Gefässchirurgie

, Volume 15, Issue 8, pp 579–588

Aktuelle Studienlage zur Shuntchirurgie

Klinischer Review

Zusammenfassung

Ein funktionierender Gefäßzugang ist eine Grundvoraussetzung für die lebenserhaltende Dialysebehandlung bei Patienten mit chronischem Nierenversagen. Komplikationen dieser Gefäßzugänge gehören zu den wesentlichen Gründen der hohen Morbidität und Letalität von dialysepflichtigen Patienten. Das Outcome des Dialyseshunts und damit auch die Lebensqualität des Patienten sind maßgeblich beeinflusst durch das Timing der Shuntanlage, die Selektion der Gefäßregion, die Wahl des Shuntverfahrens sowie die adäquate Nachsorge. Eine autologe arteriovenöse (a.v.) Fistel wird als primärer Dialysezugang angestrebt. Sie bietet im Vergleich zu alloplastischen Materialien (Shuntprothesen, Dialysekatheter) die besten Offenheits- und die geringsten Komplikationsraten. Shuntprothesen sind u.a. aufgrund ihrer hohen Verschlussraten Dialysezugänge der zweiten Wahl. Insbesondere durch pharmakologische oder neue technische Ansätze haben sich erste Fortschritte bei der Verhinderung der durch die neointimalen Hyperplasie bedingten Anastomosenstenosen von Dialyseshunts ergeben. Neue Thrombektomiekatheter haben die Ergebnisse der interventionellen Wiedereröffnung von verschlossenen Shunts zwar deutlich verbessert, jedoch die chirurgischen Verfahren nicht verdrängt. Die Behandlung von Shuntstenosen ist zunehmend eine Domäne der interventionellen Methoden, wobei sich hier momentan abhängig von der Stenosenlokalisation und -ursache verschiedene Therapieempfehlungen über die alleinige Ballonangioplastie hinaus entwickeln. Shuntinduzierte Steal-Syndrome erfordern ein differenziertes Therapiekonzept, das unterschiedliche Faktoren wie das Flussvolumen des Shuntes und seine Lokalisation sowie den Gefäßstatus und die Komorbidität des Patienten berücksichtigen sollte.

Schlüsselwörter

Shuntchirurgie Hämodialyse Arteriovenöse Fistel Dialysekatheter Shuntprothese 

Current study situation on shunt surgery

Abstract

A well-functioning vascular access is a prerequisite for life-sustaining dialysis treatment in patients with chronic renal failure. Complications of a vascular access belong to the major causes of the high morbidity and mortality in dialysis-dependent patients. The outcome of the dialysis access and patient’s quality of life is dependent on the timing of access creation, selection of the appropriate vascular region, type of access and the follow-up. Autologous arteriovenous (a.v.) fistulae are considered to be the first choice dialysis access. Compared to an alloplastic access (prosthetic grafts, dialysis catheters) a.v. fistulae offer the highest patency and lowest complication rates. Autologous arteriovenous grafts remain the second choice for dialysis access mainly due to high occlusion rates. Particularly pharmacological and new technical approaches have recently provided further progress in prevention of anastomotic stenoses caused by neo-intimal hyperplasia. Access complications are increasingly being managed by interventional therapy. New thrombectomy devices have improved results of interventional revascularization of occluded a.v. accesses but up to now have not replaced surgical techniques. Stenotic lesions of dialysis accesses are predominantly treated by interventional methods. Apart from the sole use of balloon angioplasty, different recommendations for additional interventions have emerged depending on shunt localization and type of stenosis. Shunt-induced steal syndromes require differentiated therapy which considers factors such as access flow and localization as well as vascular status and patient co-morbidities.

Keywords

Vascular access surgery Hemodialysis Arteriovenous fistula Centralvenous catheter Arteriovenous graft 

Literatur

  1. 1.
    Al Ghonaim M, Manns BJ, Hirsch DJ et al (2008) Relation between access blood flow and mortality in chronic hemodialysis patients. Clin J Am Soc Nephrol 3:387–391CrossRefGoogle Scholar
  2. 2.
    Allon M, Robbin ML (2009) Hemodialysis vascular access monitoring: current concepts. Hemodial Int 13:153–162CrossRefPubMedGoogle Scholar
  3. 3.
    Antoniou GA, Lazarides MK, Georgiadis GS et al (2009) Lower-extremity arteriovenous access for haemodialysis: a systematic review. Eur J Vasc Endovasc Surg 38:365–372CrossRefPubMedGoogle Scholar
  4. 4.
    Basile C, Lomonte C, Vernaglione L et al (2008) The relationship between the flow of arteriovenous fistula and cardiac output in haemodialysis patients. Nephrol Dial Transplant 23:282–287CrossRefPubMedGoogle Scholar
  5. 5.
    Biuckians A, Scott EC, Meier GH et al (2008) The natural history of autologous fistulas as first-time dialysis access in the KDOQI era. J Vasc Surg 47:415–421CrossRefPubMedGoogle Scholar
  6. 6.
    Casey ET, Murad MH, Rizvi AZ et al (2008) Surveillance of arteriovenous hemodialysis access: a systematic review and meta-analysis. J Vasc Surg 48:48S–54SCrossRefPubMedGoogle Scholar
  7. 7.
    Conte MS, Nugent HM, Gaccione P et al (2009) Multicenter phase I/II trial of the safety of allogeneic endothelial cell implants after the creation of arteriovenous access for hemodialysis use: the V-HEALTH study. J Vasc Surg 50:1359–1368CrossRefPubMedGoogle Scholar
  8. 8.
    Dember LM, Beck GJ, Allon M et al (2008) Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized controlled trial. JAMA 299:2164–2171CrossRefPubMedGoogle Scholar
  9. 9.
    Dixon BS, Beck GJ, Vazquez MA et al (2009) Effect of dipyridamole plus aspirin on hemodialysis graft patency. N Engl J Med 360:2191–2201CrossRefPubMedGoogle Scholar
  10. 10.
    Ferring M, Henderson J, Wilmink A et al (2008) Vascular ultrasound for the pre-operative evaluation prior to arteriovenous fistula formation for haemodialysis: review of the evidence. Nephrol Dial Transplant 23:1809–1815CrossRefPubMedGoogle Scholar
  11. 11.
    Gelbfish GA (2008) Clinical surveillance and monitoring of arteriovenous access for hemodialysis. Tech Vasc Interv Radiol 11:156–166CrossRefPubMedGoogle Scholar
  12. 12.
    Hammes M, Funaki B, Coe FL (2008) Cephalic arch stenosis in patients with fistula access for hemodialysis: relationship to diabetes and thrombosis. Hemodial Int 12:85–89CrossRefPubMedGoogle Scholar
  13. 13.
    Hasegawa T, Elder SJ, Bragg-Gresham JL et al (2008) Consistent aspirin use associated with improved arteriovenous fistula survival among incident hemodialysis patients in the dialysis outcomes and practice patterns study. Clin J Am Soc Nephrol 3:1373–1378CrossRefPubMedGoogle Scholar
  14. 14.
    Haskal ZJ, Trerotola S, Dolmatch B et al (2010) Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med 362:494–503CrossRefPubMedGoogle Scholar
  15. 15.
    Hollenbeck M, Mickley V, Brunkwall J et al (2009) Interdisziplinäre Empfehlungen deutscher Fachgesellschaften zum Gefäßzugang zur Hämodialyse. Nephrologie 4:158–176CrossRefGoogle Scholar
  16. 16.
    Huber TS, Brown MP, Seeger JM et al (2008) Midterm outcome after the distal revascularization and interval ligation (DRIL) procedure. J Vasc Surg 48:926–932CrossRefPubMedGoogle Scholar
  17. 17.
    Katzman HE, McLafferty RB, Ross JR et al (2009) Initial experience and outcome of a new hemodialysis access device for catheter-dependent patients. J Vasc Surg 50:600–607, 607CrossRefPubMedGoogle Scholar
  18. 18.
    Keuter XH, De Smet AA, Kessels AG et al (2008) A randomized multicenter study of the outcome of brachial-basilic arteriovenous fistula and prosthetic brachial-antecubital forearm loop as vascular access for hemodialysis. J Vasc Surg 47:395–401CrossRefPubMedGoogle Scholar
  19. 19.
    Keuter XH, Kessels AG, Haan MH de et al (2008) Prospective evaluation of ischemia in brachial-basilic and forearm prosthetic arteriovenous fistulas for hemodialysis. Eur J Vasc Endovasc Surg 35:619–624CrossRefPubMedGoogle Scholar
  20. 20.
    Kim YC, Won JY, Choi SY et al (2009) Percutaneous treatment of central venous stenosis in hemodialysis patients: long-term outcomes. Cardiovasc Intervent Radiol 32:271–278CrossRefPubMedGoogle Scholar
  21. 21.
    Koksoy C, Demirci RK, Balci D et al (2009) Brachiobasilic versus brachiocephalic arteriovenous fistula: a prospective randomized study. J Vasc Surg 49:171–177CrossRefPubMedGoogle Scholar
  22. 22.
    Korten E, Spronk S, Hoedt MT et al (2009) Distensibility of forearm veins in haemodialysis patients on duplex ultrasound testing using three provocation methods. Eur J Vasc Endovasc Surg 38:375–380CrossRefPubMedGoogle Scholar
  23. 23.
    Lazarides MK, Georgiadis GS, Papasideris CP et al (2008) Transposed brachial-basilic arteriovenous fistulas versus prosthetic upper limb grafts: a meta-analysis. Eur J Vasc Endovasc Surg 36:597–601CrossRefPubMedGoogle Scholar
  24. 24.
    Miller GA, Goel N, Friedman A et al (2010) The MILLER banding procedure is an effective method for treating dialysis-associated steal syndrome. Kidney Int 77:359–366CrossRefPubMedGoogle Scholar
  25. 25.
    Moist LM, Trpeski L, Na Y et al (2008) Increased hemodialysis catheter use in Canada and associated mortality risk: data from the Canadian Organ Replacement Registry 2001–2004. Clin J Am Soc Nephrol 3:1726–1732CrossRefPubMedGoogle Scholar
  26. 26.
    Murad MH, Elamin MB, Sidawy AN et al (2008) Autogenous versus prosthetic vascular access for hemodialysis: a systematic review and meta-analysis. J Vasc Surg 48:34S–47SCrossRefPubMedGoogle Scholar
  27. 27.
    Murad MH, Sidawy AN, Elamin MB et al (2008) Timing of referral for vascular access placement: a systematic review. J Vasc Surg 48:31S–33SCrossRefPubMedGoogle Scholar
  28. 28.
    Ozyer U, Harman A, Yildirim E et al (2009) Long-term results of angioplasty and stent placement for treatment of central venous obstruction in 126 hemodialysis patients: a 10-year single-center experience. AJR Am J Roentgenol 193:1672–1679CrossRefPubMedGoogle Scholar
  29. 29.
    Padberg FT Jr, Calligaro KD, Sidawy AN (2008) Complications of arteriovenous hemodialysis access: recognition and management. J Vasc Surg 48:55S–80SCrossRefPubMedGoogle Scholar
  30. 30.
    Peterson WJ, Barker J, Allon M (2008) Disparities in fistula maturation persist despite preoperative vascular mapping. Clin J Am Soc Nephrol 3:437–441CrossRefPubMedGoogle Scholar
  31. 31.
    Planken NR, Tordoir JH, Duijm LE et al (2008) Magnetic resonance angiographic assessment of upper extremity vessels prior to vascular access surgery: feasibility and accuracy. Eur Radiol 18:158–167CrossRefPubMedGoogle Scholar
  32. 32.
    Scaffaro LA, Bettio JA, Cavazzola SA et al (2009) Maintenance of hemodialysis arteriovenous fistulas by an interventional strategy: clinical and duplex ultrasonographic surveillance followed by transluminal angioplasty. J Ultrasound Med 28:1159–1165PubMedGoogle Scholar
  33. 33.
    Schild AF, Perez E, Gillaspie E et al (2008) Arteriovenous fistulae vs. arteriovenous grafts: a retrospective review of 1,700 consecutive vascular access cases. J Vasc Access 9:231–235PubMedGoogle Scholar
  34. 34.
    Schuman E, Ronfeld A, Barclay C et al (2007) Comparison of clinical assessment with ultrasound flow for hemodialysis access surveillance. Arch Surg 142:1129–1133CrossRefPubMedGoogle Scholar
  35. 35.
    Shemesh D, Goldin I, Zaghal I et al (2008) Angioplasty with stent graft versus bare stent for recurrent cephalic arch stenosis in autogenous arteriovenous access for hemodialysis: a prospective randomized clinical trial. J Vasc Surg 48:1524–1531, 1531CrossRefPubMedGoogle Scholar
  36. 36.
    Sidawy AN, Spergel LM, Besarab A et al (2008) The Society for Vascular Surgery: clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access. J Vasc Surg 48:2S–25SCrossRefPubMedGoogle Scholar
  37. 37.
    Snyder DC, Clericuzio CP, Stringer A et al (2008) Comparison of outcomes of arteriovenous grafts and fistulas at a single Veterans‘ Affairs medical center. Am J Surg 196:641–646CrossRefPubMedGoogle Scholar
  38. 38.
    Tessitore N, Bedogna V, Poli A et al (2008) Adding access blood flow surveillance to clinical monitoring reduces thrombosis rates and costs, and improves fistula patency in the short term: a controlled cohort study. Nephrol Dial Transplant 23:3578–3584CrossRefPubMedGoogle Scholar
  39. 39.
    Tonelli M, James M, Wiebe N et al (2008) Ultrasound monitoring to detect access stenosis in hemodialysis patients: a systematic review. Am J Kidney Dis 51:630–640CrossRefPubMedGoogle Scholar
  40. 40.
    Tordoir JH, Bode AS, Peppelenbosch N et al (2009) Surgical or endovascular repair of thrombosed dialysis vascular access: is there any evidence? J Vasc Surg 50:953–956CrossRefPubMedGoogle Scholar
  41. 41.
    Turmel-Rodrigues LA (2009) Regarding „Angioplasty with stent graft versus bare stent for recurrent cephalic arch stenosis in autogenous arteriovenous access for hemodialysis: a prospective randomized clinical trial“. J Vasc Surg 50:472–474CrossRefPubMedGoogle Scholar
  42. 42.
    van der Linden J, Lameris TW, Meiracker AH van den et al (2006) Forearm venous distensibility predicts successful arteriovenous fistula. Am J Kidney Dis 47:1013–1019CrossRefGoogle Scholar
  43. 43.
    van Hoek F, Scheltinga M, Luirink M et al (2009) Banding of hemodialysis access to treat hand ischemia or cardiac overload. Semin Dial 22:204–208CrossRefGoogle Scholar
  44. 44.
    Vasquez JC, DeLaRosa J, Leon JJ et al (2010) Percutaneous endovascular management of occluded HeRO dialysis access device. Vasc Endovascular Surg 44:44–47CrossRefPubMedGoogle Scholar
  45. 45.
    Voormolen EH, Jahrome AK, Bartels LW et al (2009) Nonmaturation of arm arteriovenous fistulas for hemodialysis access: A systematic review of risk factors and results of early treatment. J Vasc Surg 49:1325–1336CrossRefPubMedGoogle Scholar
  46. 46.
    Weber CL, Djurdjev O, Levin A et al (2009) Outcomes of vascular access creation prior to dialysis: building the case for early referral. ASAIO J 55:355–360CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  1. 1.Klinik für Allgemein-, Viszeral-, Gefäß- und Kinderchirurgie, Sektion Gefäßchirurgie - Endovaskuläre ChirurgieUniversitätsklinikum WürzburgWürzburgDeutschland
  2. 2.Fachbereich GefäßchirurgieKreiskrankenhaus Rastatt, Klinikum MittelbadenRastattDeutschland

Personalised recommendations