透析血管通路非中心静脉狭窄肿胀手综合征的诊治
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摘要
目的探讨透析血管通路非中心静脉狭窄肿胀手的发病机制和处置方案。方法回顾分析2015年7月~2017年7月,南京医科大学第二附属医院肾脏病中心42例非中心静脉狭窄肿胀手的内瘘病变特点、临床特征,以及治疗方法。结果 41例因内瘘外周流出道狭窄或闭塞,1例患者因新建高位瘘穿静脉回流导致肿胀手综合征,17例患者予单纯经皮穿刺腔内血管成形术(percutaneous transluminal angioplasty,PTA)治疗,20例患者予手术治疗,其中2例患者做结扎处理(1例穿静脉结扎,1例内瘘结扎),5例患者予手术结合腔内血管成形术治疗。所有患者治疗均取得一次性成功,术后第2天肿胀手明显减轻,除外做结扎处理的2例患者,余40例患者术后即可予内瘘血管穿刺透析。结论血液透析患者非中心静脉狭窄肿胀手综合征主要与内瘘流出道狭窄及逆行分流增多有关,术前详细的物理查体和影像学评估是制定合理手术方案的关键,治疗的目标在于纠正狭窄,恢复内瘘向心回流,尽可能保护内瘘血管资源。
Objective To investigate the pathogenesis and treatment of upper extremity edema syndrome due to non-central venous stenosis. Methods A total of 42 patients with upper extremity edema and treated between July 2015 and July 2017 in our department were retrospectively studied. The characteristics of lesion,clinical features and method of management were summarized. Results The causes of the 41 patients were peripheral venous stenosis or obstruction, and one of them was attributed to retrograde blood flow through the perforating vein following creation of a new arteriovenous fistula. Seventeen of the 42 patients were managed with percutaneous transluminal angioplasty(PTA), 20 with surgery, and 5 with surgery combined with transluminal angioplasty. All patients had a successful outcome after the management. Conclusion The upper extremity edema syndrome due to non-central venous stenosis is mainly caused by peripheral venous stenosis and retrograde blood flow into the peripheral venous branch of the fistula. Detailed physical and imaging examinations are essential to make a better operation plan. The goal of the treatment is to correct the stenosis, restore centripetal reflux and protect the fistula vascular resource as much as possible.
Objective To investigate the pathogenesis and treatment of upper extremity edema syndrome due to non-central venous stenosis. Methods A total of 42 patients with upper extremity edema and treated between July 2015 and July 2017 in our department were retrospectively studied. The characteristics of lesion,clinical features and method of management were summarized. Results The causes of the 41 patients were peripheral venous stenosis or obstruction, and one of them was attributed to retrograde blood flow through the perforating vein following creation of a new arteriovenous fistula. Seventeen of the 42 patients were managed with percutaneous transluminal angioplasty(PTA), 20 with surgery, and 5 with surgery combined with transluminal angioplasty. All patients had a successful outcome after the management. Conclusion The upper extremity edema syndrome due to non-central venous stenosis is mainly caused by peripheral venous stenosis and retrograde blood flow into the peripheral venous branch of the fistula. Detailed physical and imaging examinations are essential to make a better operation plan. The goal of the treatment is to correct the stenosis, restore centripetal reflux and protect the fistula vascular resource as much as possible.
引文
[1]Agarwal AK,Patel BM,Haddad NJ.Central Vein Stenosis:A Nephrologist’s Perspective[J].Semin Dial,2007,20(1):53-62.
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[5]Salman L,Beathard G.Interventional Nephrology:Physical Examination as a Tool for Surveillance for the Hemodialysis Arteriovenous Access[J].Clin J Am Soc Nephrol,2013,8(8):1220-1227.
[6]Ferring M,Claridge M,Smith SA,et al.Routine preoperative vascular ultrasound improves patency and use of arteriovenous fistulas for hemodialysis:a randomized trial[J].Clin J Am Soc Nephrol,2010,5(12):2236-2244.
[7]Kamata T,Tomita M,Iehara N.Ultrasound-guided cannulation of hemodialysis access[J].Renal Replace Therapy,2016,1(2):1-9.
[8]Palmes D,Kebschull L,Schaefer RM,et al.Perforating vein fistula is superior to forearm fistula in elderly haemodialysis patients with diabetes and arterial hypertension[J].Nephrol Dial Transplant,2011,26(10):3309-3314.
[9]Lomonte C,Basile C.On the phenomenology of the perforating vein of the elbow[J].Semin Dial,2009,3(22):300-303.
[2]Agarwal AK.Central Vein Stenosis:Current Concepts[J].Adv Chronic Kidney Dis,2009(16),5:360-370.
[3]Mac Rae JM,Ahmed A,Johnson N,et al.Central Vein Stenosis:A Common Problem in Patients on Hemodialysis[J].ASAIO J,2005,51(1):77-81.
[4]Kamata T,Yamamoto K,Okamura M,et al.An unusual case of arteriovenous fistularelated venous hypertension:sonographic detection of a culprit perforating vein with movie and compact review[J].Renal Replacement Therapy,2016,2:47.
[5]Salman L,Beathard G.Interventional Nephrology:Physical Examination as a Tool for Surveillance for the Hemodialysis Arteriovenous Access[J].Clin J Am Soc Nephrol,2013,8(8):1220-1227.
[6]Ferring M,Claridge M,Smith SA,et al.Routine preoperative vascular ultrasound improves patency and use of arteriovenous fistulas for hemodialysis:a randomized trial[J].Clin J Am Soc Nephrol,2010,5(12):2236-2244.
[7]Kamata T,Tomita M,Iehara N.Ultrasound-guided cannulation of hemodialysis access[J].Renal Replace Therapy,2016,1(2):1-9.
[8]Palmes D,Kebschull L,Schaefer RM,et al.Perforating vein fistula is superior to forearm fistula in elderly haemodialysis patients with diabetes and arterial hypertension[J].Nephrol Dial Transplant,2011,26(10):3309-3314.
[9]Lomonte C,Basile C.On the phenomenology of the perforating vein of the elbow[J].Semin Dial,2009,3(22):300-303.