Vascular access intervention therapyの早期施行は, シャントの急性閉塞と再建術を減少させるか?

Abstract

2003年4月～2005年3月までにシャントの狭窄・閉塞を認め、早期にvascular access interventional therapy(VAIVT)を施行した50名125件を対象に、その効果を検討した。VAIVTの総回数125件の内訳は、自己血管86件(非閉塞74件・閉塞12件)、人工血管39件(非閉塞21件・8件)で、人工血管の方が急性閉塞にて救急にVAIVTを施行する例が多かった。一人当たりの施行回数は1回が27例27件と最も多かったが、5回以上も7例計52件と多かった。1次開存率(再狭窄から再施行時点まで)は1ヵ月95.9%、6ヵ月62.1%、12ヵ月46.9%、24ヵ月24.5%で、2次開存率(シャント再建術時点まで)は各々98.0%、93.7%、90.7%、86.6%であった。自己血管群と人工血管群、非閉塞群と閉塞群の比較では、1次開存率、2次開存率とも有意差はなかった。自己血管および人工血管、閉塞および非閉塞の各組み合わせ4群で開存率を比較したところ、人工血管・閉塞群は自己血管・非閉塞群および人工血管・非閉塞群に比べ有意に2次開存率が低かった。検討期間とそれ以前の2年間を比較し、VAIVT件数およびシャント件数の増減を検討したところ、VAIVT総件数はほぼ同じであったが、閉塞例は有意に減少し、シャント再建術も有意に減少した。

Acute vascular access (VA) obstruction is one of the most common complications for hemodialysis patients and medical professions. We performed early vascular access intervention therapy (VAIVT) to reduce the incidence of acute VA obstruction, VAIVT and fistula reconstruction. During a 2-year period, we performed 125 procedures of VAIVT in 145 cases in 50 patients who underwent arterio-venous fistula angiography. We performed early VAIVT within two weeks since we clinically found VA stenosis. The 125 procedures of VAIVT (95 non-thrombosed cases, 30 thrombosed cases) involved 86 native fistulas (74 non-thrombosed, 12 thrombosed) and 39 graft fistulas (21 non-thrombosed, 18 thrombosed). Prevalence of thrombosed cases was significantly higher in graft fistula than in native fistula (P<0.001). The primary patency rate in 50 patients at 6, 12 and 24 months was 62.1, 46.9 and 41.7%, respectively, while the secondary patency rate was 93.7, 90.7 and 86.6%, respectively. The highest primary patency rate was found in the non-thrombosed group with native fistula and the lowest secondary patency rate was found in the thrombosed group with graft fistula. By comparing the results of this study with the events for the previous 2 years, the total VAIVT number was almost the same. The number of non-thrombosed cases increased significantly from 54 to 95, and those of thrombosed cases decreased from 68 to 30 (P < 0.001). The number of fistula reconstructions significantly decreased from 59 to 22 (P<0.001). Early VAIVT for VA stenosis could decrease acute VA obstruction and fistula reconstruction without increasing the total number of VAIVT.