目的:放射性头颅动静脉瘘历来被认为需要多次随访程序干预以达到成熟和维持通畅。国家肾脏基金会的肾脏疾病结果质量倡议(KDOQI)最近的临床实践指南强调了以患者为中心的血液透析策略,并具有新的干预率最高目标。可能与优先考虑自体前臂血液透析通路的建议相冲突。本描述性研究旨在评估放射状瘘管是否可以满足KDOQI指南基准的干预措施,并阐明与放射性头颅动静脉瘘创建后的干预时间和频率相关的临床和解剖特征。
方法:来自多中心PATENCY-1和PATENCY-2随机试验的前瞻性患者水平数据,招募接受新的放射性头颅动静脉瘘创建的患者,进行了分析(ClinicalTrials.govNCT02110901和NCT02414841)。主要结果是术后1年的干预率。计算了发病率,使用Cox比例风险模型的复发事件扩展对瘘管形成后的手术或血管内介入治疗时间进行建模.使用非参数自举计算95%水平的置信区间。
结果:该队列由914名患者组成;平均(SD)年龄为57(13)岁,女性占22%。中位随访时间为707天(IQR447-1066)。每人年干预措施的发生率(95%CI)为1.04(0.95-1.13);在使用瘘管之前为1.10(0.98-1.21),瘘管使用后0.96(0.82-1.11)。总体上最常见的干预措施是球囊血管成形术(占所有干预措施的54.9%)。静脉侧支结扎(16.4%),和开放修订(例如,从鼻烟盒接近手腕,16.4%)。需要球囊血管成形术的部位包括吻合段(51.7%的血管成形术),流出静脉(29.2%),流入动脉(14.8%),中央静脉(3.8%),和头弓(0.5%)。常见的适应症是恢复或维持通畅(所有干预措施的75.6%)。协助成熟(14.9%),改善深度(4.4%),或改善增强(3.0%)。在多元回归分析中,女性(调整后的危险比[HR]1.21,95%CI1.05-1.45),糖尿病(HR1.21,95%CI1.01-1.46),术中静脉直径<3.0mm(vs.≥4.0mm,HR1.33,95%CI1.02-1.66)与更早和更频繁的干预相关。在创建瘘管时未进行血液透析的患者接受了较低频率的干预(HR0.69,95%CI0.59-0.81)。
结论:放射性头颅动静脉瘘患者可以接受一次干预,平均而言,在创作后的第一年,这与当前的KDOQI指南一致。已经需要血液透析的病人,女性患者,糖尿病患者,术中静脉直径<3.0mm的患者重复干预的风险增加。没有亚组超过指南建议的复发干预的最大阈值。总的来说,结果表明,在适当选择的患者中,作为终末期肾脏疾病生活计划的一部分,建立放射性头颅动静脉瘘仍然是一个指南一致的策略.
Radiocephalic arteriovenous fistulas have been historically perceived as requiring multiple follow-up procedural interventions to achieve maturation and maintain patency. Recent clinical practice
guidelines from the National Kidney Foundation\'s Kidney Disease Outcomes Quality Initiative (KDOQI) emphasize a patient-centered hemodialysis access strategy with new maximum targets for intervention rates, potentially conflicting with concomitant recommendations to prioritize autogenous forearm hemodialysis access creation. The present descriptive study seeks to assess whether radiocephalic fistulas can meet the KDOQI
guideline benchmarks for interventions following access creation, and to elucidate clinical and anatomic characteristics associated with the timing and frequency of interventions following radiocephalic arteriovenous fistula creation.
Prospective patient-level data from the multicenter PATENCY-1 and PATENCY-2 randomized trials, which enrolled patients undergoing new radiocephalic arteriovenous fistula creation, was analyzed (ClinicalTrials.govNCT02110901 and NCT02414841). The primary outcome was the rate of interventions at 1 year postoperatively. Incidence rates were calculated, and time to surgical or endovascular intervention following fistula creation was modeled using recurrent event extensions of the Cox proportional hazards model. Confidence intervals at the 95% level were calculated using nonparametric bootstrapping.
The cohort consisted of 914 patients; mean age was 57 years (standard deviation, 13 years), and 22% were female. Median follow-up was 707 days (interquartile range, 447-1066 days). The incidence of interventions per person-year was 1.04 (95% confidence interval [CI], 0.95-1.13) overall; 1.10 (95% CI, 0.98-1.21) before fistula use, and 0.96 (95% CI, 0.82-1.11) after fistula use. The most common interventions overall were balloon angioplasty (54.9% of all interventions), venous side-branch ligation (16.4%), and open revisions (eg, proximalization from snuffbox to wrist, 16.4%). The locations requiring balloon angioplasty included the juxta-anastomotic segment (51.7% of angioplasties), the outflow vein (29.2%), the inflow artery (14.8%), the central veins (3.8%), and the cephalic arch (0.5%). Common indications were to restore or maintain patency (75.6% of all interventions), assist maturation (14.9%), improve depth (4.4%), or improve augmentation (3.0%). In the multivariable regression analysis, female sex (adjusted hazard ratio [HR], 1.21; 95% CI, 1.05-1.45), diabetes (HR, 1.21; 95% CI, 1.01-1.46), and intraoperative vein diameter <3.0 mm (vs ≥4.0 mm: HR, 1.33; 95% CI, 1.02-1.66) were associated with earlier and more frequent interventions. Patients not on hemodialysis at the time of fistula creation underwent less frequent interventions (HR, 0.69; 95% CI, 0.59-0.81).
Patients with radiocephalic arteriovenous fistulas can expect to undergo one intervention, on average, in the first year after creation, which aligns with current KDOQI
guidelines. Patients already requiring hemodialysis, female patients, patients with diabetes, and patients with intraoperative vein diameters <3.0 mm were at increased risk for repeated intervention. No subgroup exceeded
guideline-suggested maximum thresholds for recurrent interventions. Overall, the results demonstrate that creation of radiocephalic arteriovenous fistula remains a
guideline-concordant strategy when part of an end-stage kidney disease life-plan in appropriately selected patients.