超声引导PTA在动静脉内瘘狭窄中的应用及术后评估时机的探讨

发布时间：2018-01-04 14:33

  本文关键词：超声引导PTA在动静脉内瘘狭窄中的应用及术后评估时机的探讨　出处：《郑州大学》2017年硕士论文　论文类型：学位论文

  更多相关文章： 超声引导下PTA 术后评估时机 动静脉内瘘

【摘要】：背景和目的随着人口老龄化进程的加剧,终末期肾脏病已经成为严重威胁我国国民身体健康的主要疾病之一。血液透析是终末期肾脏病患者主要治疗方式之一,充分的血液透析需要良好的血管通路做保障。动静脉内瘘(Arteriovenous fistula,AVF)具有使用寿命长、血流量充足、并发症少等优势,被认为是目前最理想的血管通路。然而随着患者日趋老龄化和透析龄的延长,内膜增生、血栓形成、感染等原因导致的内瘘狭窄、闭塞,已成为血液透析失败的主要原因。传统上内瘘狭窄多采用外科开放重建术或放射介入,但其造成的的血管资源浪费或辐射伤害等严重阻碍着传统技术的发展。近年,经皮穿刺血管成形术(Percutaneous transluminal angioplasty,PTA)被尝试用于治疗动静脉内瘘狭窄,应用导管技术对狭窄血管或闭塞性病变进行扩张或再通。同时,超声技术在血管径路上的应用,也为血管通路的评估提供了有效的手段,不仅可以对内瘘血管结构和功能进行监测,而且能够实时多角度对介入器材和血管解剖进行显示。超声技术极大地提高了PTA术的可视化程度,也延长了动静脉内瘘的使用寿命。PTA术后通常即时进行超声检查手术效果评估,然而由于忽略了术中损伤、球囊扩张、局部浸润麻醉、血管痉挛等多种因素对内瘘血管的干扰,此时获取的血管数据存在一定程度的失真,进一步可能影响我们对手术效果的判断,导致临床决策失误,延误补救时机。本研究的主要目的是观察超声引导下经皮腔内血管成形术在治疗动静脉瘘狭窄中的应用,探讨PTA术不同时间节点手术效果最佳评估时机。研究对象和方法收集2016年2月~2017年3月在河南省人民医院血液净化中心接受超声引导下PTA治疗的前臂内瘘狭窄的透析患者15例,所有病人术前超声检查均只有一处狭窄病灶。分别于术前、术后即时、术后1天和术后3天四个时间节点对肱动脉阻力指数(RI)、血流量(FV)和内瘘最窄处直径(D)进行测量,根据直径计算内瘘处横断面积(横断面积=π×(内径/2)2)。对符合正态分布的计量资料用均数±标准差(SX±)形式表示。符合方差齐、正态分布的多组间比较采用单因素方差分析(one way ANOVA),两两比较采用LSD法。以上数据分析均采用SPSS 19.0软件包,以P0.05视为差异有统计学意义。结果1.术前共入选15例病例,其中男性9例,女性6例,平均年龄为(54.52±14.63)岁;左侧前臂内瘘狭窄9例,右侧前臂内瘘狭窄6例;糖尿病肾病3例,慢性肾炎5例,其它原因7例;透析龄7-174个月;所有病例均成功行前臂桡动脉-头静脉端侧吻合;PTA术后无残余狭窄存在,血流量充沛,引出顺畅,透析静脉压小于100mm Hg,透析血流速度200ml/min,未出现血管破裂,急性血栓形成等并发症;1例患者PTA术后出现局部肿胀、瘀斑形成,予以弹力绑带轻度加压包扎后消退。2.PTA术前、术后即时、术后1天、术后3天狭窄处横断面积分别为:(3.0±1.1)mm2、(8.2±4.0)mm2、(20.4±5.8)mm2、(20.5±6.0)mm2;肱动脉阻力指数分别为:0.57±0.07、0.64±0.07、0.51±0.06、0.50±0.06;肱动脉血流量分别为:(409.7±102.4)ml/min、(403.9±105.9)ml/min、(626.7±132.1)ml/min、(632.9±135.9)ml/min。结果显示PTA术后1天与术前和术后即时两时间点相比较三项参数变化较大,P0.05,差异具有统计学意义。术后1天内瘘血管结构和功能均发生急剧变化,狭窄处横断面积、血流量均急剧增加,阻力指数急剧降低,与术前基础值相比,狭窄处横断面积平均增加了17.4mm2,肱动脉血流量平均增加了216.3ml/min,肱动脉阻力指数平均减少了0.06。术后1天与术后3天相比较两组间参数无明显差别,P0.05,差异无统计学意义,即术后1天三项参数基本趋于稳定。由此可推测,内瘘重建术中球囊扩张、局部浸润麻醉、血管痉挛等多种因素对血管急性重塑的影响,在术后一天已基本消除,此时进行内瘘结构与功能的彩超监测更具真实性。结论1.超声引导下PTA术操作简单、微创、安全,近期效果明显,是治疗动静脉瘘狭窄的一种有效方法。2.PTA术后1天内瘘血管结构和功能趋于稳定,因此建议术后1天进行超声监测手术效果评估。
[Abstract]:Background and objective: with the population aging process intensifies, end-stage kidney disease has become one of the major diseases threatening our national health. Hemodialysis patients with end-stage renal disease is one of the main treatment, full hemodialysis vascular access requires good guarantee. The arteriovenous fistula (Arteriovenous fistula, AVF) has the advantages of long service life, adequate blood flow, less complications advantages, is considered to be the most ideal vascular access at present. However with the extension of aging patients and dialysis age of intimal hyperplasia, thrombosis, infection and other reasons of the fistula stenosis, occlusion, has become the major cause of failure of traditional hemodialysis. On the internal fistula stenosis by open surgical revascularization or interventional radiology, but the resulting waste of resources or the vessel radiation injury is a serious obstacle to the development of traditional technology. In recent years, percutaneous Thorn angioplasty (Percutaneous transluminal, angioplasty, PTA) have been tried for the treatment of arteriovenous fistula stenosis, application of stenosis or occlusion catheter lesion expansion or recanalization. At the same time, application of ultrasonic technology in vascular path, but also provides an effective means for the assessment of vascular access, not only can be monitored the internal fistula vascular structure and function, and can display the anatomy and vascular interventional equipment real-time multi angle. Ultrasound technology has greatly improved the visualization degree of PTA operation, also extended the arteriovenous fistula of the life after.PTA usually evaluate the effect of ultrasonic examination. However, due to the neglect of the intraoperative injury, balloon dilatation, local anesthesia, various factors of vascular spasm for fistula, a certain degree of distortion of vascular access data at this time, may be further. We rang the surgical results of judgment, leading to clinical decision error, delay remedial opportunity. The main purpose of this study is to observe the ultrasound guided percutaneous transluminal angioplasty in the treatment of intravenous fistula stenosis, and to explore the optimal evaluation of PTA with different time node surgery time. Research subjects and methods from February 2016 ~2017 March in the Henan Province People's Hospital blood purification center treated with ultrasound guided PTA forearm fistula stenosis in hemodialysis patients in 15 cases, all patients with preoperative ultrasonography were only a narrow focus. In preoperative, immediate postoperative, after 1 days and 3 days after operation the four time node of the brachial artery resistance index (RI), blood flow (FV) and the narrowest diameter of fistula (D) were measured according to the calculation of diameter in fistula cross-sectional area (cross-sectional area = pi * (diameter /2). 2) to conform to the normal distribution of measurement data with mean + standard The standard deviation (SX +) form. In accordance with the homogeneity of variance, normal distribution were compared with single factor analysis of variance (one way, 22 ANOVA) compared with LSD method. The above data were analyzed using SPSS 19 software package, using P0.05 as statistical significance. Results 1. before surgery were enrolled in 15 cases, there were 9 males, 6 females, mean age (54.52 + 14.63) years old; the left forearm fistula stenosis in 9 cases, right forearm fistula stenosis in 6 cases; 3 cases of diabetic nephropathy, 5 cases of chronic nephritis, 7 cases of other causes; dialysis age 7-174 months; all cases were successful for the forearm radial artery cephalic vein end to side anastomosis; no residual stenosis of PTA after operation, blood flow is abundant, leads to smooth, venous dialysis pressure less than 100mm Hg, dialysis blood flow velocity 200ml/min, there was no vascular rupture, acute thrombosis and other complications; 1 cases of patients with PTA after the local swelling and ecchymosis, be stretch 缁戝甫杞诲害鍔犲帇鍖呮墡鍚庢秷閫，

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