本文關(guān)鍵詞：超聲引導(dǎo)PTA在動(dòng)靜脈內(nèi)瘺狹窄中的應(yīng)用及術(shù)后評估時(shí)機(jī)的探討　出處：《鄭州大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

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【摘要】：背景和目的隨著人口老齡化進(jìn)程的加劇,終末期腎臟病已經(jīng)成為嚴(yán)重威脅我國國民身體健康的主要疾病之一。血液透析是終末期腎臟病患者主要治療方式之一,充分的血液透析需要良好的血管通路做保障。動(dòng)靜脈內(nèi)瘺(Arteriovenous fistula,AVF)具有使用壽命長、血流量充足、并發(fā)癥少等優(yōu)勢,被認(rèn)為是目前最理想的血管通路。然而隨著患者日趨老齡化和透析齡的延長,內(nèi)膜增生、血栓形成、感染等原因?qū)е碌膬?nèi)瘺狹窄、閉塞,已成為血液透析失敗的主要原因。傳統(tǒng)上內(nèi)瘺狹窄多采用外科開放重建術(shù)或放射介入,但其造成的的血管資源浪費(fèi)或輻射傷害等嚴(yán)重阻礙著傳統(tǒng)技術(shù)的發(fā)展。近年,經(jīng)皮穿刺血管成形術(shù)(Percutaneous transluminal angioplasty,PTA)被嘗試用于治療動(dòng)靜脈內(nèi)瘺狹窄,應(yīng)用導(dǎo)管技術(shù)對狹窄血管或閉塞性病變進(jìn)行擴(kuò)張或再通。同時(shí),超聲技術(shù)在血管徑路上的應(yīng)用,也為血管通路的評估提供了有效的手段,不僅可以對內(nèi)瘺血管結(jié)構(gòu)和功能進(jìn)行監(jiān)測,而且能夠?qū)崟r(shí)多角度對介入器材和血管解剖進(jìn)行顯示。超聲技術(shù)極大地提高了PTA術(shù)的可視化程度,也延長了動(dòng)靜脈內(nèi)瘺的使用壽命。PTA術(shù)后通常即時(shí)進(jìn)行超聲檢查手術(shù)效果評估,然而由于忽略了術(shù)中損傷、球囊擴(kuò)張、局部浸潤麻醉、血管痙攣等多種因素對內(nèi)瘺血管的干擾,此時(shí)獲取的血管數(shù)據(jù)存在一定程度的失真,進(jìn)一步可能影響我們對手術(shù)效果的判斷,導(dǎo)致臨床決策失誤,延誤補(bǔ)救時(shí)機(jī)。本研究的主要目的是觀察超聲引導(dǎo)下經(jīng)皮腔內(nèi)血管成形術(shù)在治療動(dòng)靜脈瘺狹窄中的應(yīng)用,探討PTA術(shù)不同時(shí)間節(jié)點(diǎn)手術(shù)效果最佳評估時(shí)機(jī)。研究對象和方法收集2016年2月~2017年3月在河南省人民醫(yī)院血液凈化中心接受超聲引導(dǎo)下PTA治療的前臂內(nèi)瘺狹窄的透析患者15例,所有病人術(shù)前超聲檢查均只有一處狹窄病灶。分別于術(shù)前、術(shù)后即時(shí)、術(shù)后1天和術(shù)后3天四個(gè)時(shí)間節(jié)點(diǎn)對肱動(dòng)脈阻力指數(shù)(RI)、血流量(FV)和內(nèi)瘺最窄處直徑(D)進(jìn)行測量,根據(jù)直徑計(jì)算內(nèi)瘺處橫斷面積(橫斷面積=π×(內(nèi)徑/2)2)。對符合正態(tài)分布的計(jì)量資料用均數(shù)±標(biāo)準(zhǔn)差(SX±)形式表示。符合方差齊、正態(tài)分布的多組間比較采用單因素方差分析(one way ANOVA),兩兩比較采用LSD法。以上數(shù)據(jù)分析均采用SPSS 19.0軟件包,以P0.05視為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果1.術(shù)前共入選15例病例,其中男性9例,女性6例,平均年齡為(54.52±14.63)歲;左側(cè)前臂內(nèi)瘺狹窄9例,右側(cè)前臂內(nèi)瘺狹窄6例;糖尿病腎病3例,慢性腎炎5例,其它原因7例;透析齡7-174個(gè)月;所有病例均成功行前臂橈動(dòng)脈-頭靜脈端側(cè)吻合;PTA術(shù)后無殘余狹窄存在,血流量充沛,引出順暢,透析靜脈壓小于100mm Hg,透析血流速度200ml/min,未出現(xiàn)血管破裂,急性血栓形成等并發(fā)癥;1例患者PTA術(shù)后出現(xiàn)局部腫脹、瘀斑形成,予以彈力綁帶輕度加壓包扎后消退。2.PTA術(shù)前、術(shù)后即時(shí)、術(shù)后1天、術(shù)后3天狹窄處橫斷面積分別為:(3.0±1.1)mm2、(8.2±4.0)mm2、(20.4±5.8)mm2、(20.5±6.0)mm2;肱動(dòng)脈阻力指數(shù)分別為:0.57±0.07、0.64±0.07、0.51±0.06、0.50±0.06;肱動(dòng)脈血流量分別為:(409.7±102.4)ml/min、(403.9±105.9)ml/min、(626.7±132.1)ml/min、(632.9±135.9)ml/min。結(jié)果顯示PTA術(shù)后1天與術(shù)前和術(shù)后即時(shí)兩時(shí)間點(diǎn)相比較三項(xiàng)參數(shù)變化較大,P0.05,差異具有統(tǒng)計(jì)學(xué)意義。術(shù)后1天內(nèi)瘺血管結(jié)構(gòu)和功能均發(fā)生急劇變化,狹窄處橫斷面積、血流量均急劇增加,阻力指數(shù)急劇降低,與術(shù)前基礎(chǔ)值相比,狹窄處橫斷面積平均增加了17.4mm2,肱動(dòng)脈血流量平均增加了216.3ml/min,肱動(dòng)脈阻力指數(shù)平均減少了0.06。術(shù)后1天與術(shù)后3天相比較兩組間參數(shù)無明顯差別,P0.05,差異無統(tǒng)計(jì)學(xué)意義,即術(shù)后1天三項(xiàng)參數(shù)基本趨于穩(wěn)定。由此可推測,內(nèi)瘺重建術(shù)中球囊擴(kuò)張、局部浸潤麻醉、血管痙攣等多種因素對血管急性重塑的影響,在術(shù)后一天已基本消除,此時(shí)進(jìn)行內(nèi)瘺結(jié)構(gòu)與功能的彩超監(jiān)測更具真實(shí)性。結(jié)論1.超聲引導(dǎo)下PTA術(shù)操作簡單、微創(chuàng)、安全,近期效果明顯,是治療動(dòng)靜脈瘺狹窄的一種有效方法。2.PTA術(shù)后1天內(nèi)瘺血管結(jié)構(gòu)和功能趨于穩(wěn)定,因此建議術(shù)后1天進(jìn)行超聲監(jiān)測手術(shù)效果評估。
[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 緇戝甫杞誨害鍔犲帇鍖呮墡鍚庢秷閫，

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