任安 刘巍 张雪哲 姜卫剑 吴清海 邹学广 董峰 张凌 卞维净 100029 北京，中日友好医院放射诊断科(任安、张雪哲、姜卫剑)，血液净化中心(张凌、卞维净)；北京协和医院放射科(刘巍)；进修医师(吴清海、邹学广、董峰) 中华放射学杂志 1999 0 33 4


    关键词：血液透析；血管成形术；血栓溶解疗法 期刊 zhfsxzz 0 介入放射学 fur -->


    

【摘要】 目的 总结分析3年来有关血液透析(以下简称血透)分流通道机能不全和闭塞的造影诊断及介入治疗方面的经验和教训。方法 对33例血透分流通道机能不全和闭塞做血管造影，包括27例自体血管瘘道、6例人工移植物瘘道。19例通道闭塞者行溶栓治疗，13例行经皮血管成形术。结果 初次造影结果：19例通道闭塞，12例血管狭窄，2例假性动脉瘤形成。19例通道闭塞溶栓治疗即时开通率达89%(17/19)：2例技术失败。溶栓后造影7例伴潜在血管狭窄，其中4例行血管成形术。血管成形术治疗共13例，9例为单纯狭窄，成功7例；4例为闭塞溶栓治疗后，成功1例。随访观察，溶栓后伴潜在狭窄未处理(3例)及血管成形失败者(3例)，均于1个月内发生再阻塞。结论 血管造影对通道机能不全或闭塞的诊断和介入治疗具有重要意义。溶栓治疗对非解剖因素造成的闭塞疗效确实。对通道闭塞，单纯溶栓只能即时开通通道，不能保证完全恢复通道机能。单纯狭窄做血管成形成功率高于阻塞后。应加强通道监测，发现机能不全的早期征象后，立即造影检查，如有狭窄即行血管成形术，以恢复通道机能，预防发生通道闭塞。

Dialysis access: radiographic evaluation and management

REN An^* , LIU Wei, ZHANG Xuezhe, et al. ^* Department of Radiology, China-Japan Friendship Hospital, Beijing 100029

【Abstract】 Objective To evaluate the experience of radiographic evaluation and interventional management of dialysis access. Methods Angiography in 33 cases of failing and malfunctioning hemodialysis access was done (27 Brescia-Cimino fistulas, 6 PTFE loop graft ) by puncturing the brachial artery or directly into the vascular access. 19 patients presenting acute thrombosis occlusion were treated with pulse spray thrombolysis. Post-treatment angiogram was obtained in all cases. 13 chosen patients (9 with plain stenoses and 4 with occlusion) underwent PTA. Results On the initial diagnostic angiogram, 19 occlusions, 12 plain stenoses and 2 pseudo-aneuryms were identified. Technical success (immediate clinical success) of thrombolysis were 89%(17/19), treatment was discontiuned in two cases because of formation of a large local hematoma and venous dissection. An underlying stenosis was found in 7 patients after thrombolysis procedures. 4 of them underwent immediate PTA of underlying stenoses. The 1-month primary patency rate after thrombolysis was 64% (11/17). The PTA was successful in 7of 9 patients with plain stenoses and in 1 of 4 with occlusion. The failure might be due to recoiling stenosis and highly resistant fibrotic stenosis. No patients had symptoms or signs during thrombolysis and PTA. Conclusions Radiologic evaluation plays a critical role in the diagnosis and management of failing access. Although thrombolysis effectively restore access patency immediately, it is associated with high rate of recurrent thrombosis unless the underlying stenosis is detected and corrected. Initial success rates of PTA is lower for occlusion than for plain stenoses. The optimal approach to maintaining dialysis access patency is strict surveillance. Any hemodynamic sign of shunt insufficiency (increased venous pressure or decreased arterial inflow) during dialysis should call for immediate inspection and dilation (after fistulography) to restore function and to prevent occlusion.

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