AVG狭窄闭塞处理策略及思考

AVG狭窄闭塞处理策略及思考1尿毒症数量越来越多数据来源-CNRDS2血透通路狭窄闭塞----AVG通畅率内瘘狭窄闭塞是导致内瘘失功最主要原因，严重影响透析患者的生存。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导管AVRAVR理想血透通路构建模式60%中国血液透析用血管通路专家共识(第1版)2014

4内膜增生血栓

（狭窄性、低血压、高凝状态、外压）判断AVG狭窄闭塞性质--病理生理病史：构建时间，方式，材料，使用、失功时间、血压，肿胀查体：吻合口人工血管触诊、血肿、听诊杂音判断狭窄闭塞5判断AVG狭窄闭塞部位AVG（静脉吻合口、穿刺点、动脉吻合口）静脉流出道（中心静脉）动脉流入道狭窄最好发的部位是静脉吻合口及距离吻合口3cm内的自体静脉，占90%以上，其次是穿刺部位，动脉吻合

口和回流静脉汇入深静脉处的狭窄相对较少

6挽救AVG提高AVG使用寿命尽可能经济、微创AVG失功处理目标与策略去栓：溶栓、吸栓、取栓解除狭窄：PTA、PTS

补片

AVG桥接7Case1罗**，女，68岁左前臂AVG术后1年行PTA术（2016.12.22）8溶栓勿透壁；处理狭窄前留置9静脉端造影10动脉---人工血管----静脉球扩开放血流11最后造影Case112徐**，男，55,岁左前臂AVG术后2年左前臂AVG行PTA术（2016.4.20）左前臂AVG行PTA术（2017.2.17）Case213切开取栓6*20mm切割球囊14切割球囊扩张后造影15配合高压球囊16第3次手术术后后造影17再次闭塞2017-8-1618切割球囊+高压19Viabahn目前透析良好…….2074岁女性左上肢疼痛3月余（人工血管植入处）10年前肾移植术，后逐渐失功；1年前行左上肢AVG术Case321瘘静脉吻合口+中心静脉狭窄22静脉吻合口PTA6mm8mm23左无名静脉吻合口PTA24PTS最后造影25AVG狭窄闭塞去栓不同于AVF，AVG失功常为闭塞，常常合并内膜增生及继发血栓AVG残留血栓严重影响手术成功率及通畅率切开取栓：经典、较彻底可处理血栓时间窗长（1年）

创伤、有可能再次血栓、狭窄溶栓：时间窗短，残留血栓可配合球囊碎栓、导管吸栓机械吸栓：费用贵，少数中心

26尿激酶溶栓治疗人工血管动静脉内瘘急性血栓形成

溶栓方法：静脉泵缓慢每小时5～10万U推注尿激酶。每隔1h检查人工血管有无震颤及杂音，并根据情况检测纤维蛋白原。

对已存在狭窄的通路，单纯溶栓再通后可能在短期内再次发生血栓；

内瘘溶栓治疗有一定的时间窗，

越早进行效果越好，血栓形成

超过24h后单纯溶栓很难再通药物溶栓的成功率为58%～78%

人工血管动静脉内瘘狭窄及血栓形成的防治

刘杨东

AVG狭窄闭塞解除狭窄AVG失功常存在狭窄病变，且常>1处静脉吻合口狭窄常内膜增生、纤维化严重，腔内治疗需高压球囊、甚至切割球囊、支架如何有效经济、省时省力？

29Tips1入路与置鞘双向入路，动脉方向植入5F，静脉方向6F3031

普通：CordisPP，Brotronik（135cm输送鞘—260cm导丝，球扩动脉吻合

口开通流入道，尿激酶溶栓）

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

(Brotronik),Conquest(Bard)，>14atm高压

病变血管角度大于45度以上不适用；

尺寸选择：球囊与血管直径的比例不能超过1.1:1；

缓慢膨胀和回缩：每5秒钟打1个大气压(6mm可使用6F鞘)

Tips2球囊

普通+高压→普通+高压+切割，尝试普通+切割32Pmax：25atm（各长度直径）操作杆：135cm/80cm球囊直径：3-14mm长度40-80mm4mm使用5F鞘，6mm使用5F鞘（小）回撤时间快Armada3533Pmax：24atm（各长度直径）操作杆：75cm球囊直径：4-12mm长度40-100mm4mm使用5F鞘，6mm使用5F鞘（小）回撤时间适中Mustang34Pmax：27atm（各长度直径？）操作杆：75cm球囊直径：3-12mm长度20-100mm4mm使用6F鞘，

6mm使用6F鞘回撤时间适中,“吃导丝”Passeo35HP35Pmax：30atm（各长度直径？）操作杆：50cm球囊直径：5-12mm长度20-80mm5mm使用6F鞘，

8mm使用6F鞘回撤时间快，角度大长球囊不适用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静脉吻合口狭窄处理，切割球囊应用提高了成功率，AVG的通畅率(6个月:85vs56%，1年70%vs21%,P=.037)，对狭窄长度大于2cm的血管，应选择切割球囊。Angioplastyoflongvenousstenosesinhemodialysisaccess：atlastanindicationforcuttingballoon?JVaseIntervBadiol.2007.18:994-1000切割球囊

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

药涂球囊

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,RandomizedStudyofanExpandedPolytetrafluoroethyleneStentGraftversusBalloonAngioplastyforIn-StentRestenosisinArteriovenousGraftsandFistulae:Two-YearResultsoftheRESCUEStudyPatencyoftheViabahnstentgraftforthetreatmentofoutflowstenosisinhemodialysisgrafts

Viabahn

/

Fluency

40Results:Fifteentrialsweredeemedsuitableforinclusion,investigatingninedrugtreatmentsin2,230

participants.Overall,thequalityofevidencewaslow.Threetrialscomparedticlopidine(aplateletaggregation

inhibitor)versusplaceboandfavouredactivetreatment(OR0.45,95%CI0.25to0.82;p¼.009).ThreeRCTs

assessedaspirinversusplaceboanddidnotshowastatisticalbenefit(OR0.40,95%CI0.07e2.25;p¼.30).Two

trialscomparedclopidogrelwithplacebo.Theoverallresultdidnotfavourtreatment(OR0.40,95%C