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瘤壁部分切除术治疗自体动静脉内瘘瘤样扩张的临床研究
万梓鸣, 赖其权, 陈凌, 甘华, 涂波, 陈利群     
400016 重庆, 重庆医科大学附属第一医院肾内科
[摘要] 目的 探讨瘤壁部分切除术治疗自体动静脉内瘘瘤样扩张的临床疗效。方法 选择2012年7月至2016年6月就诊于本科的自体动静脉内瘘瘤样扩张患者共39例,其中男性27例(69.2%),女性12例(30.8%),年龄(40.6±13.3)岁,不包括假性动脉瘤和吻合口处瘤样扩张病例。采用超声多普勒评估血管(肱动脉血流量,桡动脉管径,吻合口管径,瘘静脉管径,瘤样扩张最大直径)。采用瘤壁部分切除术治疗该组病例,观察手术前后瘤样扩张血管直径及肱动脉血流量变化,两组间比较行t检验,随访术后并发症。结果 39例患者均为上肢动静脉内瘘,包括鼻咽窝内瘘12例(桡动脉-头静脉),腕部/前臂内瘘25例(桡动脉-头静脉),肘部内瘘2例(肱动脉-头静脉)。其中只有1个瘤体的15例,2个瘤体的19例,3个瘤体的4例, 4个瘤体的1例。内瘘建立的时间为(41.05±14.45)个月。瘤壁部分切除术成功率为100%,随访时间为(27.73±8.59)个月。瘤样扩张段的直径缩小为(10.39±1.83)mm,较术前[(43.79±4.74)mm]下降约76.27%, 差异有统计学意义(t=41.08, P<0.01)。术后肱动脉血流量为(770.59±130.10)mL/min, 较术前肱动脉血流量[(1 647.39±250.33)mL/min]下降约53.22%(t=19.41,P<0.01)。术后随访(27.73±8.59)个月,2例患者死亡,1例死于严重脑出血,1例死于急性心肌梗死;7例患者发现瘘静脉狭窄,在超声引导下行球囊扩张术后可继续使用。结论 瘤壁部分切除术治疗自体动静脉内瘘瘤样扩张可保留内瘘的功能和穿刺的长度,延长动静脉内瘘使用时间,临床疗效显著。
[关键词] 瘤壁部分切除术     自体动静脉内瘘     瘤样扩张    
Clinical study of partial aneurysmectomy for salvage of aneurysmal dilatation of autogenous arteriovenous fistula
WAN Ziming , LAI Qiquan , CHEN Ling , GAN Hua , TU Bo , CHEN Liqun     
Department of Nephrology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
Corresponding author: CHEN Liqun, E-mail: cqll1970@163.com
[Abstract] Objective To investigate the clinical effect of partial aneurysmectomy for salvage of autogenous arteriovenous fistula with aneurysmal dilatation. Methods A total of 39 patients with aneurysmal dilatation of autogenous arteriovenous fistula admitted in our department from July 2012 to June 2016 were included in this study. They were 27 males (69.2%) and 12 females (30.8%), and at a mean age of 40.6±13.3 years. The aneurysmal dilatation of autogenous arteriovenous fistula that occurred in the anastomosis and pseudoaneurysms were excluded. All patients underwent color Doppler ultrasound examination to determine the brachial arterial blood flow, radial artery diameter, anastomotic diameter, fistula vein diameter, and maximum diameter of aneurysmal dilatation. All cases were treated with partial aneurysmectomy. The changes of the diameter of dilated blood vessels and flow of brachial artery were observed before and after the operation, and these changes were compared between the 2 groups by student's t test. The incidences of postoperative complications were observed during follow-up. Results All the patients had an upper arm arteriovenous fistula, including 12 cases of radiocephalic fistula (radial artery to cephalic vein), 25 cases of brachiocephalic fistula (radial artery to cephalic vein) and 2 cases of elbow fistula (brachial artery to cephalic vein). There were only 15 cases of 1 tumor body, 19 cases of 2 tumor bodies, 4 cases of 3 tumor bodies and 1 case of 4 tumor bodies. The arteriovenous fistulas were for a mean duration of 41.05±14.45 months. The operation was succeeded in all cases. During the mean follow-up period of 27.73±8.59 months, the diameter of the dilated section was reduced by 76.27%, from 43.79±4.74 mm preoperatively to 10.39±1.82 mm postoperatively (t=41.08, P<0.01). Blood flow of the brachial artery was also decreased by 53.22% (from 1 647.39±250.33 to 770.59±130.10 mL/min, t=19.41, P<0.01). Two patients died during follow-up, one due to severe cerebral hemorrhage and the other to acute myocardial infarction. Fistula stenosis was found in 7 patients, and the condition was relieved after balloon expansion under the guidance of color Doppler ultrasound. Conclusion Partial aneurysmectomy can retain the function of autogenous arteriovenous fistula and length of the puncture, and extend the service life of arteriovenous fistula with distinct clinical effect in the treatment of aneurysmal dilatation of autogenous arteriovenous fistula.
[Key words] partial aneurysmectomy     autogenous arteriovenous fistula     aneurysmal dilatation    

自体动静脉内瘘(arteriovenous fistula,AVF)以其较低的并发症发生率与较长的远期通畅率,成为终末期肾衰竭患者长期维持性血液透析首选的血管通路[1]。AVF的常见并发症包括感染、血栓形成、狭窄、瘤样扩张等[2-4]。其中瘤样扩张发生率为0~10%[5],与反复穿刺、狭窄以及其他因素相关。虽然大多数病例既不会影响内瘘功能,也不需要特殊处理,但扩张的瘤壁减少可供穿刺的部位,增加感染的风险,导致血栓形成, 影响内瘘的使用寿命,可明显影响患者的心脏功能,并有破裂大出血而危及患者生命的风险[4, 6]。关于瘤样扩张治疗的时机和方案的选择仍缺乏详细的指南。K/DOQI指南中关于瘤样扩张的处理意见非常有限,但指出理想的处理方法应简单、安全、经济、预期时间长、有效保留内瘘功能和穿刺长度、尽量减少人工假体的使用。而目前临床中常用的动静脉内瘘的结扎、瘤体切除后人工血管替代以及覆膜支架的植入等方法均存在不同程度的缺陷。瘤壁部分切除的手术方式是在6 mm无菌塑料管导引下,切除部分瘤壁缩窄瘤腔后重新缝合瘘静脉。因此,该术式能够保留内瘘功能和穿刺长度。国外学者已有类似术式的报道,方法不尽相同,病例数少,随访疗效并不确切[7-10]。本研究旨在系统性阐明该术式具体步骤,并对近4年于本科采用该术式治疗的39例患者的随访资料进行回顾性分析。

1 对象与方法 1.1 研究对象

纳入2012年7月至2016年6月本科收治39例因上肢自体动静脉内瘘瘤样扩张拟进行手术干预的患者作为研究对象。入选标准:使用自体动静脉内瘘维持透析的尿毒症患者,瘘静脉瘤样扩张形成。瘤样扩张处局部皮肤变薄,感染,张力明显增高,穿刺区域受限,出现高流量相关性心力衰竭以及患者自身美观要求。排除标准:瘤体搏动明显,震颤及杂音消失,血管超声评估发现瘤样扩张近心端回流静脉完全闭塞。所有患者签署知情同意书。

1.2 方法

1.2.1 诊断标准

瘤样扩张最大直径超过瘘静脉管径3倍以上,正常瘘静脉管径≥6 mm(不包括动脉瘤近心端及远心端狭窄段瘘静脉管径),或者瘤样扩张最大直径≥20 mm[11-12]。不包括假性动脉瘤和吻合口处瘤样扩张病例。

1.2.2 血管超声检查

应用Toshiba Aplio 300型彩色多普勒超声诊断仪, 高频线阵探头, 频率9~18 MHz, 二维及彩色多普勒超声模式。检查时患者平卧位, 充分暴露患侧肢体,评估肱动脉血流量、桡动脉管径、吻合口管径、瘘静脉管径、瘤样扩张最大直径、有无血栓形成及狭窄。

1.2.3 手术过程

患者平卧位,患肢外展90°,常规消毒铺巾后1%利多卡因局部麻醉。沿瘤体长轴做梭形切口(图 1A),充分游离瘤体周围组织剥离瘤体(图 1B),注意结扎表面属支血管。游离范围为瘤体两端正常瘘静脉各1~2 cm。普通肝素3 000 IU全身抗凝后血管夹分别夹持近心端和远心端瘘静脉,阻断血流。沿长轴切开瘤体,肝素生理盐水冲洗干净(图 1C)。将6 mm无菌塑料管(图 1D)置于瘤体内,切除多余瘤壁缩窄瘤腔(图 1E)。使用7-0普林灵血管缝线沿塑料管连续缝合瘘静脉血管壁(图 1F)。打开远心端血管夹排尽空气后,再打开近心端血管夹,恢复血流。局部压迫止血后关闭伤口。同样方法处理其他瘤体。

A:梭形切口;B:剥离瘤体;C:切开瘤体;D:6 mm无菌管;E:切除多余瘤壁;F:缝合瘘静脉 图 1 瘤壁部分切除术的手术过程

1.3 统计学分析

采用SPSS 17.0统计软件, 正态分布计量资料用x±s表示,两组间比较采用t检验,临床特点、手术过程等变量作描述性分析。检验水准:α=0.05。

2 结果 2.1 一般临床资料

39例均为终末期维持性血液透析患者, 其中男性27例,女性12例,年龄(40.6±13.3)岁。内瘘建立时间(41.05±14.45)个月,其中13例为36个月内,22例为36~60个月,4例在60个月以上。原发性疾病分别为糖尿病肾病4例,高血压肾病5例,多囊肾8例,慢性肾小球肾炎18例,缺血性肾病2例,其他2例;39例患者均为上肢动静脉内瘘,其中鼻咽窝内瘘12例(桡动脉-头静脉),腕部/前臂内瘘25例(桡动脉-头静脉),肘部内瘘2例(肱动脉-头静脉),内瘘均采用端侧吻合。

2.2 手术前后动静脉内瘘彩色多普勒超声检查结果

39例临床诊断为内瘘瘤样扩张患者经彩色多普勒超声测定其肱动脉血流量为(1 647.39±250.33) mL/min, 瘤样扩张直径为(43.79±4.74)mm,瘤样扩张多发生腕部内瘘;只有1个瘤体的有15例,2个瘤体的有19例,3个瘤体的有4例,4瘤体的有1例;瘤体部分切除术后肱动脉血流量为(770.59±130.10)mL/min, 较术前下降约53.22%,术后原瘤样扩张段血管直径为(10.39±1.82)mm,较术前下降约76.27%, 差异有统计学意义(P<0.01)。

2.3 治疗结果

39例患者手术均成功,术后无感染、血肿、血栓形成等并发症,2周拆线,伤口愈合情况良好。22例患者切除瘤体后,在远离伤口10 cm以上仍有足够穿刺长度用于血液透析,于术后3 d开始使用。13例患者穿刺长度短,不能满足2针穿刺,但仍能穿刺1针做动脉端,另选外周静脉作为静脉回流端进行透析,同样于3 d后开始使用。4例患者手术范围大,无足够穿刺长度,行右颈内静脉或股静脉临时置管进行透析,2周后开始使用内瘘。手术后随访(27.73±8.59)个月,2例患者死亡,1例死于严重脑出血,1例死于急性心肌梗死。7例患者随访过程中发现瘘静脉狭窄,予以超声引导下行球囊扩张术后可继续使用;其中2例患者共行3次球囊扩张,3例患者共行2次球囊扩张,2例患者行1次球囊扩张;目前均未再次出现瘤样扩张。

3 讨论

随着血液净化技术的不断发展和透析质量的不断提高,终末期肾衰竭患者生存期显著延长,血管通路并发症的问题也逐渐凸显,近年成为研究热点之一。国内外有关动静脉内瘘并发症的相关研究多集中在狭窄、血栓形成、窃血综合征等方面,而关于瘤样扩张诊治方面的研究较少,且大多以个案报道为主。关于瘤样扩张的诊断标准目前尚未统一,目前国外多数研究采用此诊断标准定义瘤样扩张,即瘤样扩张应定义为最大直径超过瘘静脉管径3倍以上,正常瘘静脉管径≥6 mm(不包括动脉瘤近心端及远心端狭窄段瘘静脉管径)或者瘤样扩张最大直径≥20 mm。本研究病例纳入标准主要参照此标准。瘤样扩张形成的病理机制尚不完全清楚, 文献[2-3, 13-15]报道瘤样扩张形成主要与定点穿刺、内瘘未成熟而过早使用、高血压等有关,反复定点血管穿刺可导致局部组织损伤、局部炎症反应及管壁的进一步损害及局部瘘静脉壁胶原蛋白变性所致血管重塑;另外血流动力学方面,瘤样扩张近心端的狭窄可以使血管内压力增加,而发生在远心端的狭窄导致紊乱的湍流,均可加速瘤样扩张的形成。

美国NKF-K/DOQI指南指出:当患者自体血管内瘘瘤样扩张形成出现内瘘表面皮肤损伤、内瘘有破裂出血危险或有效穿刺部位非常有限时建议修复。对于动静脉内瘘瘤样扩张处理,结扎或切除动静脉内瘘虽然可以有效治疗瘤样扩张,但会以牺牲整个通路为代价[10, 16],而且在新的内瘘成熟之前,需要临时导管的置入以行血液透析治疗。局部瘤样扩张切除后近心端重建动静脉内瘘,仅适合内瘘重建后仍有充足穿刺长度的病例,应用范围有限;局部瘤样扩张切除后人工血管替代,可以有效保留内瘘及穿刺长度,但后期狭窄、血栓、感染的风险明显增加,且价格昂贵。有学者采用经皮血管腔内覆膜支架来治疗瘤样扩张[17-19],但自体动静脉内瘘不同于人工血管,管径并不统一,尤其是在瘤样扩张区域;而且支架植入部位不能进行穿刺,减少了有效穿刺长度,同时增加了血栓形成、感染的风险以及治疗的费用。本研究采用瘤壁部分切除的方法来治疗瘤样扩张,在6 mm无菌塑料管的导引下切除部分瘤壁后缝合,可以精确缩窄瘤腔至6 mm[15],保证手术成功率。本研究39例患者中共35例(约89.7%)瘤壁部分切除后仍能有足够穿刺长度满足血液透析治疗,而随访39例患者(27.73±8.59)个月,其中有2例因基础疾病死亡,只有7例(约17.9%)患者出现内瘘狭窄的并发症。由此可见,该术式可以有效保留内瘘功能和瘘静脉穿刺长度,避免了异物的植入,经长期随访并发症少,通畅率高,疗效显著。

该手术也存在一定不足之处:虽然本组病例随访时间内未再出现新的瘤样扩张,但部分患者穿刺部位已出现管径变化,尚未达到瘤样扩张诊断标准,还需长期随访观察, 因此该术式并不能阻止瘤样扩张的再形成。本研究并未纳入假性动脉瘤和瘤样扩张发生在吻合口处的病例。这是因为假性动脉瘤并不存在真实的血管壁,治疗应以修补血管壁破口为主。而对于发生在吻合口附近的瘤样扩张,常常伴有吻合口自身的扩张,而且该处组织粘连较重,解剖层次复杂,游离困难,分离过程中常容易导致血管破裂出血,手术操作要求高。即使能完整暴露整个吻合口处血管,呈“T”型走形的动静脉也并不适合该术式。因此,临床上多以关闭内瘘近心端重建为主。

综上所述,瘤壁部分切除治疗自体动静脉内瘘瘤样扩张疗效明显,可作为临床一线手术方式推广。

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http://dx.doi.org/10.16016/j.1000-5404.201710221
中国人民解放军总政治部、国家科技部及国家新闻出版署批准,
由第三军医大学主管、主办

文章信息

万梓鸣, 赖其权, 陈凌, 甘华, 涂波, 陈利群.
WAN Ziming, LAI Qiquan, CHEN Ling, GAN Hua, TU Bo, CHEN Liqun.
瘤壁部分切除术治疗自体动静脉内瘘瘤样扩张的临床研究
Clinical study of partial aneurysmectomy for salvage of aneurysmal dilatation of autogenous arteriovenous fistula
第三军医大学学报, 2018, 40(6): 532-536
Journal of Third Military Medical University, 2018, 40(6): 532-536
http://dx.doi.org/10.16016/j.1000-5404.201710221

文章历史

收稿: 2017-10-31
修回: 2017-12-14

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