【摘要】目的探究超声测定血流动力学参数对血液透析动静脉内瘘功能的评估价值及预测血栓形成的价值。方法选取广东省肇庆市第一人民医院124 例血液透析患者，均行自体动静脉内瘘(arteriovenous fistula, AVF)，采用超声测定手术前后桡动脉管径(radial artery diameter，RAD)、桡动脉血流量(radial volume of blood flow，RVF)、头静脉管径(cephalic veindiameter，CVD)、头静脉血流量(cephalic venous blood flow，CVF)评估动静脉内瘘成熟度情况，统计手术后6 周内动静脉瘘狭窄、血栓形成发生率，并分为通畅组、狭窄组及血栓形成组，对比3 组头静脉、桡动脉血流动力学参数[血管内径(diameter, D)、最大峰值流速(peak systolic velocity，PSV)、血流阻力指数(resistance index，RI)]，评价各参数对血栓形成的预测价值。结果手术后2 周、4 周、6 周RAD、RVF、CVD 高于手术前，RAD、RVF、CVD、CVF 随时间延长呈逐渐升高趋势(F=170.024、475.914、438.537、70.986，P 均＜0.001)；124 例患者手术后6 周通畅率为71.77%，动静脉瘘狭窄发生率为11.29%，血栓形成发生率为16.94%；3 组头静脉、桡动脉D、PSV、RI 差异有统计学意义(F=30.075、60.959、22.278、24.005、15.490、37.178，P 均＜0.001)；Logistic多因素分析示头静脉、桡动脉D(OR= 0.589、0.622，95% CI：0.204～0.589、0.235～0.622，P 均＜0.001)、PSV(OR=0.390、0.283，95% CI：0.229～0.663、0.229～0.663，P 均＜0.001)、RI(OR=6.371、6.739，95% CI：1.896～21.407、2.418～18.779，P 均＜0.001)与血栓形成相关；ROC 曲线分析示头静脉D、PSV、RI 联合预测血栓形成的AUC 为0.877(95% CI：0.806～0.929)，敏感度为80.95%，特异度为84.47%，高于各参数单独预测(Z=5.336、3.259、5.810，P＜0.001、0.012、＜0.001)；桡动脉D、PSV、RI 联合预测血栓形成的AUC 为0.864 (95% CI：0.791～0.919)，敏感度为76.19%，特异度为87.38%，高于各参数单独预测(Z=8.006、5.147、7.863，P 均＜0.001)。结论超声测定RAD、RVF、CVD、CVF 可准确评估AVF 功能，头静脉、桡动脉D、PSV、RI 可作为预测血栓形成的重要指标，联合预测价值较为可靠，能为临床制定防治措施提供依据。
【Abstract】Objective To explore the value of hemodynamic parameters measured by ultrasound to assess hemodialysis arteriovenous fistula (AVF) function and to predict thrombosis in AVF. Methods A total of 124 hemodialysis patients with autologous AVF from the First People’s Hospital of Zhaoqing City, Guangdong Province were recruited. Ultrasound was used to measure radial artery diameter (RAD), radial volume of blood flow (RVF), cephalic vein diameter (CVD), cephalic venous blood flow (CVF) to assess the maturity of the AVF. The presence of AVF stenosis and thrombosis within 6 weeks after surgery were collected, and then divided the patients into patency group, stenosis group and thrombosis group. The hemodynamic parameters of vascular diameter (D), maximum peak velocity (PSV) and blood flow resistance index (RI) were compared among the three groups to evaluate the predictive value of these parameters for thrombosis. Result The RAD, RVF, and CVD after the operation for 2, 4 and 6 weeks were higher than those before the operation. The RAD, RVF, CVD, and CVF showed a gradual increase over time (F= 170.024, 475.914, 438.537 and 70.986 respectively, P＜0.001). In the 124 patients after surgery for 6 weeks, the patency rate was 71.77%,the incidence of AVF stenosis was 11.29%, and the incidence of thrombosis was 16.94%. There were statistically
differences in D, PSV, and RI of the cephalic vein and radial artery among the three groups. (F=30.075, 60.959, 22.278, 24.005, 15.490 and 37.178 respectively, P＜0.001). Logistic multivariate analysis showed that D (OR=0.589 and 0.622, 95% CI: 0.204～0.589 and 0.235～0.622, P<0.001), PSV (OR=0.390 and 0.283, 95% CI: 0.229～0.663 and 0.229～0.663, P<0.001) and RI (OR= 6.371 and 6.739, 95% CI: 1.896～21.407 and 2.418～18.779, P<0.001) of the cephalic vein and radial artery were related to thrombosis in AVF. ROC curve analysis showed that the AUC of combined cephalic vein D, PSV and RI to predict thrombosis was
0.877 (95% CI 0.806～0.929), with the sensitivity of 80.95% and the specificity of 84.47%, higher than the prediction ability using the parameters individually (Z= 5.336, 3.259 and 5.810 respectively, P<0.001, 0.012 and <0.001); the AUC of combined radial artery D, PSV and RI to predict thrombosis was 0.864 (95% CI: 0.791～0.919), with the sensitivity of 76.19% and the specificity of 87.38%, also higher than the prediction ability using the parameters individually (Z=8.006, 5.147 and 7.863 respectively, P< 0.001). Conclusion Ultrasound measurement of RAD, RVF, CVD and CVF can accurately assess the AVF function. The D, PSV and
RI of cephalic vein and radial artery can be used as important indicators for predicting thrombosis. The combined use of D, PSV and RI parameters was relatively reliable to predict thrombosis in AVF, providing a basis for the establishment of clinical prevention and treatment measures.
[1] Liao MT,Chen MK,Hsieh MY,et al.Drug-coated balloon versus conventional balloon angioplasty of hemodialysis arteriovenous fistula or graft: A systematic review and meta-analysis of randomized controlled trials[J].PLoS One,2020,15(4):e0231463.
[2] 刘镭,刘力,许晓华,等.动静脉内瘘血流量对维持性血液透析患者心功能的影响[J].血管与腔内血管外科杂志,2018,4(4):317-320,348.
[3] Lelamali K,Papirachanat P,Puavilai T.Predicting arterio-venous fistula failure by urea-method derived access blood flow in chronic hemodialysis patients[J].J Vasc Access,2020,21(6):1011-1016.
[4] 孙春艳,宋利,莫雅文,等,陈迎归,符霞.高通量透析对维持性血液透析患者自体动静脉内瘘7年次级通畅率的影响[J].中国血液净化,2020,19(3):187-190.
[5] 刘瑶,程叙扬,郑茜子,等,陶珍晖,陈育青,王志稳.自体动静脉内瘘功能不良监测方法的研究进展[J].中国血液净化,2019,18(10):722-724.
[6] Lubas A,Kade G,Ryczek R,et al.Ultrasonic evaluation of renal cortex arterial area enables differentiation between hypertensive and glomerulonephritis-related chronic kidney disease[J].Int Urol Nephrol,2017,49(9):1627-1635.
[7] 禤晓燕,李杰峰,梁子安,等.高通量血液透析对终末期肾病患者心脏功能和IL-6、IL-8、TNF-α水平的影响[J].海南医学院学报,2020,26(5):347-350,354.
[8] 段文兵,曹勇,李卓颖,等.血液灌流结合血液透析对终末期肾病患者钙磷代谢及心脏功能的影响[J].医学临床研究,2019,36(1):195-196.
[9] 聂钰璐,施月仙,侯姣慧,等.维持性血液透析患者动静脉内瘘维护的最佳证据分析[J].中国全科医学,2020,23(6):742-746.
[10] Yolg?steren A.Relationship between hemodialysis patients' educational level and arteriovenous fistula patency[J].Vascular,2020,28(5):604-608.
[11] 欧月秀,秦曙光,林昌平,等.血液透析病人自体动静脉内瘘失功能危险因素的logistic回归分析[J].安徽医药,2019,23(1):72-75.
[12] 楚文武,徐成亮.CT血管成像联合血管彩超在血透患者内瘘评估中的应用[J].甘肃医药,2020,39(10):916-917.
[13] V R N,M E.Optimized Blood Volume Monitoring during Hemodialysis Procedure based on Ultrasonic Speed Measurement[J].J Biomed Phys Eng,2019,9(3):373-380.
[14] 陈晓慧.彩色多普勒超声在血液透析动静脉内瘘功能评估 及病变检测中的应用价值[J].影像研究与医学应用,2019,3(17):137-138.
[15] 谢凌,程瑞红,朱丽萍.彩色多普勒超声评估血透患者动静脉内瘘并发症的应用价值[J].中国数字医学,2019,14(9):53-55,52.
[16] Ishii H,Miyoshi C,Hirai K,et al.Induction of hemodialysis with an arteriovenous fistula in a patient with hemophilia A[J].CEN Case Rep,2020,9(3):225-231.
[17] 杨新军,汪晶华,林静,等.不同血液透析龄患者自体动静脉内瘘功能状态临床分析[J].临床误诊误治,2020,33(9):73-77.
[18] Kocaaslan C,Kehlibar T,Yilmaz M,et al.Outcomes of arteriovenous fistula for hemodialysis in octogenarian population[J].Vascular,2018,26(5):509-514.
[19] 李晓萌,陈玉珍,白玉梅,等.维持性血液透析患者自体动静脉内瘘血管并发症的超声观察[J].中国中西医结合肾病杂志,2017,18(8):726-727.
[20] 吴宗壁,韩晓苇,林珣,等.多普勒超声及血管构图的可视化内瘘管理在自体动静脉内瘘中的应用效果[J].广西医学,2019,41(22):2940-2943.
[21] 苑欣,菅梅,陈琼.彩色多普勒超声在血液透析患者动静脉内瘘并发症防治中的价值[J].中国医学影像技术,2018,34(10):1490-1493.
[22] 王海燕.维持性血液透析患者自体动静脉内瘘血管并发症的超声观察[J].实用医技杂志,2018,25(8):840-841.
