不同静脉入路策略在血液透析患者中心静脉狭窄或闭塞腔内治疗中的比较研究

Comparison of venous access strategies for endovascular management of central venous stenosis or occlusion in hemodialysis patients

摘要:

背景与目的 中心静脉狭窄或闭塞（CVSO）影响血液透析疗效，但最佳静脉入路策略尚不明确。本研究比较单向静脉入路（UVA）与双向静脉入路（BVA）在维持性血液透析患者CVSO行经皮腔内血管成形术（PTA）或支架植入术（PTS）时的适用条件及技术成功率、临床成功率，并根据病变的位置和类型进行分层分析，旨在为不同病变制定个体化的静脉入路选择标准。方法 回顾性分析2019年7月—2024年2月赣南医科大学第一附属医院及南昌大学第二附属医院63例维持性血液透析CVSO患者的临床资料，其中UVA组37例、BVA组26例。比较不同静脉入路在CVSO介入治疗中的技术成功率（残余狭窄<30%）、临床成功率（症状缓解）及通畅率。结果 两组患者基线特征差异无统计学意义（均P>0.05）。总体技术成功率与临床成功率在UVA组与BVA组之间差异均无统计学意义（均P>0.05）。亚组分析显示，UVA组在上腔静脉及头臂静脉狭窄中的技术成功率高于BVA组，且UVA组在头臂静脉狭窄中的临床成功率高于BVA组；而在锁骨下静脉闭塞中，BVA的技术成功率及临床成功率均优于UVA（均P<0.05）。两组6个月及12个月一期、二期通畅率差异均无统计学意义（均P>0.05）。结论 对于上腔静脉或头臂静脉狭窄，优先采用UVA可获得较高的成功率；而在锁骨下静脉闭塞的介入治疗中，BVA更具优势。基于病变部位和类型合理选择静脉入路，有助于提高CVSO介入治疗的成功率并降低操作难度。

Abstract:

Background and Aims Central venous stenosis or occlusion (CVSO) compromises the effectiveness of hemodialysis; however, the optimal venous access strategy remains unclear. This study compared the applicability, technical success rates, and clinical success rates of unidirectional venous access (UVA) and bidirectional venous access (BVA) in maintenance hemodialysis patients with CVSO undergoing percutaneous transluminal angioplasty (PTA) or percutaneous transluminal stenting (PTS). Stratified analyses were performed according to lesion location and type, aiming to establish individualized venous access selection criteria for different lesion subtypes.Methods A retrospective analysis was conducted on the clinical data of 63 maintenance hemodialysis patients with CVSO treated between July 2019 and February 2024 at the First Affiliated Hospital of Gannan Medical University and the Second Affiliated Hospital of Nanchang University, including 37 patients in the UVA group and 26 patients in the BVA group. Technical success (residual stenosis <30%), clinical success (symptom relief), and patency outcomes of different venous access strategies in the endovascular treatment of CVSO were compared.Results Baseline characteristics were comparable between the two groups (all P>0.05). No significant differences were observed in overall technical or clinical success rates (both P>0.05). Subgroup analysis demonstrated that the UVA group achieved a higher technical success rate in superior vena cava and brachiocephalic vein stenosis compared to the BVA group, along with a better clinical success rate specifically in brachiocephalic vein stenosis, whereas BVA was associated with significantly higher technical and clinical success rates in subclavian vein occlusion (all P<0.05). No significant differences were found in primary or secondary patency rates at 6 and 12 months (all P>0.05).Conclusion UVA is preferable for stenotic lesions of the superior vena cava and brachiocephalic vein, whereas BVA should be prioritized for subclavian vein occlusion. Tailoring venous access strategies according to lesion location and type may enhance procedural success in endovascular treatment of CVSO.