Subscribe to RSS
DOI: 10.1055/s-2002-22034
© Georg Thieme Verlag Stuttgart · New York
Ist die chirurgische Revision von ePTFE-Dialyseshunts gerechtfertigt?
Patency of Surgically Revised ePTFE-Dialysis Access GraftsPublication History
Publication Date:
14 March 2002 (online)
Zusammenfassung
Die Möglichkeit der Anlage nativer a-v. Dialyseshunts ist aufgrund der begrenzten Anzahl geeigneter Venen limitiert. Bei Fehlen geeigneter Gefäße muss auf Kunststoff-Shunts zurückgegriffen werden. Diese weisen im Vergleich mit a-v. Fisteln eine höhere Verschlussrate auf. Die Studie untersucht die Ergebnisse der chirurgischen Revision von gestreckten PTFE-Dialyseshunts.
Methode: Retrospektive Untersuchung aller gestreckten Oberarm-Dialyseshunts von 1/94-8/99.
Ergebnisse: Im Untersuchungszeitraum wurden insgesamt 67 Patienten wegen Shuntkomplikationen behandelt. Verschlussursache war in 22 % eine Stenose im Bereich der venösen Anastomose, in 9 % eine Stenose der zentralen Venen, in 12 % eine Stenose im Bereich der arteriellen Anastomose und in 6 % eine Prothesenläsion. Bei 9 von 67 Patienten
wurde der Shunt aufgrund einer Infektion bzw. eines periprothetischen Hämatoms revidiert. In 37 % konnte die Verschlussursache intraoperativ nicht geklärt werden. Nach 6 Monaten waren 29 % der Shunts funktionstüchtig. 7 Shunts blieben länger als 1 Jahr offen (11 %, mediane Laufzeit 80 Wochen). Weder Verschlussursache noch Operationsverfahren hatten Einfluss auf die Funktionsrate. Die primäre bzw. sekundäre 1-Jahres-Offenheitsrate nach Revision betrug 11 % bzw. 29 %.
Schlussfolgerung: Die Ergebnisse der Revisionschirurgie bei Verschluss von Kunststoff-Dialyseshunts sind zunächst enttäuschend. Da radiologisch-interventionelle Verfahren jedoch keine Alternative bieten, ist die chirurgische Revision verschlossener Kunststoff-Shunts gerechtfertigt.
Summary
Native av-fistulas are the access of first choice for long-term hemodialysis. However, a large number of patients require an alternative vascular access, e. g. ePTFE grafts. Patency of ePTFE grafts is inferior to that of native av-fistulas.
Purpose: To analyse the effectiveness of surgical revisions of occluded straight ePTFE dialysis access grafts.
Methods: Retrospective review of all upper arm dialysis access procedures from 1/94 to 8/99.
Results: Redo surgery was performed in 67 patients. Av-fistula dysfunction was caused by venous anastomotic stenoses (22 %), outflow occlusion (9 %), arterial anastomotic stenoses/inflow occlusion (12 %), and intragraft stenoses (6 %). 9 grafts had to be revised due to infection or perigraft hematoma (14 %). In 37 % the cause of graft occlusion
could not be identified. Neither the cause of occlusion nor the type of treatment correlated with patency after revision. 6- and 12-months primary patency after surgery were 29 % and 11 %. 59 shunts required up to 12 revisions to maintain patency. Thus, secondary 1 yr-patency after revision was 29 %.
Conclusion: Patency after redo surgery is disappointing. However, with repeated procedures ePTFE grafts remain open > 1 year in 29 % of the patients.
Schlüsselwörter
Shunt - a-v. Shuntkomplikationen - Funktionsrate - Chirurgie - Revision
Key words
Dialysis access graft - Complication of av-fistula - Patency - Surgery - Revision
Literatur
- 1 III. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: update 2000. Am J Kidney Dis. 2001; 37 S137-S181
- 2 Agoda L Y, Eggers P W. Renal replacement therapy in the United States: data from the United States Renal Data System. Am J Kidney Dis. 1995; 25 119-133
- 3 Ascher E, Gade P, Hingorani A, Mazzariol F. et al . Changes in the practice of angioaccess surgery: Impact of dialysis outcome and quality initiative recommendations (DOQI). J Vasc Surg. 2000; 31 84-92
- 4 Baker L D, Johnson J M, Goldferb D. Expanded PTFE subcutaneous arteriovenous conduit: an improved vascular access for chronic hemodialysis. Trans Am Soc Artif Intern Organs. 1976; 22 382-387
- 5 Beathard G A, Welch B R, Maidment H J. Mechanical thrombolysis for the treatment of thrombosed hemodialysis access grafts. Radiology. 1996; 200 711-716
- 6 Bitar G, Yang S, Badosa F. Balloon versus patch angioplasty as an adjuvant treatment to surgical thrombectomy of hemodialysis grafts. Am J Surg. 1997; 174 140-142
- 7 Brescia M J, Cimino J E, Appel K, Hurwich B J. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med. 1966; 275 1089-1092
- 8 Brothers T E, Morgan M, Robison J G, Elliott B M. et al . Failure of dialysis access: revise or replace?. J Surg Res. 1996; 60 312-316
- 9 Brotman D N, Fandos L, Faust G R, Doscher W, Cohen J R. Hemodialysis graft salvage. J Am Coll Surg. 1994; 178 431-434
- 10 Carlson D M, Duncan D A, Naessens J M, Johnson W J. Hospitalization in dialysis patients. Mayo Clin Proc. 1984; 59 769
- 11 Cinat M E, Hopkins J, Wilson S E. A prospective evaluation of PTFE graft patency and surveillance techniques in hemodialysis access. Ann Vasc Surg. 1999; 13 191-198
- 12 Cohen M A, Kumpe D A, Durham J D, Zwerdlinger S C. Improved treatment of thrombosed hemodialysis access sites with thrombolysis and angioplasty. Kidney Int. 1994; 46 1375-1380
- 13 Diskin C J, Stokes T J, Thomas J M, Lock S. The importance of timing of surgery for hemodialysis vascular access thrombectomy. Nephron. 1997; 75 233-237
- 14 Dougherty M J, Calligaro K D, Schindler N, Raviola C A, Ntoso A. Endovascular versus surgical treatment for thrombosed hemodialysis grafts: A prospective, randomized study. J Vasc Surg. 1999; 30 1016-1023
- 15 Gelbfish G A. Surgery versus percutaneous treatment of thrombosed dialysis access grafts: Is there a best method?. J Vasc Interv Radiol. 1998; 9 875-877
- 16 Hodges T C, Fillinger M F, Zwolak R M, Walsh D B, Bech F, Cronenwett J L. Longitudinal comparison of dialysis access methods: risk factors for failure. J Vasc Surg. 1997; 26 1009-1019
- 17 Hood D B, Yellin A E, Richman M F, Weaver F A, Katz M D. Hemodialysis graft salvage with endoluminal stents. Am Surg. 1994; 60 733-737
- 18 Hurlbert S N, Mattos M A, Henretta J P, Ramsey D E. et al . Long-term patency rates, complications and cost-effectiveness of polytetrafluoroethylene (PTFE) grafts for hemodialysis access: a prospective study that compares Impra versus Gore-Tex grafts. Cardiovasc Surg. 1998; 6 652-656
- 19 Kanterman R Y, Vesely T M, Pilgram T K, Guy B W, Windus D W, Picus D. Dialysis access grafts: anatomic location of venous stenosis and results of angioplasty. Radiology. 1995; 195 135-139
- 20 Kherlakian G M, Roedersheimer L R, Arbaugh J J, Newmark K J, King L R. Comparison of autogenous fistula versus expanded polytetrafluoroethylene grafts for angio-access in hemodialysis. Am J Surg. 1986; 152 238-243
- 21 Lumsden A B, Hughes J D, MacDonald M J, Ofenloch J C. The thrombosed arteriovenous graft: an endovascular model for vascular surgeons. Cardiovasc Surg. 1997; 5 401-407
- 22 Lumsden A B, MacDonald M J, Kikeri D, Cotsonis G A, Harker L A, Martin L G. Prophylactic balloon angioplasty fails to prolong the patency of expanded polytetrafluoroethylene arteriovenous grafts: Results of a prospective randomized study. J Vasc Surg. 1997; 26 382-392
- 23 Lumsden A B, MacDonald M J, Kikeri D K, Harker L A, Allen R C. Hemodialysis access graft stenosis: percutaneous transluminal angioplasty. J Surg Res. 1997; 68 181-185
- 24 Marston W A, Criado E, Jaques P F, Mauro M A, Burnham S J, Keagy B A. Prospective randomized comparison of surgical versus endovascular management of thrombosed dialysis access grafts. J Vasc Surg. 1997; 26 373-381
- 25 Overbosch E H, Pattynama P M, Aarts H J, Schultze Kool L J, Hermans J, Reekers J A. Occluded hemodialysis shunts: Dutch multicenter experience with the hydrolyser catheter. Radiology. 1996; 201 485-488
- 26 Palder S B, Kirkman R L, Whittemore A D, Hakim R, Lazarus J M, Tilney N L. Vascular access for hemodialysis. Patency rates and results of revision. Ann Surg. 1985; 202 235-239
- 27 Schuman E S, Quinn S F, Standage B A, Gross G. Thrombolysis versus thrombectomy for occluded hemodialysis grafts. Am J Surg. 1994; 167 473-476
- 28 Schwab S J. Hemodialysis vascular access. In: Jacobson H, Striker G, Klahr S (eds). The principles and practice of nephrology. Decker, Philadelphia 1990; 766-772
- 29 Schwartz C I, McBrayer C V, Sloan J H, Meneses P, Ennis W J. Thrombosed dialysis grafts: Comparison of treatment with transluminal angioplasty and surgical revision. Radiology. 1995; 194 337-341
- 30 Wada H, Ierardi R P, Coll D, Matsumoto T. Immediate postoperative complications following hemodialysis access procedures. Int Surg. 1996; 81 99-101
- 31 Windus D W. Permanent vascular access: a nephrologist's view. Am J Kidney Dis. 1993; 21 457-471
- 32 Zibari G B, Rohr M S, Landreneau M D, Bridges R M. et al . Complications from permanent hemodialysis vascular access. Surgery. 1988; 104 681-686
Dr. M. J. Utzig
Chirurgische Klinik und Poliklinik I
Abteilung für Allgemein-, Gefäß- und Thoraxchirurgie
Universitätsklinikum Benjamin Franklin
Hindenburgdamm 30
12200 Berlin
Phone: 0 30/84 45-25 43
Fax: 0 30/84 45-27 40
Email: martin.utzig@ukbf.fu-berlin.de