穿静脉单一流出道动静脉内瘘的多中心处理探讨

doi:10.3969/j.issn.1004-583X.2026.03.006

摘要/Abstract

摘要：

目的回顾分析多中心穿静脉(antecubital perforating vein,APV)单一流出道动静脉内瘘(arteriovenous fistula,AVF)失功进行手术干预的临床诊治情况,探讨此类AVF手术处理策略。方法回顾性分析2019年8月-2025年8月,在三所三甲医院肾内科诊断APV单一流出道血液透析AVF失功进行手术的临床资料、处理方式及随访结果。评估不同手术方式技术成功率、并发症、初级及次级通畅率。结果共纳入27例,平均年龄(64.55±11.58)岁,AVF建立时间50.00(17.00,124.00)月,共进行了29次手术,手术方式包括人工血管移植、贵要静脉(basilic vein,BV)转位吻合、APV-肱静脉(brachial vein,BRV)吻合、AVF重建和(或)联合经皮腔内血管成形术(percutaneoius transluminal angioplasty,PTA)。26例AVF功能恢复,技术成功率89.66%,3次手术失败均在PTA组,中位随访时间21.00(11.75,27.50)月,总通畅率84.61%, 6月、12月、18月、24月初级通畅率分别为88.50%、69.80%、41.90%、41.90%。随访期间,57.69%(15/26)的患者再次失功,经PTA治疗后再通,2年次级通畅率100%。其中人工血管组再次手术干预概率比其他几组高。结论手术重建AVF流出道是APV单一流出道AVF功能障碍的有效处理方式,手术成功率较高,远期易再次失功,尤其是人工血管间置组,PTA可辅助其获得良好的远期通畅率。

关键词: 动静脉内瘘, 穿静脉单一流出道, 功能障碍, 重建流出道, 通畅率

Abstract:

Objective To retrospectively analyze the clinical diagnosis and treatment of surgically treated dysfunctional arteriovenous fistulas (AVFs) for a single vein outflow tract in the antecubital perforating vein (APV), and to explore the surgical management strategies for such AVFs. Methods Clinical data, treatment modalities, and follow-up outcomes of hemodialysis patients diagnosed with dysfunctional AVFs for a single vein outflow tract in the APV and required for surgical interventions in the Nephrology Department of three medical institutions from August 2019 to August 2025 were retrospectively reviewed. Success rate, complications, and primary/secondary patency rates were analyzed. Results A total of 27 patients were included, with a mean age of 64.55±11.58 years. The AVF had been established for 50.00 (17.00, 124.00) months. A total of 29 surgeries were performed, including interposition of artificial blood vessel, transposition and anastomosis of the basilic vein(BV), anastomosis of the transvenous BV, AVF reconstruction, and/or combined percutaneous transluminal angioplasty (PTA). AVF function was restored in 26 patients, with a technical success rate of 89.66%, and three failed operations were performed in PTA group. The median follow-up duration was 21.00 (11.75, 27.50) months, and the overall patency rate was 84.61%. The primary patency rate at 6, 12, 18, and 24 months was 88.50%, 69.80%, 41.90%, and 41.90%, respectively. During the follow-up period, 57.69% (15/26) of patients experienced recurrent AVF failures, which was restored by PTA. The 2-year secondary patency rate was 100%. The probability of repeat surgical intervention for AVF in the artificial blood vessel group was higher than that in the other groups. Conclusion Surgical reconstruction of the AVF outflow tract is an effective treatment for dysfunctional AVFs for a single vein outflow tract in the APV, with a high surgical success rate. However, the probability of long-term recurrent AVF failure is high, especially after an interposition of the artificial blood vessel. PTA can be used as an adjunct to achieve good long-term patency.

Key words: arteriovenous fistula, single venous outflow tract through vein, dysfunction, outflow tract reconstruction, patency rate

中图分类号:

R654.4

程慧栋, 娄文苑, 刘同强, 李婧, 冒文彬, 牟洪宾, 何建强. 穿静脉单一流出道动静脉内瘘的多中心处理探讨[J]. 临床荟萃, 2026, 41(3): 228-234.

Cheng Huidong, Lou Wenyuan, Liu Tongqiang, Li Jing, Mao Wenbin, Mou Hongbin, He Jianqiang. Multi-center management of arteriovenous fistulas for hemodialysis with a single venous outflow tract in the antecubital perforating vein[J]. Clinical Focus, 2026, 41(3): 228-234.

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链接本文: https://www.lchc.cn/CN/10.3969/j.issn.1004-583X.2026.03.006

https://www.lchc.cn/CN/Y2026/V41/I3/228

图/表 7

图1 APV单一流出道AVF的超声、造影及示意图 a.横切面;b.纵切面: 超声示MBV、CV狭窄闭塞,APV开放扭结(白色箭头);c.造影:前臂中段MBV、CV支及贵要静脉无显影,造影剂经APV汇入深静脉,肘部血管反“Z”字形;d、e.示意图:仅通过APV向肱静脉引流的桡头静脉,上臂CV、MBV闭塞;APV处植入覆膜支架 (白色箭头)开通血流。

Fig.1 Ultrasound scan, contrast imaging and schematic diagram of dysfunctional AVF with a single outflow tract in APV a. Transverse section, b. Longitudinal section: Ultrasound shows stenosis and occlusion of MBV and CV, while APV is open and knotted (white arrow); c. Contrast imaging: The MBV, CV branches and vital veins in the middle section of the forearm were not visualized. The contrast agent flowed into the deep veins through the APV, and the blood vessels at the elbow were in a reverse "Z" shape. D. e. Schematic diagram: Radial vein that only drains to the brachial vein through APV, with CV and MBV of the upper arm occluded; A covered stent (indicated by the white arrow) was implanted at the APV to open up blood flow.

图2 患者筛选流程图

Fig.2 Flowchart of patient screening

表1 患者一般资料(n=27)

Tab.1 General information of patients(n=27)

项目	数值
年龄(岁)	64.55±11.58
男[例(%)]	13(48.15)
透析龄(月)	52.00(30.00, 146.00)
原发病[例(%)]
糖尿病	8(29.63)
高血压病	6(22.22)
原发性肾小球疾病	3(11.11)
自身免疫相关肾脏病	2(7.41)
病因不明	8(29.63)
AVF建立时间(月)	50.00(17.00,124.00)
确诊时化验资料
血红蛋白(g/L)	99.22±12.07
白蛋白(g/L)	37.69±1.29
血肌酐(μmol/L)	906.75±114.73
血尿素氮(mmol/L)	24.29±3.94
胆固醇(mmol/L)	3.70±1.00
甘油三酯(mmol/L)	1.40(1.16, 1.87)
钾(mmol/L)	4.23(3.94,4.98)
磷(mmol/L)	1.74(1.38,2.00)
钙(mmol/L)	2.03(2.00, 2.09)
甲状旁腺激素(pg/ml)	362.89±124.28
D-二聚体(mg/L)	0.38(0.14, 0.64)
临床表现[例(%)]
震颤减弱	5(18.52)
震颤消失	9(33.33)
流量下降	7(25.93)
静脉压高	2(7.41)
疼痛	3(11.11)
其他	1(3.70)
血栓形成[例(%)]	13(48.15)

图3 1例伴动脉瘤的APV流出道梗阻手术图 1例合并吻合口后动脉瘤患者,静脉全程血栓,手术较复杂,a:取栓、动脉瘤切除、AVF修补、APV-BRV吻合术;b:PTA扩张狭窄段CV;术后4周顺利启用AVF。

Fig.3 Surgical diagram of one case of APV outflow tract obstruction accompanied by an aneurysm A patient with post-anastomotic aneurysm and whole-course venous thrombosis was treated by a complicated surgery. a: After thrombectomy, aneurysm resection, AVF repair, and APV-BRV anastomosis; b: PTA dilation stenosis section CV; AVF was successfully activated 4 weeks after the operation.

表2 各中心手术次数汇总情况(例)

Tab.2 Date summary of surgeries in each center(n)

项目	总手术次数(n=29)	江苏大学附属医院(n=20)	常州市第二人民医院(n=6)	苏北人民医院(n=3)
AVG	12	7	2	3
PTA	7	6	1	0
血管转位	8	7	1	0
自体血管间置	1	0	1	0
BV-尺动脉AVF	1	0	1	0

表3 患者手术效果及随访情况

Tab.3 Surgical outcomes and follow-up for the patients

组别	手术次数		技术成功率 [例(%)]	并发症 [例(%)]	随访时间 (月)			初级通畅率[例(%)]
组别	手术次数		技术成功率 [例(%)]	并发症 [例(%)]	随访时间 (月)			6月	12月		18月		24月
总数	29		26(89.66)	3(10.34)	21.00(11.75,27.50)			22(88.50)	13(69.80)		5(41.90)		2(41.90)
AVG	12		12(100.00)	2(16.70)	22.50(13.75,63.75)			10(83.30)	7(64.80)		2(21.60)		/
血管转位	8		8(100.00)	0	19.50(13.00,25.25)			8(100.00)	5(75.00)		2(75.00)		1(75.00)
PTA	7		4(57.14)	1(14.29)	8.50(5.00,10.50)			3(100.00)	/		/		/
其他	2		2(100.00)	0	24.50(23.00,24.50)			1(50.00)	1(50.00)		1(50.00)		1(50.00)
χ²/Z值			10.516	1.788	6.834			5.349	0.673		1.122		1.406
P值			0.017	0.672	0.107			0.217	0.652		0.408		0.378
组别		次级通畅率[例(%)]								总通畅率 [例(%)]		再手术概率 (次/人)
组别		6月		12月		18月	24月			总通畅率 [例(%)]		再手术概率 (次/人)
总数		25(100.00)		19(100.00)		15(100.00)	9(100.00)			22(84.61)		1.12
AVG		12(100.00)		10(100.00)		9(100.00)	5(100.00)			8(66.70)		1.67
血管转位		8(100.00)		7(100.00)		4(100.00)	2(100.00)			8(100.00)		0.75
PTA		3(100.00)		/		/	/			3(75.00)		0.50
其他		2(100.00)		2(100.00)		2(100.00)	2(100.00)			2(100.00)		0.50
χ²/Z值		/		/		/	/			1.651		9.365
P值		/		/		/	/			0.362		0.027

图4 通畅率(K-M曲线) a.所有患者初级、次级通畅率比较; b.4组初级通畅率比较。

Fig.4 Patency rate (K-M curve) a. Comparison of the initial and secondary patency rates for all patients; b. Comparison of the primary patency rates among the four groups.

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