Objectives: To investigate the effects of prophylactic flow restriction for brachiocephalic arteriovenous fistula on postoperative high-flow-related complications and patency rate in patients undergoing hemodialysis.
Methods: Clinical data of patients with end-stage renal disease who underwent brachiocephalic arteriovenous fistula surgery for hemodialysis from February 2017 to May 2022 in Department of Nephrology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine were retrospectively analyzed. During surgery, a 4-5 mm vascular suture loop was placed around the vein near the anastomosis as a flow restriction device in 43 patients (flow restriction group), while 42 patients did not receive the prophylactic flow restriction ring (control group). All patients were followed up for 1 to 5 years. The incidence rates of complications related to the hemodialysis access pathway, including distal ischemia syndrome, the formation of arteriovenous fistula aneurysms, high-flow congestive heart failure, and cephalic arch stenosis, were compared between the two groups. The natural blood flow rate of the arteriovenous fistula, anastomosis size, the internal diameter of the vein near the anastomosis,primary patency rate, assisted primary patency rate, and secondary patency rate of the arteriovenous fistula, were also evaluated and compared in two groups. Logistic regression analysis was used to investigate the factors affecting arteriovenous fistula patency rates, as well as the impact of the flow-restricting ring on postoperative factors.
Results: Ultrasound measurements showed that the internal diameter of the vein at the site of the flow restriction ring in the flow restriction group was (3.7±0.6) mm three months postoperatively, which was significantly smaller than the internal diameter of the narrowest part of the vein near the anastomosis in the control group (4.1±1.0 mm, t=－2.416, P<0.01). The postoperative anastomotic diameter and natural blood flow rate of the arteriovenous fistula in the flow restriction group were both significantly lower than those in the control group (both P<0.05). Furthermore, the incidence rates of various complications in the flow restriction group were significantly lower than those in the control group (all P<0.05). At 6, 12, and 24 months postoperatively, the primary patency rate and assisted primary patency rate in the flow restriction group were significantly higher than those in the control group (both P<0.05), while there was no significant difference in secondary patency rates between the two groups (P>0.05). Binary logistic regression analysis indicated that age, diabetes, and natural blood flow rate of the arteriovenous fistula at 3 months postoperatively were independent risk factors for primary patency rate, while the flow restriction for brachiocephalic arteriovenous fistula was an independent protective factor for primary patency rate (all P<0.05). The application of flow restriction was negatively correlated with anastomotic diameter at 6 and 12 months, natural arteriovenous fistula blood flow, and the incidence rates of cephalic arch stenosis and aneurysm formation (all P<0.05).
Conclusions: The prophylactic constriction during brachiocephalic arteriovenous fistula surgery in patients undergoing hemodialysis can limit the size of the anastomosis and postoperative arteriovenous fistula blood flow, reducing complications such as cephalic arch stenosis and high-flow heart failure, and increasing primary patency rates of arteriovenous fistula and delay the reintervention of the fistula.
目的: 观察血液透析患者肱动脉-头静脉内瘘术中使用预防性限流环对术后高流量相关并发症以及通畅率的影响。方法: 回顾性收集2017年2月至2022年5月在浙江大学医学院附属邵逸夫医院肾内科接受治疗的所有因终末期肾病血液透析建立肱动脉-头静脉内瘘的患者。其中43例在术中使用血管缝线于吻合口近旁的静脉上套一个4~5 mm的线圈作为限流环（限流组），42例未使用上述限流环（对照组）。两组患者均随访1~5年。比较两组血透通路相关性肢端缺血综合征、动静脉内瘘动脉瘤形成、流量过高的充血性心力衰竭、头静脉弓狭窄等并发症的发生率，动静脉内瘘自然血流量，吻合口内径，吻合口附近静脉血管内径以及内瘘的初级通畅率、辅助初级通畅率和次级通畅率等。采用Logistic回归分析动静脉内瘘通畅率的影响因素以及限流环对术后各因素的影响。结果: 超声结果显示，限流组术后3个月限流环部位的血管内径（3.7±0.6）mm，小于同期对照组吻合口旁静脉最小部位的内径（4.1±1.0）mm，差异有统计学意义（t=－2.416，P<0.01）。与对照组比较，限流组术后动静脉内瘘自然血流量、吻合口内径均减少（均P<0.05），各种并发症的发生率均降低（均P<0.05）；术后6、12、24个月时初级通畅率和辅助初级通畅率均增加（均P<0.05），但次级通畅率无明显差异（P>0.05）。二元Logistic回归分析结果显示，年龄、糖尿病、术后3个月动静脉内瘘自然血流量是初级通畅率的独立危险因素，术中使用限流环是初级通畅率的独立保护因素（均P<0.05）；使用限流环与6、12个月吻合口内径、动静脉内瘘自然血流量以及与头静脉弓狭窄、动脉瘤的发生率呈负相关（均P<0.05）。结论: 在肱动脉-头静脉内瘘术中使用预防性限流环可以限制吻合口径和术后动静脉内瘘血流量，减少头静脉弓狭窄、高血流量心力衰竭等并发症发生，使动静脉内瘘有更高的初级通畅率，延长了内瘘的再次干预时间。.
Keywords: Brachiocephalic arteriovenous fistula; Complications; Constriction ring; Patency rate; Stenosis.