Clinical analysis of 52 cases of arteriovenous fistula by epidural anesthesia

Xue Lei ZhangAbstract: objective to make the radial artery and cephalic vein become more successful. Methods using epidural anesthesia cathe

Content

Xue Lei Zhang

Abstract: objective to make the radial artery and cephalic vein become more successful. Methods using epidural anesthesia catheter 3~5cm, two terminal are respectively inserted into the radial artery and cephalic vein proximal to end after docking interrupted suture, avoids the difficulties and requirements are too small blood vessels suturing under the surgical microscope stitching technique. Results in 52 patients with uremia, the diameter of cephalic vein was less than 1.5mm, and the suture was successful in only one case in 41 cases. Only one patient died of radial artery spasm in 1 cases. Maintenance hemodialysis in August without occlusion. The longest use has reached 9 years. Blood flow meets the requirements of hemodialysis. It is suggested that the suture method has the advantages of simple operation, high success rate and no need of special conditions.

Key words hemodialysis vascular access arteriovenous fistula

Autologous arteriovenous fistula is the main vascular access in patients with long-term hemodialysis, and an ideal long-term vascular access is one of the important conditions for long-term survival of patients with uremia. Forearm radial artery and cephalic vein internal fistula for hemodialysis because of its long-term patency rate, low infection rate is the best choice [1]. At present the main non traumatic suture and anastomosis with titanium wheel nail. The former difficult to suture when the blood vessels are difficult, often poor blood flow after suture, the application of surgical suture technique requires high. The latter is commonly used titanium wheel nail caliber 2.5mm diameter (2.0mm diameter dialysis blood flow, blood vessels to make less) everting difficult, surgery is not easy to succeed. Due to arteriosclerosis and chronic diseases, the head vein is thin, and the expansion is poor. Since 1995, our hospital has been using epidural catheter to suture and suture, without special conditions, the success rate is greatly improved.

1 materials and methods

1.1 information

There were 29 males and 23 females with an average age of years (range, 16~76 years). Onset time 2~12 years. Primary disease: 37 cases of chronic glomerulonephritis, diabetic nephropathy in 6 cases, hypertensive nephropathy in 4 cases, congenital polycystic kidney in 3 cases, obstructive nephropathy in 2 cases. Hemoglobin 55.0~85.5g/L, blood urea nitrogen was higher than 25.2mmol/L, serum creatinine were higher than 800µ mol/L.

1.2 surgical methods

First, the ulnar artery was normal before operation. 34 cases of patients with left (right) side of the forearm wrist radial artery and cephalic vein were anastomosed, sterilize the skin with 1% lidocaine local anesthesia, from the forearm wrist volar wrist wrist crease first 2~3cm 2.5cm transverse arc incision, cut the skin and subcutaneous fascia layer, free head vein 1.5~2cm. Cut open the radial artery sheath, free radial artery ligation and cut off its branches, for free, convenient suture, prevent anastomotic vascular distortion, avoid tension and angle etc.. 8 cases of the use of snuff bottles of radial artery and cephalic vein were anastomosed, in the snuff bottle to reach radial artery pulse longitudinal incision after the local routine disinfection of skin 1.0~1.5cm, free skin head vein and branches. Cut the dorsum of hand, between the extensor pollicis longus and extensor pollicis brevis tendon free radial artery branch ligation, radial artery and cephalic vein, were cut off. Free radial artery and cephalic vein with sufficient length, so that no tension. Occlusion of the radial artery and the proximal end of the cephalic vein. The diameter of cephalic vein was less than 1.5mm. The two operations were followed by ligation of the distal end of the femoral artery and vein respectively by line 1, and the vessels were transected at a distance of 1 mm. Take epidural anesthesia catheter 3~5cm long, two ends were inserted into the radial artery and the proximal end of the cephalic vein, so that the end of the butt, 7~0 nylon cord for intermittent suture, the final 1~2 needle to pull out the catheter and then knotted. The utility model is used for the anastomosis of the blood vessels and the opening of the blood vessels. Check the anastomosis and the wound has active bleeding, hemostasis, unobstructed after a layer of suture skin, do not pressure anastomosis. The vascular murmur in the vicinity of the vascular anastomosis. Appropriate amount of heparin can be used as anticoagulant to prevent thrombosis. Antibiotics were not used in all cases. After 3~4 weeks, the filling of the fistula was obvious. Elastic ring grip exercise training can increase venous filling degree, improve blood flow.

2 Results

51 cases of internal fistula surgery with the success of a suture, the mouth of the sound, 4 weeks after the blood flow can reach 150 ~200ml/ points, in line with the requirements of hemodialysis. 1 cases of the elderly as snuff fistula surgery, because the radial movement spasm of epidural anesthesia catheter dilatation after anastomotic support, although the use of heparin and urokinase, postoperative fistula murmur disappeared soon, operation failed. After a period of dialysis in the radial artery and cephalic vein were anastomosed to the side of the wrist, no artery spasm, successful operation. Another 1 cases of elderly patients with radial movement spasm in wrist radial artery and cephalic vein fistula, surgery to dilute rigitine vasodilator after anastomosis, surgical success. There was no anastomotic infection after operation. 3 cases were followed up for a period of 8 months, and the fistula thrombosis was occluded in all the patients in the 4 year after dialysis, and the bleeding and bleeding occurred in the puncture site in the puncture site in 4 cases after dialysis for the first time in 2 years, and in the puncture site of the blood vessel in the 5 year after dialysis in 4 cases. 25 cases of internal fistula use for up to 9 years, is still in use. Other dialysis patients 2~4 years due to various reasons the termination of dialysis, the fistula still unobstructed.

3 discussion

Forearm radial artery and cephalic vein as internal fistula due to small trauma, vascular conditions, simple operation and maintenance of hemodialysis classic fistula formation. But as a result of arteriosclerosis, chronic diseases can make blood vessels is fine, operation difficulty increase, it is difficult to suture in the eyes of the general operation, the doctor is difficult to grasp the operation skills under the microscope, commonly used in 2.5mm with titanium wheel nail, such as vascular intima too small, difficult to be fixed on the titanium wheel nail, sometimes excessive expansion of vessel diameter. Cause of vascular intimal injury and thrombosis. Grafts or artificial vascular fistula as economically and operation difficulty is not the direct use of radial artery and cephalic vein fistula for superior [2], it should be possible to use its anatomical location for vascular fistula, which should give priority to the use of the radial artery and cephalic vein. In this method, the epidural anesthesia catheter was used as the support in the blood vessel, and the position of the needle insertion was easy to control. 1 patients with cephalic vein diameter of less than 1mm, the conventional method of suture is not smooth for the 3 time, then switch to a successful suture. After the operation, such as less light, can be used as a small dose of heparin anticoagulant 1~2 days. After removing the suture grasping elastic ring contributes to vascular filling. After 52 cases of surgery, for the beginning of hemodialysis patients, such as poor blood vessels of the forearm can try this method, to avoid the high cost of vascular graft or artificial vascular fistula, the difficulty of surgery and more complications. Snuffbox arteriovenous fistula for more detailed, easy to make the success of the operation with this method, the patient can puncture vein length, more can use for a long time, and the operation after the failure of easy to rebuild [3]. It was also found that there were some effects on the patients with radial artery spasm in the treatment of patients with radial artery spasm.

Reference

In the 1 season. The sand column, m a vascular access for hemodialysis and its complications. Journal of renal transplantation, 1997,6 (1): 71

2 Lu Ming, Zhang Jinyuan, Sun Jing, et al. Establishment and clinical application of artificial vascular dialysis pathway. Journal of Nephrology and dialysis kidney transplantation, 1995,4 (4): 328

3 Wang Yueqiang, Yang Jinpu. A snuff box arteriovenous fistula hemodialysis: report of 38 cases. Yunnan medical journal, 2002, 23 (4): 294

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