人工血管解剖外途径静脉搭桥术治疗血液透析相关症状性中心静脉狭窄的单中心回顾性研究

Extra-anatomic venous bypass using prosthetic grafts for hemodialysis-related symptomatic central venous stenosis: a single-center retrospective study

摘要:

背景与目的 中心静脉狭窄（CVS）是血液透析通路功能障碍的重要原因。对于保守治疗无效、腔内治疗失败或因病变解剖特点不适合继续腔内干预的复杂CVS患者，如何缓解静脉高压并保留既有的透析通路仍是临床难点。本研究旨在评价以颈内静脉为流出道的人工血管解剖外途径静脉搭桥术治疗血液透析相关症状性CVS的安全性、有效性及中期通畅率。方法 回顾性分析2021年12月—2025年1月中南大学湘雅二医院血管外科收治的25例接受人工血管解剖外途径静脉搭桥术治疗的血液透析相关症状性CVS患者临床资料。所有患者术前均行上肢及中心静脉系统计算机断层静脉造影，根据病变部位、范围及静脉流出道条件个体化选择旁路流入道、流出道及移植物走行路径。记录围手术期情况、症状改善、并发症及移植物通畅情况；采用Kaplan-Meier法分析一期和二期通畅率。结果 25例患者均成功完成手术，技术成功率为100%。其中，头静脉-同侧颈内静脉搭桥7例、头静脉-对侧颈内静脉搭桥6例、腋静脉-对侧颈内静脉搭桥6例、腋静脉-同侧颈内静脉搭桥2例、双侧颈内静脉搭桥3例、人工血管动静脉瘘-同侧颈内静脉搭桥1例。术后患者上肢、头面部或胸壁肿胀等静脉高压相关症状均明显改善，前臂患侧与健侧周径差及透析期间静脉压均较术前降低（均P<0.05）。围手术期发生急性左心衰竭1例、切口血肿2例，经相应处理后均缓解；无围手术期死亡及移植物感染。中位随访时间为22个月。随访期间，5例发生旁路移植物闭塞，3例发生吻合口狭窄并经经皮腔内血管成形术联合切开取栓后恢复通畅。术后1年一期通畅率和二期通畅率均为86%，术后2年分别为64%和74%。结论 以颈内静脉为流出道的人工血管解剖外途径静脉搭桥术可安全、有效地缓解血液透析相关症状性CVS患者的静脉高压症状，并有助于保留既有透析通路。对于保守治疗无效、腔内治疗失败或不适合进一步腔内干预的复杂CVS患者，该术式可作为重要的外科补救策略。流入道和流出道的个体化选择是获得良好疗效的关键。

Abstract:

Background and Aims Central venous stenosis (CVS) is an important cause of hemodialysis access dysfunction. For patients with complex CVS who have failed conservative or endovascular treatment, or whose lesion anatomy is unsuitable for further endovascular intervention, relief of venous hypertension while preserving the existing dialysis access remains challenging. This study aimed to evaluate the safety, effectiveness, and midterm patency of extra-anatomic venous bypass using prosthetic grafts with the internal jugular vein as the outflow tract for hemodialysis-related symptomatic CVS.Methods The clinical data of 25 patients with hemodialysis-related symptomatic CVS who underwent extra-anatomic venous bypass using prosthetic grafts at the Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, between December 2021 and January 2025 were retrospectively reviewed. All patients underwent computed tomography venography of the upper extremity and central venous system before surgery. The inflow and outflow vessels, as well as the bypass route, were individually selected according to the location and extent of the lesion and the venous outflow condition. Perioperative outcomes, symptom relief, complications, and graft patency were assessed. Primary and secondary patency rates were estimated using the Kaplan-Meier method.Results Technical success was achieved in all 25 patients. The procedures included cephalic vein-to-ipsilateral internal jugular vein bypass in 7 patients, cephalic vein-to-contralateral internal jugular vein bypass in 6 patients, axillary vein-to-contralateral internal jugular vein bypass in 6 patients, axillary vein-to-ipsilateral internal jugular vein bypass in 2 patients, bilateral internal jugular vein bypass in 3 patients, and arteriovenous graft-to-ipsilateral internal jugular vein bypass in 1 patient. Venous hypertension-related symptoms, including limb, facial, or chest wall swelling, improved markedly after surgery. The difference in forearm circumference between the affected and contralateral limbs and venous pressure during hemodialysis were both significantly reduced after surgery (both P<0.05). One patient developed acute left heart failure and 2 developed wound hematoma; all recovered after appropriate treatment. No perioperative death or graft-related infection occurred. The median follow-up duration was 22 months. During follow-up, 5 patients developed bypass graft occlusion. Anastomotic stenosis occurred in 3 patients and was successfully treated with percutaneous transluminal angioplasty combined with open thrombectomy. The 1-year primary and secondary patency rates were both 86%, while the corresponding 2-year rates were 64% and 74%, respectively.Conclusion Extra-anatomic venous bypass using prosthetic grafts with the internal jugular vein as the outflow tract is a safe and effective option for hemodialysis-related symptomatic CVS. This procedure may preserve the existing dialysis access and relieve venous hypertension in patients with failed conservative or endovascular treatment, or with anatomy unsuitable for further endovascular intervention. Individualized selection of the inflow and outflow vessels is essential for achieving favorable outcomes.