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获得性下肢动静脉瘘

Author
Emile R Mohler III, MD
Section Editors
Denis L Clement, MD, PhD
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Translators
刘杨东, 副主任医师，副教授

引言

动静脉瘘(arteriovenous fistula, AVF)是指动脉与静脉系统之间不经过正常解剖毛细血管床的异常交通。AVF可发生在全身任何部位，可单发也可多发，既可为先天性的也可为获得性的(如，创伤所致)(表 1)。腹股沟区是经皮动、静脉通路的常用部位，因此下肢获得性AVF是目前最常发生的AVF。

本文将总结下肢AVF。其他部位(如，脑、肺)发生的AVF及动脉导管未闭将单独讨论。 (参见“中枢神经系统血管畸形”和“成人肺动静脉畸形的流行病学、病因学及病理学”和“动脉导管未闭的临床表现和诊断”)

病理生理学

全身的动脉和静脉都是紧密伴行的。大多数动脉旁都有成对的静脉，它们具有静脉间交通(即，并行静脉)经过动脉前方或后方。大动脉可能只有一条紧密伴行的静脉，或者还具有另一条可能较小的伴行静脉。静脉分支也常在汇入较大静脉前经过动脉前方。

任何穿过动脉或静脉的装置、器械或抛射物都有可能导致AVF。穿透的方向可以是从动脉到静脉，也可以是从静脉到动脉。在建立经皮通路时，穿刺时针偏内或偏外，或置针时穿透并行静脉或分支静脉均可导致动静脉复合穿刺伤。在许多病例中，操作者可发现针穿刺位置错误(如，穿刺动脉时出现暗红色回血，穿刺静脉时出现搏动性回血)并退针。在大多数病例中，动脉与静脉间的通路会自然闭合。然而，当具有某些危险因素时，这种异常通路可能不会自行闭合，将发生AVF。

长期AVF可导致肢体肿胀、高输出量性心力衰竭或动脉内动脉瘤样变性[1-5]。较大的股总动脉AVF可导致血流动力学改变，原因为血流从高阻力的动脉循环流向低阻力的静脉循环。这种血液分流增加了静脉的血容量和压力，并降低了外周血管阻力。随后增加的心脏每搏输出量和心率可能导致心输出量显著增加。高流量AVF的另一个结果是减少了流向下肢的血流量，此时如果已存在外周动脉疾病(peripheral artery disease, PAD)，则可导致下肢缺血症状的发生或加重[6]。 (参见下文‘临床评估’)

                

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Literature review current through: 2017-06 . | This topic last updated: 2017-02-22.
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