Читать книгу CKD-Associated Complications: Progress in the Last Half Century - Группа авторов - Страница 11

Adequate vascular access (VA) is essential to ensure successful management of maintenance hemodialysis (HD) in patients with end-stage renal disease. The autologous arteriovenous fistula (AVF) has been the gold standard since the introduction of the radiocephalic wrist fistula by Cimino and Brescia in 1966 and is the basis of the current National Kidney Foundation Kidney Disease Outcomes and Quality Initiative (NKF-K/DOQI) guidelines [1]. According to the NKF-K/DOQI guidelines, an autogenous AVF should ideally be placed in a peripheral-to-central sequence, and radiocephalic and brachiocephalic fistulas are the preferred types of AVF.

The rapid growth of the aging population and the high prevalence of comorbidities, particularly diabetes mellitus and peripheral vascular disease, in patients requiring HD inevitably decrease the ability to construct and maintain a conventional AVF because of the lower vascular adaptability in these patients.

A prosthetic arteriovenous graft (AVG) is occasionally considered when suitable vascular anatomy is unavailable for fistula formation in areas such as the forearm and cubital fossa or when the superficial venous vasculature is inadequate for cannulable arterialization. However, evidence clearly shows that the AVF has superior patency, is associated with fewer complications, and requires fewer re-interventions than the AVG. The AVF also ultimately improves patient survival rates [1, 2]. Although proximal AVF construction is feasible, the inaccessibility of the arterialized vein because of its deep location in the upper arm is a matter of concern. Therefore, the availability of autologous vessels, including deeply located veins, should be carefully assessed when deciding the type of VA for AVF construction.

AVF superficialization has been suggested as an alternative form of VA to maximize the availability of autologous veins and, when used for surgical revision, should improve the accessibility of arterialized veins. The procedures for superficialization include tunnel transposition, elevation, lipectomy, and liposuction. In the tunnel transposition approach, which is also simply termed “transposition,” the deeply situated vein is dissected free from its surrounding tissue, transposed to a superficial position through a subcutaneous tunnel, and anastomosed with the artery. In the elevation approach (also termed “elevation transposition” or the “fistula elevation procedure”), an AVF is constructed and the arterialized vein is raised and positioned in the pocket created in the subcutaneous space along the incision. In the lipectomy or liposuction approach, the subcutaneous fat layer above the arterialized vein is removed through 2 transverse incisions or using ultrasound guidance, respectively.