Background. The maximum duration of vascular access for hemodialysis functioning rarely exceeds 4 years. The main tool for diagnosing access dysfunction is duplex ultrasound. Dynamic ultrasound examination of vascular access is not included in the standard examination of patient undergoing hemodialysis in Russia.Objective. To study the structure of complications and changes in hemodynamics in the vascular access for hemodialysis and to determine the risk factors contributing to its development.Design and methods. Ultrasound, clinical and laboratory examination was performed in 550 patients undergoing program hemodialysis, 517 (94.0 %) of them had arteriovenous fistula, 33 (6.0 %) patients had arteriovenous graft.Results. Vascular access complications occurred in 26.7 % (147 patients), there was no significant difference in the detection rate of thrombosis (26.5 %), stenosis (23.8 %), and aneurysm (21.1 %). A combination of two complications was observed in 20.4 %, the steal syndrome — in 8.2 %. A correlation was established between the presence of significant stenosis, aneurysm of the outflow vein and the development of thrombosis, between the presence of concomitant diseases of the peripheral arteries and the development of steal syndrome and stenosis of the inflow artery and the anastomosis zone.Conclusion. Duplex ultrasound allows to diagnose complications of vascular access for hemodialysis and determine its causes.
Introduction. The most common complication of the vascular access for hemodialysis, that can lead to its loss, is thrombosis. The method of choice in diagnosing fistula thrombosis is duplex ultrasound. Purpose: to study the ultrasound signs and changes in hemodynamics data in thrombosed fistulas and to determine the risk factors contributing to its development. Materials and methods. Duplex ultrasound was performed in 550 patients with vascular access for hemodialysis. Access thrombosis was detected in 12,0%, non-occlusive thrombosis was observed in 60,6%, occlusive thrombosis — in 39,4%. Thrombosis was significantly more common in women than in men (p=0,025). In patients with graft, thrombosis was more common (24,2%) than in those with arteriovenous fistula (11,2%), p=0,026. A correlation was found between the presence of significant vascular access stenosis, aneurysm of the outflow vein or graft, and the development of thrombosis (p<0,02). Duplex ultrasound allows to diagnose vascular access thrombosis and to determine the causes of its development.
Introduction. Successful hemodialysis is impossible without effective vascular access. However, the average duration of its normal functioning is 2.53.0 years that is associated with complications, one of them is steal syndrome of the hand. Objective. To examine hemodynamic parameters in vascular access and forearm arteries in hemodialysis patients with hand ischemia. Methods. Duplex ultrasound was performed in 550 patients, 517 of which (94.0%) had an arteriovenous fistula, 33 (6.0%) had an arteriovenous graft. The inflow artery, anastomotic zone, outflow vein and arteries distal to the anastomotic zone were assessed during ultrasound examination, linear and volumetric speed indicators, peripheral resistance indices were measured. Results. Steal syndrome was detected in 2.7% of cases. The main reasons are the inflow artery alterations due to diabetes and atherosclerosis that lead to insufficient growth of blood flow through the artery (20,0%); huge anastomosis diameter that causes a vein dilation and significant increase in access flow (13,3%); insufficient blood flow through the ulnar, anterior interosseous arteries and the absence of collateral branches that did not compensate for retrograde blood flow in the radial artery distal to anastomosis (40,0%); microcirculatory dysfunction of the hand and alterations of the regulation mechanisms of the resistive vessels tone (26,7%). Conclusion. Dynamic ultrasound examination of vascular access can detect adverse changes in hemodynamics and avoid severe ischemic complications. The main reason of steal syndrome is the condition of the forearm arteries not participating in the fistula formation and the hand microvasculature.
The socioeconomic significance of chronic kidney disease in the terminal stage is due to the fact that expensive methods of treatment are required, the number of patients on hemodialysis increases annually and most of them are of working age. The most preferred vascular access for hemodialysis treatment is an arteriovenous fistula, yet its dysfunction occurs in more than 30% of patients. Adequate long-term functioning of the fistula depends on its successful maturation, timely diagnosis and elimination of possible complications of permanent vascular access. The main method for diagnosing dysfunction of an arteriovenous fistula is duplex ultrasound, which allows determining the diameters, the state of the walls and blood vessels lumen, the access flow, identifying such complications as stenosis of inflow artery, anastomotic zone and outflow vein, fistula thrombosis, hand ischemia. Ultrasound diagnosis of vascular access complications allows for their timely correction, which increases the duration of fistula adequate functioning.
ель исследования. Разработать алгоритм ультразвукового исследования постоянного сосудистого доступа (ПСД) для гемодиализа. Материалы и методы. Дуплексное сканирование выполнено 54 пациентам перед формированием доступа и 146 пациентам с сформированным ПСД. Оценивали приводящую артерию, зону анастомоза артерии и вены, отводящую вену на всем протяжении, определяли диаметр сосудов, линейные скоростные показатели и объемную скорость кровотока (ОСК).Результаты. У 9,3% пациентов сосуды предплечья недоминантной руки были непригодны к формированию ПСД, что привело к созданию доступа на доминантной руке, у 13,0% была сформирована проксимальная (плечевая) фистула в связи с небольшим диаметром сосудов на предплечьях. Размер анастомоза, при котором фистула не достигла успешного созревания, составил 2,2±0,3 мм. Адекватное функционирование ПСД наблюдалось при ОСК в фистуле равной 600-1500 мл/мин, в протезе -800-1700 мл/мин. Осложнения были выявлены у 43,8% пациентов, из них стеноз наблюдался в 19,9% случаях, тромбоз отводящей вены -в 13,0%, аневризматическая дилатация вены -в 8,2%, ишемический синдром обкрадывания кисти -2,7%.Обсуждение. Для создания ПСД подходит артерия диаметром более 2,0 мм, вена -не менее 2,5 мм при глубине залегания не более 5-6 мм. Минимальная ОСК, способная обеспечить эффективный гемодиализ, составляет 350-400 мл/мин, оптимальная -не менее 600 мл/мин в фистуле и 800 мл/мин в протезе. Критериями стеноза являются пиковая систолическая скорость в зоне стеноза более 400 см/с, отношение скоростных показателей в престенотической и постстенотической зонах больше 2,0 и снижение ОСК. Причинами синдрома обкрадывания кисти считают стенозы приводящей артерии, избыточное шунтирование крови через анастомоз в результате его большого диаметра и патологию микроциркуляторного русла кисти.Заключение. В результате исследования был разработан алгоритм дуплексного сканирования сосудистого доступа для гемодиализа.Ключевые слова: артериовенозная фистула, гемодиализ, дуплексное сканирование, стеноз, тромбоз, синдром обкрадывания кисти.
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