AVG狹窄閉塞處理策略及思考

AVG狹窄閉塞處理策略及思考1尿毒癥數(shù)量越來(lái)越多數(shù)據(jù)來(lái)源-CNRDS2血透通路狹窄閉塞----AVG通暢率內(nèi)瘺狹窄閉塞是導(dǎo)致內(nèi)瘺失功最主要原因，嚴(yán)重影響透析患者的生存。Decreasedcumulativeaccesssurvivalinarteriovenousfistulasrequiringinterventionstopromotematuration.ClinJAmSocNephro2011;l6:575–581,TheSocietyforVascularSurgery:Clinicalpracticeguidelinesforthesurgicalplacementandmaintenanceofarteriovenoushemodialysisaccess;JOURNALOFVASCULARSURGERY,NovemberSupplement2008Results:Over8000studieswerereviewed,andfromthese,318studieswereincludedcomprising62,712accesses.Forfistulastheprimaryunassisted,primaryassisted,andsecondarypatencyratesat1yearwere64%,73%and79%respectively,howevernotallfistulasreportedaspatentcouldbeconfirmedasbeingclinically

usefulfordialysis(i.e.functionalpatency).Forfistulasthatwerereportedasmature,meantimetomaturationwas3.5months,howeveronly26%ofcreatedfistulaswerereportedasmatureat6monthsand21%offistulaswereabandonedwithoutuse.Overallriskofinfectioninfistulapatientswas4.1%andtheoverallrateper100accessdayswas0.018.

JVascSurg2016;64:236-43

875,269vascularaccesses.Overall,studiesappeared

tohaveprovidedincidenceratesatlowtomoderateriskofbias.Theoverallprimarypatencyat2yearswashigherforfistulasthanforgraftsandcatheters(55%,40%,and50%,respectively).Patencywaslowerinindividualswithdiabetes,coronaryarterydisease,olderindividuals,andinwomen.Mortalityat2yearswashighestwithcatheters,followedby

graftsthenfistulas(26%,17%,and15%）

3AVFAVG導(dǎo)管AVRAVR理想血透通路構(gòu)建模式60%中國(guó)血液透析用血管通路專家共識(shí)(第1版)2014

4內(nèi)膜增生血栓

（狹窄性、低血壓、高凝狀態(tài)、外壓）判斷AVG狹窄閉塞性質(zhì)--病理生理病史：構(gòu)建時(shí)間，方式，材料，使用、失功時(shí)間、血壓，腫脹查體：吻合口人工血管觸診、血腫、聽診雜音判斷狹窄閉塞5判斷AVG狹窄閉塞部位AVG（靜脈吻合口、穿刺點(diǎn)、動(dòng)脈吻合口）靜脈流出道（中心靜脈）動(dòng)脈流入道狹窄最好發(fā)的部位是靜脈吻合口及距離吻合口3cm內(nèi)的自體靜脈，占90%以上，其次是穿刺部位，動(dòng)脈吻合

口和回流靜脈匯入深靜脈處的狹窄相對(duì)較少

6挽救AVG提高AVG使用壽命盡可能經(jīng)濟(jì)、微創(chuàng)AVG失功處理目標(biāo)與策略去栓：溶栓、吸栓、取栓解除狹窄：PTA、PTS

補(bǔ)片

AVG橋接7Case1羅**，女，68歲左前臂AVG術(shù)后1年行PTA術(shù)（2016.12.22）8溶栓勿透壁；處理狹窄前留置9靜脈端造影10動(dòng)脈---人工血管----靜脈球擴(kuò)開放血流11最后造影Case112徐**，男，55,歲左前臂AVG術(shù)后2年左前臂AVG行PTA術(shù)（2016.4.20）左前臂AVG行PTA術(shù)（2017.2.17）Case213切開取栓6*20mm切割球囊14切割球囊擴(kuò)張后造影15配合高壓球囊16第3次手術(shù)術(shù)后后造影17再次閉塞2017-8-1618切割球囊+高壓19Viabahn目前透析良好…….2074歲女性左上肢疼痛3月余（人工血管植入處）10年前腎移植術(shù)，后逐漸失功；1年前行左上肢AVG術(shù)Case321瘺靜脈吻合口+中心靜脈狹窄22靜脈吻合口PTA6mm8mm23左無(wú)名靜脈吻合口PTA24PTS最后造影25AVG狹窄閉塞去栓不同于AVF，AVG失功常為閉塞，常常合并內(nèi)膜增生及繼發(fā)血栓AVG殘留血栓嚴(yán)重影響手術(shù)成功率及通暢率切開取栓：經(jīng)典、較徹底可處理血栓時(shí)間窗長(zhǎng)（1年）

創(chuàng)傷、有可能再次血栓、狹窄溶栓：時(shí)間窗短，殘留血栓可配合球囊碎栓、導(dǎo)管吸栓機(jī)械吸栓：費(fèi)用貴，少數(shù)中心

26尿激酶溶栓治療人工血管動(dòng)靜脈內(nèi)瘺急性血栓形成

溶栓方法：靜脈泵緩慢每小時(shí)5～10萬(wàn)U推注尿激酶。每隔1h檢查人工血管有無(wú)震顫及雜音，并根據(jù)情況檢測(cè)纖維蛋白原。

對(duì)已存在狹窄的通路，單純?nèi)芩ㄔ偻ê罂赡茉诙唐趦?nèi)再次發(fā)生血栓；

內(nèi)瘺溶栓治療有一定的時(shí)間窗，

越早進(jìn)行效果越好，血栓形成

超過(guò)24h后單純?nèi)芩ê茈y再通藥物溶栓的成功率為58%～78%

人工血管動(dòng)靜脈內(nèi)瘺狹窄及血栓形成的防治

劉楊東

AVG狹窄閉塞解除狹窄AVG失功常存在狹窄病變，且常>1處?kù)o脈吻合口狹窄常內(nèi)膜增生、纖維化嚴(yán)重，腔內(nèi)治療需高壓球囊、甚至切割球囊、支架如何有效經(jīng)濟(jì)、省時(shí)省力？

29Tips1入路與置鞘雙向入路，動(dòng)脈方向植入5F，靜脈方向6F3031

普通：CordisPP，Brotronik（135cm輸送鞘—260cm導(dǎo)絲，球擴(kuò)動(dòng)脈吻合

口開通流入道，尿激酶溶栓）

高壓：Armada35(abbott),Mustang(Bostonscientific),passeo35HP

(Brotronik),Conquest(Bard)，>14atm高壓

病變血管角度大于45度以上不適用；

尺寸選擇：球囊與血管直徑的比例不能超過(guò)1.1:1；

緩慢膨脹和回縮：每5秒鐘打1個(gè)大氣壓(6mm可使用6F鞘)

Tips2球囊

普通+高壓→普通+高壓+切割，嘗試普通+切割32Pmax：25atm（各長(zhǎng)度直徑）操作桿：135cm/80cm球囊直徑：3-14mm長(zhǎng)度40-80mm4mm使用5F鞘，6mm使用5F鞘（小）回撤時(shí)間快Armada3533Pmax：24atm（各長(zhǎng)度直徑）操作桿：75cm球囊直徑：4-12mm長(zhǎng)度40-100mm4mm使用5F鞘，6mm使用5F鞘（?。┗爻窌r(shí)間適中Mustang34Pmax：27atm（各長(zhǎng)度直徑？）操作桿：75cm球囊直徑：3-12mm長(zhǎng)度20-100mm4mm使用6F鞘，

6mm使用6F鞘回撤時(shí)間適中,“吃導(dǎo)絲”Passeo35HP35Pmax：30atm（各長(zhǎng)度直徑？）操作桿：50cm球囊直徑：5-12mm長(zhǎng)度20-80mm5mm使用6F鞘，

8mm使用6F鞘回撤時(shí)間快，角度大長(zhǎng)球囊不適用Conquest36Prospective,randomizedstudyofcuttingballoonangioplastyversusconventionalballoonangioplastyforthetreatmentofhemodialysisaccessstenoses.JVascSurg.2014Sep;60(3):735-40

Thestudyrandomized623patientsintotwogroups,andthedurationoffollow-upwas1563months.Inthecuttingballoonangioplastygroup,theclinicalsuccessratewas89%(282of316stenoses).Intheconventionalballoonangioplastygroup,theclinicalsuccessratewas86%(265of307stenoses;P[.637).AssistedprimarypatencyforcuttingPTAwasstatisticallysignificantlyhigherat6monthsand1year(86%and63%)thanthatforconventionalPTA(56%and37%,respectively;P[.037)inthetreatmentofstenosisofthegraft-to-veinanastomosis.Inthevenousstenosissubgroup,equivalentprimaryassistedpatencyat6monthsand1yearwasobservedforcuttingPTA(84%and55%)andconventionalPTA(70%and46%,respectively;P[.360).Intheintragraftstenosissubgroup,primaryassistedpatencywasequivalentat6monthsand1yearforcuttingPTA(67%and39%)andconventionalPTA(62%and49%,respectively;P[.371).Inthearterialanastomoticstenosissubgroup,assistedprimarypatencyat6monthsand1yearwasequivalentforcuttingPTA(70%and30%)andconventionalPTA(75%and33%,respectively;P[.921).

AVG靜脈吻合口狹窄處理，切割球囊應(yīng)用提高了成功率，AVG的通暢率(6個(gè)月:85vs56%，1年70%vs21%,P=.037)，對(duì)狹窄長(zhǎng)度大于2cm的血管，應(yīng)選擇切割球囊。Angioplastyoflongvenousstenosesinhemodialysisaccess：atlastanindicationforcuttingballoon?JVaseIntervBadiol.2007.18:994-1000切割球囊

372017-8-28FDA批準(zhǔn)Bardlutonix（4-12mm）用于AVF71.4%targetlesionprimarypatencyat180dayswithsuperiorresultsat210days(DCB,64.1%vsPTA,52.5%)2017-5-24Medtronic‘sIN.PACTAVAccessDCB（IDEStudy）用于AVF

藥涂球囊

38Prospective,Randomized,Concurrently-ControlledStudyofaStentGraftversusBalloonAngioplastyforTreatmentofArteriovenousAccessGraftStenosis:2-YearResultsoftheRENOVAStudyPTAVS.stentgraft--RENOVAStudy

Thestudywascompletedby191patients(97SG,94PTA).Fivepatientswerelosttofollow-uporwithdrew;74patientsdiedduringthestudy(38SG,36PTA).At12months,treatmentareaprimarypatency(TAPP)wasSG47.6%versusPTA24.8%(P

<.001),accesscircuitprimarypatency(ACPP)wasSG24%versusPTA11%(P

=.007),andindexofpatencyfunction(IPF)wasSG5.2months/intervention±4.1versusPTA4.4months/intervention±3.5(P

=.009).At24months,TAPPwasSG26.9%versusPTA13.5%(P

<.001),ACPPwasSG9.5%versusPTA5.5%(P

=.01),andIPFwasSG7.1months/intervention±7.0versusPTA5.3months/intervention±5.2;estimatednumberofreinterventionsbeforegraftabandonmentwas3.4forSGpatientsversus4.3forPTApatients.Therewerenosignificantdifferencesinadverseevents(P

>.05)exceptforrestenosisrequiringreinterventionratesof82.6%inPTApatientsversus63.0%inSGpatients(P

<.001).

支架

39AProspective,RandomizedStudyofanExpandedPolytetra?uoroethyleneStentGraftversusBalloonAngioplastyforIn-StentRestenosisinArteriovenousGraftsandFistulae:Two-YearResultsoftheRESCUEStudyPatencyoftheViabahnstentgraftforthetreatmentofoutflowstenosisinhemodialysisgrafts

Viabahn

/

Fluency

40Results:Fifteentrialsweredeemedsuitableforinclusion,investigatingninedrugtreatmentsin2,230

participants.Overall,thequalityofevidencewaslow.Threetrialscomparedticlopidine(aplateletaggregation

inhibitor)versusplaceboandfavouredactivetreatment(OR0.45,95%CI0.25to0.82;p?.009).ThreeRCTs

assessedaspirinversusplaceboanddidnotshowastatisticalbenefit(OR0.40,95%CI0.07e2.25;p?.30).Two

trialscomparedclopidogrelwithplacebo.Theoverallresultdidnotfavourtreatment(OR0.40,95%C