目的:血液透析通路诱导的远端缺血(HAIDI)是已知的血液透析(HD)通路并发症。远端血运重建和间隔结扎(DRIL)是许多外科医生首选的HAIDI治疗方法。动脉流入近端(PAI)是一种有前途的替代技术,与钻井不同,保留天然动脉流入。这项研究的目的是报告我们对一系列64例患者的PAI经验。
方法:这是一个单中心,2017年至2023年接受HAIDIPAI治疗的房室瘘和移植物患者的回顾性队列研究.在大多数情况下,使用4x7锥形聚四氟乙烯(PTFE)移植物将HD入口入流连接到腋窝动脉。该研究的主要结果是HAIDI的解决(完整,局部,或无决议)。次要结果包括功能通畅(原发性和继发性)和PAI后30天并发症。
结果:在2017年5月至2023年8月期间确定患有PAI的71例患者中,有7例失去随访。总的来说,包括64例患者,平均年龄为65岁(SD15),59.4%(38/64)女性,和37.5%(24/64)非洲裔美国人。研究人群在许多合并症方面值得注意,包括95.3%(61/64)HTN,50%(32/64)CAD,79.7%(51/64)糖尿病,43.8%(28/64)吸烟史。在PAI对HAIDI进行干预之后,55/64(85.9%)患者的缺血症状完全缓解,5/64(7.8%)患者部分消退,2/64(3.1%)患者没有解决,和2/64(3.1%)患者的分辨率未知.在1、12和24个月的主要通畅率为94%,81%,71%,分别。1个月、12个月和24个月时的二次通畅率为97%,87%,84%,分别。30天并发症发生率为10.9%(7/64),5/64(7.8%)血栓形成,1/64(1.6%)血栓形成和感染,1/64(1.6%)继发于中心静脉狭窄的上肢肿胀(通过中心静脉系统血管成形术解决)。12个月和24个月的血栓形成失败率分别为14%(9/64)和15.6%(10/64),分别。
结论:我们的研究,迄今为止最大的PAI病例系列,证明PAI是HAIDI干预的可靠选择,其安全性和有效性结果与DRIL相当.此外,PAI具有维持天然动脉途径的额外益处。有必要对PAI进行进一步调查,以作为HAIDI管理的DRIL的有希望的替代方案。
OBJECTIVE: Hemodialysis access-induced distal ischemia (HAIDI) is a known complication of hemodialysis (HD) access. Distal revascularization and interval ligation (DRIL) is the preferred treatment for HAIDI by many surgeons. Proximalization of arterial inflow (PAI) is a promising alternative technique that, unlike DRIL, preserves the native arterial inflow. The purpose of this study is to report our experience with PAI on a series of 64 patients.
METHODS: This is a single-center, retrospective cohort study of patients with both arteriovenous (AV) fistulas and grafts who underwent PAI for HAIDI from 2017 to 2023. A 4 × 7 tapered polytetrafluoroethylene (PTFE) graft was used to connect HD access inflow to the axillary artery in the majority of cases. The primary outcome of the study is resolution of HAIDI (complete, partial, or no resolution). Secondary outcomes include functional patency (primary and secondary) and 30-day complications following PAI.
RESULTS: Of the 71 patients identified to have had PAI between May 2017 to August 2023, seven were lost to follow-up. In total, 64 patients were included, with an average age of 65 years (standard deviation, 15 years), 59.4% (38/64) female, and 37.5% (24/64) African American. The study population was notable for numerous comorbid conditions including 95.3% (61/64) hypertension; 50% (32/64) coronary artery disease; 79.7% (51/64) diabetes; and 43.8% (28/64) smoking history. Following PAI intervention for HAIDI, 55 of 64 patients (85.9%) experienced complete resolution of ischemic symptoms; five of 64 patients (7.8%) had partial resolution; two of 64 patients (3.1%) had no resolution, and two of 64 patients (3.1%) had unknown resolution. Primary patency at 1, 12, and 24 months was 94%, 81%, and 71%, respectively. Secondary patency at 1, 12, and 24 months was 97%, 87%, and 84%, respectively. The 30-day complication rate was 10.9% (7/64), with five of 64 (7.8%) thromboses, one of 64 (1.6%) thrombosis and infection, and one of 64 (1.6%) upper extremity swelling secondary to central venous stenosis (resolved with angioplasty of central venous system). Failure rate due to thrombosis at 12 and 24 months was 14% (9/64) and 15.6% (10/64), respectively.
CONCLUSIONS: Our study, the largest case series of PAI to date, demonstrates that PAI is a reliable option for HAIDI intervention and has comparable safety and efficacy results to DRIL, despite the use of a synthetic graft. Furthermore, PAI has the added benefit of maintaining the native arterial pathway. Further investigation of PAI is warranted as a promising alternative to DRIL for HAIDI management.