Damar Çaplarının Hemodiyaliz için Oluşturulan Arteriovenöz Fistüllerin Olgunlaşma ve Açıklıkları Üzerine Etkileri

Öz

Arteriovenöz fistülün (AVF) primer yetersizliği ciddi bir sorundur. Yetersizlik oranlarını azaltmak için, damarların preoperatif ultrasonografik değerlendirilmesi son yıllarda popülerdir. Ancak, çoğu klinikte ultrasonografik değerlendirme rutin değildir. Ameliyat genellikle fizik muayeneden sonra yapılmaktadır. Bu çalışmanın amacı primer yetersizlik nedenlerini, damar çapları ile primer yetersizlik arasındaki ilişkiyi değerlendirmektir. 01.01.2012-31.12.2015 arasında yapılan AVF oluşturma, revizyonlar ve kapatmalar dahil olmak üzere 448 operasyon retrospektif olarak değerlendirildi. Hastalar yaş, cinsiyet, ırk, operasyon yeri, tarafı, operasyon, nedeni, kullanılan arter, ven, çapları, anastomoz tipi, tril, açık kalım ve eşlik eden hastalıkları açısından değerlendirildi. Açık kalımlar 10. günde, 1. ve 6. aylarda, 1. ve 2. yılda kontrol edildi. 448 operasyonun  %86.38’i oluşturma, %3.79’u kapatma ve %9.82’si revizyondu. En sık revizyon nedeni ve uygulanan prosedür tromboz (%56.81) ve trombektomiydi. Kapatmaların en sık nedeni iskemiydi (%35.29). Ortalama brakiyal arter çapı 4.45±0.45 mm ortalama radial arter çapı 2.52±0.42 mm idi. Ortalama bazilik ven çapı 3.31±0.60 mm ortalama cephalic ven çapı 2.47±0.64 mm idi. Brakiyal arter çapı 4.45 mm’den (p<0.003) ve cephalic ven çapı 2.15 mm‘den (p<0.005) küçük olan hastalarda, dismatürasyon veya yetersizlik oranları anlamlı olarak yüksekti. Damarlarınn preoperatif ultrasonografik değerlendirilmesi, fizik muayene bulguları iyi bile olsa iyi bir seçenektir. Uzun ömürlü, yeterli bir AVF için minimum 4.45 mm’lik brakial arter, minimum 2.15 mm’lik cephalic ven ve minimum 2.20 mm’lik radial arter çapı olmasını öneririz. Ayrıca operasyon sonunda tril varlığı da uzun ömürlü, yeterli bir AVF için önemli bir işarettir. 

Anahtar Kelimeler

• Arteriyovenöz Fistül,Damar Açık Kalımı,Hemodiyaliz,Kardiyovasküler Cerrahi Prosedür,Ultrasonografi

The Effects of Vascular Diameters on the Maturation and Patency of the Arteriovenous Fistulas for Hemodialysis

Öz

Primary failure of arteriovenous fistula (AVF) is a serious problem. For decreasing the failure rates, pre-operative ultrasonographic evaluation of the target vessels is popular in recent years. However, in most clinics ultrasonographic evaluation is not routine. Operation is usually performed after physical examination. The aim of this study is to evaluate the primary failure reasons and the relation between vessel diameters and primary failure. 448 operations, including AVF creation, revisions and closures performed between 01.01.2012-31.12.2015 were evaluated retrospectively. Age, gender, race, site, side, operation, reason(s), used artery and vein, diameters, anastomosis type, thrill, patency and co-morbid diseases evaluated. Patencies were controlled on the 10th day, on the 1st, 6th months, 1st and 2nd years. Of the 448 operations, 86.38% was creation, 3.79% was closure and 9.82% were revision. Leading revision reason and performed procedure was thrombosis (56.81%) and thrombectomy. Leading reason of closures was ischemia (35.29%). Mean brachial artery diameter was 4.45±0.45 mm and mean radial artery diameter was 2.52±0.42 mm. Mean vein diameters were 3.31±0.60 mm for basilic vein and 2.47±0.64 mm for cephalic vein. In patients with less than diameter of 4.45 mm for brachial artery (p<0.003) and less than diameter of 2.15 mm for cephalic vein (p<0.005), dysmaturation or failure rates were significantly higher. Preoperative ultrasonographic evaluation of the vessels is a good choice even if the physical examination of the patient is good. We recommend min 4.45 mm brachial artery, min 2.15 mm cephalic vein and min 2.20 mm radial artery diameter. Presence of thrill at the end of the AVF creation is an important marker for an adequate, long lasting AVF. 

Anahtar Kelimeler

• Hemodialysis,Ultrasonography,Arteriovenous Fistulas,Cardiovascular Surgical Procedure,Vascular Patency

Kaynakça

1. 1. Jin DC, Han JS. Renal replacement therapy in Korea, 2012. Kidney Res Clin Pract. 2014;33(1):9-18.
2. 2. Ravani P, Palmer SC, Oliver MJ, et al. Associations between hemodialysis access type and clinical outcomes: a systematic review. J Am Soc Nephrol. 2013;24(3):465-73.
3. 3. Grubbs V, Wasse H, Vittinghoff E, et al. Health status as a potential mediator of the association between hemodialysis vascular access and mortality. Nephrol Dial Transplant. 2014;29(4):892-8.
4. 4. Malas MB, Canner JK, Hicks CW, et al. Trends in incident hemodialysis access and mortality. JAMA Surg. 2015;150(5): 441-8.
5. 5. Al-Jaishi AA, Lok CE, Garg AX, et al. Vascular access creation before hemodialysis initiation and use: a population-based cohort study. Clin J Am Soc Nephrol. 2015(3);10: 418-27.
6. 6. Ng LJ, Chen F, Pisoni RL, et al. Hospitalization risks related to vascular access type among incident US hemodialysis patients. Nephrol Dial Transplant. 2011;26(11):3659-66.
7. 7. Mat Said N, Musa KI, Mohamed Daud MA, et al. The combination of sonography and physical examination improves the patency and suitability of hemodialysis arteriovenous fistula in vascular access. Malays J Med Sci. 2016;23(4):26-32.
8. 8. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis. 2006;48(Suppl 1): S176-247.

9. 9. Dember LM, Imrey PB, Duess MA, et al. Vascular function at baseline in the hemodialysis fistula maturation study. J Am Heart Assoc. 2016;5(7): e003227.
10. 10. Nakata J, Io H, Watanabe T, et al. Impact of preoperative ultrasonography findings on the patency rate of vascular access in Japanese hemodialysis patients. Springer plus. 2016;5:462.
11. 11. Choi JW, Joh JH, Park HC. The usefulness of duplex ultrasound for hemodialysis access selection. Vasc Specialist Int. 2017;33(1):22-6.
12. 12. National Kidney Foundation. KDOQI Clinical practice guidelines and clinical practice recommendations for 2006 updates: hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Am J Kidney Dis 2006;48(Suppl 1):1-322.
13. 13. Ferring M, Henderson J, Wilmink A, et al. Vascular ultrasound for the preoperative evaluation prior to arteriovenous fistula formation for haemodialysis: review of the evidence. Nephrol Dial Transplant. 2008;23(6):1809-15.
14. 14. Allon M, Robbin ML. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int. 2002;62(4):1109-24.
15. 15. Kazemzadeh GH, Modaghegh MHS, Ravari H, et al. Primary patency rate of native AV fistula: long term follow up. Int J Clin Exp Med. 2012;5(2):173-8.
16. 16. Wang W, Murphy B, Yilmaz S, et al. Comorbidities do not influence primary fistula success in incident hemodialysis patients: a prospective study. Clin J Am Soc Nephrol. 2008;3(1):78-84.
17. 17. Bhalodia R, Allon M, Hawxby AM, et al. Comparison of radiocephalic fistulas placed in the proximal fore arm and in the wrist. Semin Dial. 2011;24(3):355-7.
18. 18. Kim SM, Han Y, Kwon H, et al. Ann Surg Treat Res. 2016;90(4):224-30.
19. 19. Lok CE, Allon M, Moist L, et al. Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas (REDUCE FTM I). J Am Soc Nephrol. 2006;17(11): 3204-12.
20. 20. Tordoir J, Canaud B, Haage P, et al. EBPG on vascular access. Nephrol Dial Transplant. 2007;22(Suppl 2):88-117.
21. 21. Sato M, Io H, Tanimoto M, et al. Relationship between preoperative radial artery and postoperative arteriovenous fistula blood flow in hemodialysis patients. J Nephrol. 2012;25(5):726-31.
22. 22. Allon M, Lockhart ME, Lilly RZ, et al. Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients. Kidney Int. 2001;60(5):2013-20.
23. 23. Mendes RR, Farber MA, Marston WA, et al. Prediction of wrist arteriovenous fistula maturation with preoperative vein mapping with ultrasonography. J Vasc Surg. 2002;36(3):460-3.
24. 24. Lauvao LS, Ihnat DM, Goshima KR, et al. Vein diameter is the major predictor of fistula maturation. J Vasc Surg. 2009;49(6):1499-504.
25. 25. Malovrh M. Native arteriovenous fistula: preoperative evaluation. Am J Kidney Dis. 2002;39(6):1218-25.
26. 26. Sahasrabudhe P, Dighe T, Panse N, et al. Prospective long-term study of patency and outcomes of 505 arteriovenous fistulas in patients with chronic renal failure: Authors experience and review of literature. Indian J Plast Surg. 2014;47(3):362-9.
27. 27. Saran R, Elder SJ, Goodkin DA, et al. Enhanced training in vascular access creation predicts arteriovenous fistula placement and patency in hemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study. Ann Surg 2008;247(5):885-91.