measured with ultrasonic measurement before and after the operation. The postoperative vascular patency rate was calculated and the postoperative complications were observed. The observation lasted a total of 12 months. Results All the 34 patients had significant tremors after operation. The internal fistula construction was used for hemodialysis on the second day after operation. The dialysis flow rate was above 200 mL/min. The clinical success rate was 94.4%. The average internal diameter of the vascular stenosis site was(3.1±0.6) before operation(4.5±0.8) after operation, with the difference of statistical significance(P<0.05,The stenosis after treatment was significantly improved. K-M curve analysis showed a patency of 80%. No severe postoperative complications occurred in 36 patients. Only 2 cases of swollen hand syndrome occurred and the symptoms disappeared after treatment. Conclusions Surgical operation combined with urethral catheter thrombectomy + dilatation is suitable for patients with partial arteriovenous fistula obstruction. In particular, for primary medical institutions that cannot carry out PTA and other techniques,it has special advantages and has certain application prospects.
Objective To explore the advantages and disadvantages of surgical operation combined with urethral catheter thrombectomy and dilation for the treatment of arteriovenous fistula failure, and to provide new ideas for the treatment of long-term hemodialysis patients with fistula vessel obstruction due to thrombosis caused by internal fistula vessel stenosis. Methods Thirty-six patients with complications of arteriovenous fistula in the forearm caused by thrombosis were enrolled in the study. The arterialized cephalic vein was incised above the arteriovenous anastomosis, and the urethral catheter was used to remove the thrombus and expand the proximal stenosis. At last,vascularanastomosis and incision closure were performed. The clinical success rate was observed, and the internal diameter of the internal fistula vessel was measured with ultrasonic measurement before and after the operation. The postoperative vascular patency rate was calculated and the postoperative complications were observed. The observation lasted a total of 12 months. Results All the 34 patients had significant tremors after operation. The internal fistula construction was used for hemodialysis on the second day after operation. The dialysis flow rate was above 200 mL/min. The clinical success rate was 94.4%. The average internal diameter of the vascular stenosis site was(3.1±0.6) before operation(4.5±0.8) after operation, with the difference of statistical significance(P<0.05,The stenosis after treatment was significantly improved. K-M curve analysis showed a patency of 80%. No severe postoperative complications occurred in 36 patients. Only 2 cases of swollen hand syndrome occurred and the symptoms disappeared after treatment. Conclusions Surgical operation combined with urethral catheter thrombectomy + dilatation is suitable for patients with partial arteriovenous fistula obstruction. In particular, for primary medical institutions that cannot carry out PTA and other techniques,it has special advantages and has certain application prospects.
引文
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[11] 王玉柱,叶朝阳,金其庄,等.中国血液透析用血管通路专家共识[J].中国血液净化,2014,13(8):549-558.
[12] 叶有新,胡为民,冯剑,等.腔内血管成型术治疗动静脉内瘘狭窄[J].肾脏病与透析移植杂志,2009,18(3):242-244.
[13] 郭世奎,王昆华,龚昆梅,等.Fogarty取栓管联合导尿管在细肝外胆管结石手术中的临床应用[J].西南国防医药,2011,21(1):221-224.
[14] 任树风,张丽红,刘音,等.自体动静脉内瘘局部血流动力学研究[J].临床肾脏病杂志,2014,14(8):472-474.
[15] 袁红伶,张金黎,徐剑,等.硬膜外麻醉导管在动静脉内瘘成形术中的应用[J].中华肾脏病杂志,2009,25(7):565.
[16] 刘明生,周红庆,邓体斌,等.不同术式处理血液透析患者动静脉内瘘血栓的疗效分析[J].临床肾脏病杂志,2017,17(10):606-609.
[17] 王立华,姜埃利,魏芳.动静脉内瘘建立后的血流动力学变化[J].中华肾脏病杂志,2015,30(10):797-800.
[18] 熊晓玲,冯剑,陆明晰,等.切割球囊治疗常规球囊扩张失败的动静脉内瘘狭窄[J].中华肾脏病杂志,2015,31(9):658-662.
[19] 刘杨东,胡良柱.人工血管动静脉内瘘狭窄及血栓形成的防治[J].临床肾脏病杂志,2017,17(4):196-199.
[20] 詹申,杨涛,张丽红,等.血液透析动静脉内瘘狭窄的介入治疗 [J].中国血液净化,2014,13(8):595-597.
[21] 李康峰,周玉坤严连喜,等.血管扩张器法解除内瘘狭窄的临床疗效观察[J].临床肾脏病杂志,2012,12(10):465-467.
[2] 付平,崔天蕾.自体动静脉内瘘血栓的处理[J].肾脏病与透析肾移植杂志,2013,22(2):139-140
[3] 姚国明,胡日红,王文荣,等.胆道探条局部扩张在动静脉内瘘重建中的应用[J].中华肾脏病杂志,2015,31(3):235-236.
[4] 曾海鸥,袁丽萍,陈圳炜,等.不同动静脉内瘘重建手术方式比较[J].临床肾脏病杂志,2015,15(3):165-168.
[5] 刘明生,周红庆,邓体斌.不同术式处理血液透析患者动静脉内瘘血栓的疗效分析 [J].临床肾脏病杂志,2017,17(10):606-609.
[6] 徐元恺,甄景琴,张文云,等.内瘘静脉最小内径可作为判断自体动静脉内瘘狭窄的指标[J].中华肾脏病杂志,2017,33(3):187-190.
[7] 杨涛,詹申,王新玲,等.透析用自体动静脉内瘘狭窄介人治疗的初步分析[J].中华放射学杂志,2017,48(4):308-310.
[8] Mima A.Hemodialysis vascular access dysfunction molecular mechanisms and treatment[J].Ther Apher Dial,2012,16(6):321-327.
[9] 余燕婷,高占辉,赵刘兵,等.经皮腔内血管成形术与手术治疗血液透析患者自体动静脉内瘘狭窄的临床效果比较[J].医学研究生学报,2017,30(12):1305-1308.
[10] 童进东,田众一,赖碧红,等.前臂失功动静脉内瘘修复的临床研究[J].中国中西医结合肾病杂志,2015,16(5):414-417.
[11] 王玉柱,叶朝阳,金其庄,等.中国血液透析用血管通路专家共识[J].中国血液净化,2014,13(8):549-558.
[12] 叶有新,胡为民,冯剑,等.腔内血管成型术治疗动静脉内瘘狭窄[J].肾脏病与透析移植杂志,2009,18(3):242-244.
[13] 郭世奎,王昆华,龚昆梅,等.Fogarty取栓管联合导尿管在细肝外胆管结石手术中的临床应用[J].西南国防医药,2011,21(1):221-224.
[14] 任树风,张丽红,刘音,等.自体动静脉内瘘局部血流动力学研究[J].临床肾脏病杂志,2014,14(8):472-474.
[15] 袁红伶,张金黎,徐剑,等.硬膜外麻醉导管在动静脉内瘘成形术中的应用[J].中华肾脏病杂志,2009,25(7):565.
[16] 刘明生,周红庆,邓体斌,等.不同术式处理血液透析患者动静脉内瘘血栓的疗效分析[J].临床肾脏病杂志,2017,17(10):606-609.
[17] 王立华,姜埃利,魏芳.动静脉内瘘建立后的血流动力学变化[J].中华肾脏病杂志,2015,30(10):797-800.
[18] 熊晓玲,冯剑,陆明晰,等.切割球囊治疗常规球囊扩张失败的动静脉内瘘狭窄[J].中华肾脏病杂志,2015,31(9):658-662.
[19] 刘杨东,胡良柱.人工血管动静脉内瘘狭窄及血栓形成的防治[J].临床肾脏病杂志,2017,17(4):196-199.
[20] 詹申,杨涛,张丽红,等.血液透析动静脉内瘘狭窄的介入治疗 [J].中国血液净化,2014,13(8):595-597.
[21] 李康峰,周玉坤严连喜,等.血管扩张器法解除内瘘狭窄的临床疗效观察[J].临床肾脏病杂志,2012,12(10):465-467.