Study On The Relationship Between Intima-media Thickness Of Cephalic Vein And Early Failure Of Arteriovenous Fistula

Objective:Hemodialysis is one of the important methods of renal replacement therapy in patients with end-stage renal disease.Arteriovenous fistula is currently recognized as the most ideal long-term hemodialysis vascular access,it has advantages such as convenient puncture,good safety,low recirculation rate and less complications.However,arteriovenous fistula is prone to early failure within 3 months after surgery,and its incidence can reach60%,which is the biggest problem for vascular access doctors and patients.The main pathological basis of arteriovenous fistula failure is venous neointimal hyperplasia.Animal studies have found that venous neointimal hyperplasia can occur early after surgery,which can lead to uneven thickening of the venous intima and eccentric stenosis of the veins,resulting in poor function or occlusion of arteriovenous fistula.The venous media also thickens significantly after arteriovenous fistula,mainly manifested as smooth muscle cell and fibroblast hyperplasia.Studies have found that patients with end-stage renal disease have prevalent venous intimal hyperplasia before the establishment of arteriovenous fistula surgery,and there are also lesions such as media collagen accumulation and muscle layer disorders.However,the current study does not clarify the correlation between preoperative venous intima-media lesions and arteriovenous fistula failure.In this study,by observing the thickness and histological changes of the intima-media of the cephalic vein before and after the operation of the arteriovenous fistula,the relationship between it and the early failure of the arteriovenous fistula was analyzed,and the early failure of the arteriovenous fistula was further discussed The possible pathogenesis of the disease provides a new theoretical basis for the early prediction of early failure of arteriovenous fistula,ultra-early intervention,and early postoperative treatment.Methods:A total of 99 CKD 5 patients who underwent autologous arteriovenous fistula in the Department of Nephrology of the Affiliated Hospital of Guilin Medical University from February 2016 to July 2019 were selected.Divide all cases into 2 groups:(1)First arteriovenous fistula group(50 cases):the surgical side limb was the first establishment of arteriovenous fistula,and the patients were divided into early failure group and non-early failure group according to whether or not early arteriovenous fistula failure occurred within 3 months.(2)Second arteriovenous fistula group(49 cases):first arteriovenous after the internal fistula fails,the second operation of the intravenous fistula near the opening of the original arteriovenous fistula,the patients were divided into early failure reconstruction group and late failure reconstruction group according to whether the reconstruction of arteriovenous fistula failed within 3 months.Each patient underwent unified standard preoperative vascular assessment,surgical techniques,postoperative nursing education and arteriovenous fistula pro-mature exercises to control experimental bias.Observe the differences in gender,age,hemodialysis age,primary disease,preoperative arterial diameter,preoperative vein diameter and anastomosis of the subgroups of patients in the first arteriovenous fistula group and the second arteriovenous fistula group.The first arteriovenous fistula group retains the cephalic vein specimens discarded during the operation of arteriovenous fistulas,and the second arteriovenous fistula group retains the cephalic vein specimens discarded during the reconstruction of arteriovenous fistulas.After HE staining,observe and measure the maximum thickness of the intima,medial and intima-medial of the cephalic vein.Observation indicators:(1)Observe the pathological changes of the venous intima and media in the first arteriovenous fistula;(2)Observe the pathological changes of the venous intima and media in the case of arteriovenous fistula failure;(3)Within and between groups cross-comparison to evaluate the relationship between preoperative and postoperative venous intima and media thickness and early failure of arteriovenous fistula;(4)Analyze the nutritional status(hemoglobin,albumin),coagulation status(platelets,fibrinogen),calcium and phosphorus metabolism(parathyroid hormone,calcium,phosphorus),blood lipid metabolism(triglyceride,cholesterol)and inflammation(C reactive protein)of patients before arteriovenous fistula,and explore the relationship between these factors and early failure of arteriovenous fistula.(5)Continue to observe the use of arteriovenous fistulas in the first group of arteriovenous fistulas.After the arteriovenous fistula stenosis or thromboembolism is reopened,continue to observe and follow up for a period of 1 year.Compare the early failure group and non-early failure group’s one-year cumulative survival rate of fistula.Use SPSS 22.0 statistical software to perform statistical analysis on the obtained data.The count data are represented by n(%),and the continuous variable data are all expressed by(?x±s);the count data are analyzed by?~2test,and the measurement data group conforming to the normal distribution The independent sample t-test was used for the comparison;Kaplan-Meire survival curve analysis was used to compare the 1-year cumulative survival rate of arteriovenous fistulas in the early failure group and non-early failure group;P<0.05 indicated that the difference was statistically significant.Results:1.Clinical characteristics:(1)There was no statistically significant difference in gender,age,hemodialysis age,primary disease,preoperative arterial diameter,and preoperative venous diameter between the early failure group and non-early failure group(P>0.05).(2)There was no statistically significant difference in gender,age,primary disease,preoperative arterial diameter and preoperative vein diameter between the early failure reconstruction group and late failure reconstruction group(P>0.05).2.HE staining results:(1)the first arteriovenous fistula group:(1)Histological changes of venous intima:68%of patients already have venous neointimal hyperplasia before arteriovenous fistula.There are several cases of venous intimal lesions.One is the uneven thickening of the intima,which leads to obvious eccentric stenosis.Endothelial cells,fibrous tissue,interstitial edema and capillary formation can be seen in the proliferated intima.The other is that the intimal hyperplasia is diffuse,but the thickness is not heavy.It is mainly manifested by the massive proliferation of endothelial cells,which are closely arranged in the intimal layer,and the fibrous tissue under the endothelium proliferates.In some patients,the endothelial cell layer is necrotic and edema,and some patients have the endothelial cell layer completely disappeared.(2)Histological changes of vein media:70%of patients mainly manifested in the proliferation of media smooth muscle and fibrous tissue,some patients had inflammatory cell infiltration,mucoid degeneration,hyaloid degeneration and water degeneration,some patients had media smooth muscle atrophy,the ratio of intima to media was more than 3:1.(2)The second arteriovenous fistula group:(1)Histological changes of venous intima:All patients had varying degrees of venous intimal hyperplasia,which was mainly manifested as eccentric hyperplasia,leading to stenosis of the lumen.Intimal hyperplasia is mainly smooth muscle cells and fibroblasts,most of which are accompanied by mucus degeneration and hyaline degeneration,infiltration of inflammatory cells,and in some cases hyperplasia of thin-walled small blood vessels.(2)Histological changes of vein media:81.6%of patients have venous medial lesions,there are mainly two cases of venous media lesions.One is the medial smooth muscle hyperplasia with fibrous tissue hyperplasia,and the other is when the intimal hyperplasia is severe,smooth muscle compression occurs,resulting in smooth muscle fiber breakage,disordered arrangement,and focal necrosis Atrophy and thinning,hyaline degeneration and mucus degeneration in part of the smooth muscle interstitial,and a few cases of multifocal lymphocytes,plasma cells and neutrophils infiltration.3.Comparison of intima-media thickness between early failure group and non-early failure group:In the first arteriovenous fistula group,in patients with early failure,the average intima thickness was(0.16±0.09)mm,average media thickness was(0.51±0.17)mm,and average intima-media thickness was(0.66±0.21)mm;in patients without early failure,the average intima thickness was(0.05±0.03)mm,the average media thickness was(0.31±0.08)mm,and the average intima-media thickness was(0.35±0.09)mm.The thickness of intima,media,and intima-media in early failure group were all greater than those in non-early failure group,and the difference between the two groups was statistically significant(P<0.05).Further analysis based on the above positive results:Grouped according to the intima,media,and intima-media thickness of patients in the first arteriovenous fistula group,and compared the early power loss of arteriovenous fistula in the two groups of patients.Patients with thicker intima,media,or intima-media are more prone to early failure(P<0.05).4.Comparison of intima-media thickness between early failure reconstitution group and late failure reconstitution group:In the the second arteriovenous fistula group,the average intima thickness of the early failure reconstruction group was(0.53±0.29)mm,the average media thickness was(0.51±0.16)mm,and the average intima-media thickness was(1.04±0.39)mm;in the late failure reconstitution group,the average intima thickness was(0.63±0.35)mm,the average media thickness was(0.57±0.27)mm,and the average intima-media thickness was(1.20±0.41)mm.Comparing the thickness of intima,media,and intima-media between the two groups,the difference was not statistically significant(P>0.05).5.Comparison of intima-media thickness between the first arteriovenous fistula group and the second arteriovenous fistula group:The average intimal thickness of the first arteriovenous fistula group was(0.07±0.06)mm,the average media thickness was(0.34±0.13)mm,and the average intima-media thickness was(0.41±0.17)mm;in the second arteriovenous fistula group,the average intima thickness was(0.61±0.34)mm,the average media thickness was(0.56±0.26)mm,and the average intima-media thickness was(1.17±0.41)mm.The thickness of the venous intima,media,and intima-media in the second arteriovenous fistula group was significantly greater than that in the first arteriovenous fistula group,and the difference between the two groups was statistically significant(P<0.05).6.Comparison of intima-media thickness between early failure group and early failure reconstruction group:Comparing the venous intima,media,and intima-media thickness of the early failure group in the first arteriovenous fistula group with the early failure reconstruction group in the second arteriovenous fistula group,it was found that the thickness of the cephalic intima,intima-media was significantly greater than that in the early failure group,and the difference between the two groups was statistically significant(P<0.05);the difference in the thickness of the media between the two groups was not statistically significant(P>0.05).7.Comparison of test indicators between early failure group and non-early failure group:The biochemical results of the early failure group and non-early failure group in the first arteriovenous fistula group are as follows:hemoglobin(HB)(89.67±15.56 vs 86.37±17.88)g/L,albumin(ALB)(36.44±4.34 vs35.67±5.66)g/L,platelet(PLT)(208.11±66.31 vs 204.63±72.11)×10~9/L,prothrombin(FIB)(3.73±1.15 vs 4.03±0.99)mg/L,parathyroid hormone(PTH)(22.4±7.8 vs24.9±6.9)pmol/L,calcium(Ca)(1.96±0.36 vs 1.88±0.28)mmol/L,phosphorus(P)(1.74±0.56 vs 2.10±0.52)mmol/L,triglyceride(TG)(1.20±0.38 vs 1.32±0.55)mmol/L,cholesterol(CHOL)(3.96±0.92 vs 4.10±1.5)mmol/L,C-reactive protein(CRP)(6.77±2.32 vs6.63±2.65)mg/L.Comparing the test indexes between the two groups,the difference was not statistically significant(P>0.05).8.Comparison of the 1-year cumulative survival rate of arteriovenous fistula between the early failure group and the non-early failure group:after treatment of percutaneous transluminal angioplasty(PTA)in the early failure group It can promote mature use,and observe that there are still 6 cases of arteriovenous fistula patency at 1 year,and the 1-year cumulative survival rate of arteriovenous fistula is 75%;when the fistula in the non-early failure group appears to be dysfunctional,it can be used continuously by PTA treatment.At1 year,36 cases of arteriovenous fistula were still unobstructed,and the 1-year cumulative survival rate of arteriovenous fistula was 88%;Kaplan-Meire survival curve analysis of the two groups of patients suggested that Log Rank test P=0.085,and there was no difference between the two groups Learn meaning.Conclusions:1.The thickness of cephalic vein intima,media or intima-media before arteriovenous fistula is related to early postoperative dysfunction,but has nothing to do with the cumulative patency of arteriovenous fistula for 1year.The impact of patency rate is for further study.2.The levels of HB,ALB,PLT,FIB,PTH,Ca,P,TG,CHOL,and CRP before arteriovenous fistula are not related to early postoperative dysfunction.3.Venous intimal hyperplasia is the main pathological condition when arteriovenous fistula fails.It may be the fastest period of venous intimal hyperplasia within 3 months after surgery,and the rate of venous intima hyperplasia may be relatively uniform.The late dysfunction of the fistula after3 months of arteriovenous fistula surgery may be more affected by other factors besides some effects of the slow proliferation of the intima and media.This requires continuous observation of changes before and after the operation through a large number of matched cases to further confirm these pathological changes.