南方医科大学学报

南方医科大学学报 ›› 2013, Vol. 33 ›› Issue (10): 1538-.

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终末期肾病自体动静脉内瘘术后狭窄的手术修复策略

周忠信，潘春球   

  • 出版日期:2013-10-20 发布日期:2013-10-20

Surgical strategy for management of postoperative stenosis of ateriovenous fistula in patients with end-stage renal disease

  • Online:2013-10-20 Published:2013-10-20

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摘要： 目的探讨终末期肾病（ESRD）患者自体动静脉内瘘（AVF）狭窄的手术修复方法和疗效。方法本院近3年415例ESRD患
者29例12月内发生AVF狭窄，Ⅰa型5例，Ⅰb型17例，Ⅱ型3例，Ⅲ型2例。5例Ⅰa型于桡动脉近心端重置吻合。17例Ⅰb型
截取副头静脉间置狭窄（5例）或转位替代狭窄（12例）以重建头静脉。3例Ⅱ型中1例截取副头静脉间置于头静脉，1例截取大隐
静脉间置于吻合口与肘正中静脉，1例以前臂贵要静脉与桡动脉重置吻合。2例Ⅲ型中1例以前臂贵要静脉与桡动脉重置吻合，
1例改为对侧桡动脉-头静脉内瘘术。结果29例患者28例适合修复并成功（96.6%，28/29），1例术后12 h血栓形成，急诊取栓重
置吻合；2例术后9月再狭窄，予以分期球囊扩张（PTA）后恢复，12月内再狭窄发生率7.1%(2/28)。28例AVF修复ESRD患者均
完成12月规律HD。结论重建吻合口、选择合适的自体血管替代狭窄节段或以前臂贵要静脉作为透析通道能使大多数AVF狭
窄得以修复后继续使用。

Abstract: Objective To explore the surgical approaches for management of postoperative stenosis of ateriovenous fistula (AVF)
in patients with end-stage renal disease (ESRD). Methods Of the 415 patients with ESRD receiving radial-cephalic end-to-side
anastomosis during the last 3 years, 29 developed postoperative AVF stenosis (of type Ia in 5 cases, type Ib in 17 cases, type II
in 3 cases, and type II in 2 cases). A proximal anastomosis was created between the radical artery and cephalic vein for type Ia
stenosis. In the 17 cases with type Ⅰb stenosis, 5 were managed by interception of suitable segments from the accessory
cephalic veins for cephalic vein reconstructions, and 12 by transposition of the accessory cephalic veins. Of 3 cases with type II
stenosis, 1 was managed by interception of the accessory cephalic vein for interposing into the cephalic vein, 1 by interception
of the distal great saphenous vein for interposing into the cephalic vein, and 1 by transposition of the forearm basilic vein for
end-to-side anastomosis with the radial artery. The 2 cases with type III were managed by end-to-side anastomosis between
the forearm basilic vein and the radial artery or by conversion to AVF repair on the contralateral forearm. Results Twenty-eight
of the 28 patients finally received surgical repair of AVF stenosis and the surgeries were completed successfully. Thrombosis of
the outflow vein occurred 12 h after the repair in 1 case to require emergency embolectomy and anastomosis; restenosis
occurred in 2 cases at 9 months postoperatively, for which progressive percutaneous transluminal angioplasty (PTA) was
performed. The rate of restenosis was 7.1% (2/28). All the 28 patients undergoing AVF stenosis repair had successful HD for 12
months after the operation. Conclusion Reconstructing the arteriovenous anastomosis, replacing the stenosis segment with an
accessory cephalic vein or great saphenous vein graft, or altering the outflow with the forearm basilic vein can be surgical
options for repairing postoperative AVF stenosis