使用改进的非接触技术在前臂中创建放射性头动静脉瘘
Summary
我们提出了一种改进的无接触技术（MNTT）来创建放射性头动静脉瘘（RC-AVF），其中静脉和动脉壁避免血运脱，桡动脉不会切断。
Abstract
自体动静脉瘘（AVF）是获得血液透析治疗血管通路的主要和最佳选择。其他选择包括动静脉移植物 （AVG） 和中心静脉导管插入术 （CVC）。在前臂实施放射头颅自体动静脉瘘（RC-AVF）是血管状况较好的患者的首选。然而，早期瘘管衰竭的发生率很高。所选择的手术方法被认为对瘘管的成熟有影响。对于并列吻合口狭窄，新的外科手术（如桡动脉偏移和再植入 （RADAR））已得到显著改善。然而，还发现了新的问题，如动脉狭窄和手术适应症变窄。在本报告中，我们提出了一种改进的无接触技术（MNTT）来创建RC-AVF，其中静脉和动脉壁避免血运脱，桡动脉不会切断。
Introduction
放射性头颅自体动静脉瘘 （RC-AVF） 被认为是血液透析患者血管通路的主要和最佳选择1，2。然而，早期未能成熟仍然是RC-AVF创建的主要问题3。不同的手术方法有不同程度的血管损伤，影响RC-AVF的成熟。1996年，Souza4首次提出使用无接触技术（NTT）分离冠状动脉旁路移植术中的大隐静脉，并取得了良好的效果5，6，7。Horer等人是第一个使用NTT构建RC-AVF的人。在1年的随访中，原发性通畅率为54%，继发通畅率为80%。Sadaghianloo等人进一步扩展了无接触技术的概念，提出了桡动脉偏斜和再植入（RADAR）技术。这种技术与较少的并列吻合口狭窄有关。然而，流入动脉狭窄在雷达上更为突出。我们推测这可能与桡动脉的切断和动脉远端的骨架化有关。
为了进一步减少手术过程中对静脉和动脉的伤害，我们提出了一种新的改良无接触技术（MNTT），该技术显着提高了通畅率和瘘管成熟度10。该技术的目的是主要避免静脉和动脉壁的血运脱以及桡动脉的切断。切开皮肤和皮下组织后，在浅筋膜下方看到头静脉及其周围的脂肪组织。在浅筋膜和头静脉壁上做一个8-10毫米长的切口，将桡动脉椎弓根（包括桡动脉及其伴随的静脉）隔离40-50毫米。动脉椎弓根未被切断，桡动脉椎弓根抬高至接近头静脉。在动脉中做了一个8-10毫米长的切口。侧对侧进行吻合术，并连接远端静脉以形成功能性的端到端吻合术（图1）。
10例手术前通过多普勒超声对血管进行评估：桡动脉和头静脉无狭窄，桡动脉直径≥1.6 mm，头静脉直径≥2 mm。超声心动图显示左心室评分>60%，患者无手术禁忌证。动脉和静脉之间<2 cm的距离被确定为拟议的吻合部位。
图 1.AVF中吻合类型的示意图12. a：AVF的常规手术。 b：使用 NTT 创建的 AVF。 c：使用MNTT和功能性端到端吻合器创建的AVF。AVF：动静脉瘘;NTT：无接触技术。 请点击此处查看此图的放大版本。
Protocol
Representative Results
Discussion
静脉并列吻合口狭窄是影响AVF5成熟的主要因素之一。已知它与内膜增生密切相关13，14，15。然而，内膜增生的预防策略仍然有限。经修改的外科手术16 （如 RADAR）已被证明具有较少的静脉并列吻合口狭窄，成熟度和通畅性增加，以及较少的二次干预9，<sup class="xref"…
Declarações
The authors have nothing to disclose.
Acknowledgements
我们感谢我院的周峰、马天田、朱东明医生为超声检查提供帮助。
Materials
| Curved hemostatic forceps | Xinhua Surgical Instrument Co., Ltd. | ZH131R/RN | |
| Dissecting Forceps | Xinhua Surgical Instrument Co., Ltd. | ZDO25R/RN | |
| Electrotome | Changzhou Yanling Electronic Equipment Co., Ltd. | TY21205812 | |
| Eyelld Retractor | Xinhua Surgical Instrument Co., Ltd. | Z014602T | |
| Lidocaine | Hebei Tiancheng Pharmaceutical Co., Ltd. | 1B200612104 | |
| Halsey needleholder | Xinhua Surgical Instrument Co., Ltd. | ZM208R/RN | |
| Micro forceops | Xinhua Surgical Instrument Co., Ltd. | ZD275RN/T | |
| Micro needle holder forceps | Xinhua Surgical Instrument Co., Ltd. | ZF2618RB/T | |
| Micro scissors | Xinhua Surgical Instrument Co., Ltd. | ZF022T | |
| Micro vessel knife | Xinhua Surgical Instrument Co., Ltd. | ZF1549RN | |
| Non-absorbable suture 3-0 | Ethicon,LLC | SA84G | |
| Poly propylene 7-0 | Ethicon,LLC | PDB601 | |
| Sharp blade | Suzhou Medical Products Factory Co., Ltd. | TY21232001 | |
| scalpel handle | Shanghai Medical Instrument (Group) Co., Ltd. Surgical Instruments Factory | J11030 | |
| Syringe with needle (5ml) | BD medical devices (Shanghai) Co., Ltd | 2006116 | |
| Triangle needle | Hangzhou Huawei medical supplies Co., Ltd | 7X17 | |
| Vessel clamp | Xinhua Surgical Instrument Co., Ltd. | ZF220RN | |
| Vessel loop | Shenzhen Yiman Technology Co., Ltd | EM-SR1 |
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