和歌山県および泉南地区におけるシャントの現況

Abstract

Within the last decade the techniques of renal transplantation and dialysis therapy have been expanded and perfected until now. Presently, these methods are the generally accepted forms of treatment for renal failure. Most adult patients with end-stage renal failure can now be offered these forms of treatment with the hope of leading reasonably normal lives. Advances in techniques of dialysis therapy include development of a safe and efficient artificial kidney and the provision of reliable methods for regular access to the circulation, i.e., connection of the patient to the machine. Scribner's introduction of the teflon-silastic arteriovenous shunt first made hemodialysis feasible; other methods which followed include the arteriovenous fistula, autogenous vein graft and the large vessel applique. These shunts and fistulas used for access to the circulation have a recognized symbolic importance, but their added influence on the quality of life to patients on dialysis goes beyond symbolism. Among the array of possible choices for reliable and uncomplicated blood access there is no one ideal or best method. This paper describes practical aspects of obtaing blood access for hemodialysis and discusses the hemodynamics of arteriovenous shunts and fistulas. We have made regular and repeated blood access 512 times on 191 patients living in Wakayama Prefecture and in the Sennan Area of Osaka Prefecture. There were 246 arteriovenous shunts and 266 fistulas with survival time over one year occurring in 94.6% of patients. Apart from the technicalities of dialysis, a patient's well-being depends very much upon the reliability of long-term access to the circulation. Until the introduction of the internal arteriovenous fistula, long-term intermittent hemodialysis depended upon availability of suitable sites for external shunts but since then numerous reports have described a variety of ingenious techniques which allow access to the circulation. Since the long-term prospect of the patient is largely dependent upon the availability of blood access, it is essential to plan for this in the early stages of the patient's disease. We have also used alternative methods including Bovine xenograft, PTFE (poly tetrafluoroethylene) , vein autograft, femoral artery repositioning and Allen-Brown shunt. The majority of patients, who are maintained on hemodialysis with a regular blood access available, have experienced no difficulties and we find that if an internal A-V fistula is inserted early in the management of the patient it is not necessary to later find another access site. In 8 patients (4% in this area), however, a Bovine arteriograft was required because of repeated thrombosis of shunts and poor flow in A-V fistulas; the standard technique in these patients was to fashion a graft loop in the thigh under local anesthesia. In these patients the grafts were functioning well twenty months later.