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防止血液透析动静脉移植物血栓形成的检查与监测

Author
Michael Allon, MD
Section Editors
Jeffrey S Berns, MD
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editors
Alice M Sheridan, MD
Kathryn A Collins, MD, PhD, FACS
Translators
王德光, 主任医师，副教授

引言

血液透析需要建立快速体外循环血流的血管通路。自体动静脉(arteriovenous, AV)瘘和人造血管移植物是目前满足这些要求的最好选择。 (参见“长期血液透析通路用动静脉瘘及人工血管内瘘”)

检查与监测以防血液透析动静脉移植物血栓形成和移植失败的相关问题见此专题。有关血液透析动静脉瘘的类似问题将单独讨论。 (参见“成熟血液透析动静脉内瘘的临床检查与监测”)

动静脉移植物检查和监测的理由

采用临床检查和无创监测方法进行血液透析动静脉移植物狭窄的评估。遗憾的是，能够发现狭窄病变不一定意味着临床结局得到改善，如血栓形成率降低和/或移植物存活改善[1]。

超过90%形成血栓的移植物存在狭窄病变，提示这一解剖结构异常是移植物血栓形成的必要条件。无创检查方法对50%以上的移植物狭窄具有相对高的阳性预测值(positive predictive value, PPV)。一项随机对照试验[2]发现，对于血流动力学上显著的动静脉移植物狭窄，临床检查检测到异常的PPV为70%，而双功能超声的PPV达80%。然而，一般而言，具有50%以上狭窄的移植物如果不进行抢先血管成形术，注定会形成血栓的比例不足一半。任何一种抢先识别和治疗狭窄的计划必然会引起很多不必要的血管成形术。更糟糕的是，血管成形术所致的血管损伤实际上可刺激新生内膜增生、加速移植物再狭窄和潜在移植物丢失[3]。

临床检查

临床检查指的是对通路进行体格检查或应用透析患者治疗期间收集到的易获得信息进行评估[4]。一些研究已经发现，临床检查有异常的患者中，70%-90%存在血流动力学显著的狭窄(狭窄程度>50%)[2,5-9]。临床检查的主要优势包括：免费、不需要额外的设备和人员，以及许多医护人员都可执行。

          

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Literature review current through: 2017-06 . | This topic last updated: 2017-03-06.
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References
Top
  1. Lumsden AB, MacDonald MJ, Kikeri D, et al. Prophylactic balloon angioplasty fails to prolong the patency of expanded polytetrafluoroethylene arteriovenous grafts: results of a prospective randomized study. J Vasc Surg 1997; 26:382.
  2. Robbin ML, Oser RF, Lee JY, et al. Randomized comparison of ultrasound surveillance and clinical monitoring on arteriovenous graft outcomes. Kidney Int 2006; 69:730.
  3. Chang CJ, Ko PJ, Hsu LA, et al. Highly increased cell proliferation activity in the restenotic hemodialysis vascular access after percutaneous transluminal angioplasty: implication in prevention of restenosis. Am J Kidney Dis 2004; 43:74.
  4. Allon M, Robbin ML. Hemodialysis vascular access monitoring: current concepts. Hemodial Int 2009; 13:153.
  5. Maya ID, Oser R, Saddekni S, et al. Vascular access stenosis: comparison of arteriovenous grafts and fistulas. Am J Kidney Dis 2004; 44:859.
  6. Cayco AV, Abu-Alfa AK, Mahnensmith RL, Perazella MA. Reduction in arteriovenous graft impairment: results of a vascular access surveillance protocol. Am J Kidney Dis 1998; 32:302.
  7. Robbin ML, Oser RF, Allon M, et al. Hemodialysis access graft stenosis: US detection. Radiology 1998; 208:655.
  8. Safa AA, Valji K, Roberts AC, et al. Detection and treatment of dysfunctional hemodialysis access grafts: effect of a surveillance program on graft patency and the incidence of thrombosis. Radiology 1996; 199:653.
  9. Schwab SJ, Raymond JR, Saeed M, et al. Prevention of hemodialysis fistula thrombosis. Early detection of venous stenoses. Kidney Int 1989; 36:707.
  10. Krivitski NM. Theory and validation of access flow measurement by dilution technique during hemodialysis. Kidney Int 1995; 48:244.
  11. Moist LM, Churchill DN, House AA, et al. Regular monitoring of access flow compared with monitoring of venous pressure fails to improve graft survival. J Am Soc Nephrol 2003; 14:2645.
  12. Schwab SJ, Oliver MJ, Suhocki P, McCann R. Hemodialysis arteriovenous access: detection of stenosis and response to treatment by vascular access blood flow. Kidney Int 2001; 59:358.
  13. Besarab A, Sullivan KL, Ross RP, Moritz MJ. Utility of intra-access pressure monitoring in detecting and correcting venous outlet stenoses prior to thrombosis. Kidney Int 1995; 47:1364.
  14. Besarab A, Frinak S, Sherman RA, et al. Simplified measurement of intra-access pressure. J Am Soc Nephrol 1998; 9:284.
  15. Ram SJ, Work J, Caldito GC, et al. A randomized controlled trial of blood flow and stenosis surveillance of hemodialysis grafts. Kidney Int 2003; 64:272.
  16. Dember LM, Holmberg EF, Kaufman JS. Randomized controlled trial of prophylactic repair of hemodialysis arteriovenous graft stenosis. Kidney Int 2004; 66:390.
  17. Malik J, Slavikova M, Svobodova J, Tuka V. Regular ultrasonographic screening significantly prolongs patency of PTFE grafts. Kidney Int 2005; 67:1554.
  18. McCarley P, Wingard RL, Shyr Y, et al. Vascular access blood flow monitoring reduces access morbidity and costs. Kidney Int 2001; 60:1164.
  19. Tonelli M, James M, Wiebe N, et al. Ultrasound monitoring to detect access stenosis in hemodialysis patients: a systematic review. Am J Kidney Dis 2008; 51:630.
  20. Miller CD, Robbin ML, Barker J, Allon M. Comparison of arteriovenous grafts in the thigh and upper extremities in hemodialysis patients. J Am Soc Nephrol 2003; 14:2942.
  21. Martin LG, MacDonald MJ, Kikeri D, et al. Prophylactic angioplasty reduces thrombosis in virgin ePTFE arteriovenous dialysis grafts with greater than 50% stenosis: subset analysis of a prospectively randomized study. J Vasc Interv Radiol 1999; 10:389.
  22. Dember LM, Holmberg EF, Kaufman JS. Value of static venous pressure for predicting arteriovenous graft thrombosis. Kidney Int 2002; 61:1899.
  23. McDougal G, Agarwal R. Clinical performance characteristics of hemodialysis graft monitoring. Kidney Int 2001; 60:762.
  24. Murray BM, Rajczak S, Ali B, et al. Assessment of access blood flow after preemptive angioplasty. Am J Kidney Dis 2001; 37:1029.
  25. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48 Suppl 1:S176.