Ôîðìèðîâàíèå àðòåðèîâåíîçíûõ ôèñòóë ìåòîäîì òðàíñïîçèöèè âåí âåðõíåé êîíå÷íîñòè Îðèãèíàëüíûå ñòàòüè

Îðèãèíàëüíûå ñòàòüè
Ôîðìèðîâàíèå àðòåðèîâåíîçíûõ ôèñòóë
ìåòîäîì òðàíñïîçèöèè âåí âåðõíåé
êîíå÷íîñòè
А.Ю.Беляев
Городсаялиничесаябольница№52,.Мосва
The creation of arterio-venous fistulas by transposition
of the upper arm veins
A.Y.Beliaev
Êëþ÷åâûå ñëîâà: ïðîãðàììíûé ãåìîäèàëèç, ïîñòîÿííûé ñîñóäèñòûé äîñòóï, àðòåðèîâåíîçíàÿ
ôèñòóëà.
Ïàöèåíòû, ïîëó÷àþùèå ïîñòîÿííûé ãåìîäèàëèç, íóæäàþòñÿ â äîëãîñðî÷íîì íàäåæíîì ñîñóäèñòîì
äîñòóïå. Àðòåðèîâåíîçíàÿ ôèñòóëà, ñôîðìèðîâàííàÿ èç òðàíñïîíèðîâàííîé àóòîëîãè÷íîé âåíû è áðàõèàëüíîé àðòåðèè, îáåñïå÷èâàåò ïîñòîÿííûé ñîñóäèñòûé äîñòóï (ÏÑÄ) ïðè îòñóòñòâèè òðåáóåìîé ïîâåðõíîñòíîé âåíû, îíà îáåñïå÷èâàåò äîëãîñðî÷íûé ÏÑÄ è äîëæíà ðàññìàòðèâàòüñÿ êàê ìåòîä âûáîðà
ïåðåä óñòàíîâêîé ñîñóäèñòîãî ïðîòåçà.
Patients who require long-term hemodialysis need long-term vascular access. The transposed autologous vein to
brachial artery arteriovenous fistula provides vascular access in the absence of adequate superficial vein. Transposed basilic (brachial) vein to brachial artery fistula have a good long-term patency rate and should be considered
early, before prosthetic grafting, in the absence of a suitable superficial veins.
Ââåäåíèå
Ñîçäàíèå àäåêâàòíîãî ïî îáúåìó êðîâîòîêà è áåçîïàñíîãî â ýêñïëóàòàöèè ïîñòîÿííîãî ñîñóäèñòîãî
äîñòóïà (ÏÑÄ) ó áîëüíûõ ñ òåðìèíàëüíîé õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ ÿâëÿåòñÿ ïðèîðèòåòíîé çàäà÷åé ñ öåëüþ îáåñïå÷åíèÿ ýôôåêòèâíîãî è
äîëãîâðåìåííîãî ïðîâåäåíèÿ ïðîãðàììíîãî ãåìîäèàëèçà.
 íàèáîëüøåé ñòåïåíè òðåáîâàíèÿì, ïðåäúÿâëÿåìûì ê îïòèìàëüíîìó ñîñóäèñòîìó äîñòóïó, óäîâëåòâîðÿåò íàòèâíàÿ àðòåðèîâåíîçíàÿ ôèñòóëà (ÀÂÔ),
áåçîãîâîðî÷íî ïðèçíàþùàÿñÿ ìåòîäîì âûáîðà ïðè
ôîðìèðîâàíèè ÏÑÄ, ÷òî îáóñëîâëåíî íèçêîé ÷àñòîòîé îñëîæíåíèé è ñòàáèëüíîé ôóíêöèåé â òå÷åíèå
ìíîãèõ ëåò ýêñïëóàòàöèè [1, 21, 25]. Ïîýòîìó ñòðàòåãè÷åñêèì íàïðàâëåíèåì ðåøåíèÿ ïðîáëåìû ñîñóäèñòîãî äîñòóïà äëÿ ãåìîäèàëèçà ÿâëÿåòñÿ ìàêñèìàëüíî âîçìîæíîå óâåëè÷åíèå äîëè ÀÂÔ â îáùåé ñòðóêòóðå ÏÑÄ [32, 34].
Ê ñîæàëåíèþ, âî ìíîãèõ ñëó÷àÿõ ôîðìèðîâàíèå
ñòàíäàðòíîé äèñòàëüíîé èëè ïðîêñèìàëüíîé ÀÂÔ íåâîçìîæíî ïî ïðè÷èíå ìíîãî÷èñëåííûõ ïðåäøåñòâóþùèõ ñîñóäèñòûõ îïåðàöèé, èíäèâèäóàëüíûõ îñîáåííîñòåé àðõèòåêòîíèêè ñîñóäîâ èëè èõ ïàòîëîãè÷åñêèõ èçìåíåíèé.  ýòîé ñèòóàöèè âûáîð ñïîñîáà
îáåñïå÷åíèÿ ÏÑÄ îáû÷íî îñóùåñòâëÿåòñÿ ìåæäó èì-
ïëàíòàöèåé ñèíòåòè÷åñêîãî ñîñóäèñòîãî ïðîòåçà
(ÑÑÏ) èëè òîííåëüíîãî öåíòðàëüíîãî âíóòðèâåííîãî êàòåòåðà (ÖÂÊ), ôîðìèðîâàíèåì ðåòðîãðàäíîé
ÀÂÔ, òðàíñïîçèöèåé îäíîé èç âåí êîíå÷íîñòè.
Èìïëàíòàöèÿ ÑÑÏ íå èìååò ñóùåñòâåííûõ ïðåèìóùåñòâ ïåðåä íàòèâíîé ÀÂÔ, à ïî ðÿäó ïîêàçàòåëåé
çíà÷èòåëüíî óñòóïàåò åé.  ïîñëåäíèå ãîäû îòìå÷åíà
âûðàæåííàÿ òåíäåíöèÿ ê îãðàíè÷åíèþ ïîêàçàíèé äëÿ
ïðèìåíåíèÿ ÑÑÏ â êà÷åñòâå ïåðâè÷íîãî ñîñóäèñòîãî
äîñòóïà [24, 27]. Ýòî îáúÿñíÿåòñÿ ñòàòèñòè÷åñêè äîñòîâåðíî ìåíüøåé äëèòåëüíîñòüþ ôóíêöèîíèðîâàíèÿ
ÑÑÏ è áîëüøèì êîëè÷åñòâîì íåîáõîäèìûõ êîððèãèðóþùèõ ïðîöåäóð â ïîñëåîïåðàöèîííîì ïåðèîäå ïî
ñðàâíåíèþ ñ ÀÂÔ [12, 22]. Êðîìå ýòîãî, ÑÑÏ ÿâëÿþòñÿ
ñåðüåçíûì ôàêòîðîì ðèñêà â îòíîøåíèè âîçìîæíûõ
èíôåêöèîííûõ îñëîæíåíèé [28, 31]. Íåñìîòðÿ íà òî
÷òî ïðè íàëè÷èè àäåêâàòíûõ ìàãèñòðàëüíûõ ñîñóäîâ
êîíå÷íîñòè íå ñóùåñòâóåò òåõíè÷åñêèõ ïðîáëåì â
èìïëàíòàöèè ÑÑÏ äëÿ ãåìîäèàëèçà, ôóíêöèîíàëüíî
ïðèãîäíàÿ íàòèâíàÿ ÀÂÔ ïðåäïî÷òèòåëüíåå ñîñóäèñòîãî äîñòóïà, ñîçäàííîãî ñ ïðèìåíåíèåì ñèíòåòè÷åñêèõ ìàòåðèàëîâ [29, 30].
Êàê àëüòåðíàòèâó ÑÑÏ â îòäåëüíûõ ñîñóäèñòûõ
öåíòðàõ ôîðìèðóþò òàê íàçûâàåìûå «ðåòðîãðàäíûå»
ÀÂÔ [14, 19], çàðåêîìåíäîâàâøèå ñåáÿ, ñ îäíîé ñòîðîíû, âûñîêîé âûæèâàåìîñòüþ è âîçìîæíîñòüþ îòñðî÷êè ïðèìåíåíèÿ ÑÑÏ äëÿ ñîçäàíèÿ ÏÑÄ, ñ äðóãîé – íèç-
Àäðåñ äëÿ ïåðåïèñêè: 123182, ã. Ìîñêâà, Ïåõîòíàÿ óë., ä. 3/2. ÃÊÁ ¹ 52
130 Íåôðîëîãèÿ è äèàëèç · Ò. 10, ¹ 2 2008
Ôîðìèðîâàíèå àðòåðèîâåíîçíûõ ôèñòóë ìåòîäîì òðàíñïîçèöèè âåí âåðõíåé êîíå÷íîñòè
êèìè ôóíêöèîíàëüíûìè ïîêàçàòåëÿìè (íå áîëåå 65%
ÀÂÔ òàêîãî òèïà ïðèãîäíû ê ýêñïëóàòàöèè) è áîëüøîé ÷àñòîòîé ðàçâèòèÿ îñëîæíåíèé [2]. Íåñìîòðÿ íà
õîðîøèå ïîêàçàòåëè äëèòåëüíîñòè ôóíêöèîíèðîâàíèÿ è îòíîñèòåëüíóþ ïðîñòîòó õèðóðãè÷åñêîãî âûïîëíåíèÿ ðåòðîãðàäíûõ ÀÂÔ, áîëüøèíñòâî ñïåöèàëèçèðîâàííûõ ñîñóäèñòûõ öåíòðîâ íå ïðèìåíÿþò ýòîò
âàðèàíò ñîñóäèñòîãî äîñòóïà ïî ïðè÷èíå áûñòðîãî
ðàçâèòèÿ îñëîæíåíèé è èõ çíà÷èòåëüíîé âûðàæåííîñòè (îòåê êîíå÷íîñòè, òðîôè÷åñêèå íàðóøåíèÿ â ìÿãêèõ òêàíÿõ âïëîòü äî èçúÿçâëåíèÿ, äëèòåëüíûå ïîñòèíúåêöèîííûå êðîâîòå÷åíèÿ èç àíåâðèçìàòè÷åñêè
èçìåíåííûõ ó÷àñòêîâ) (ðèñ. 1). Âñå ýòî íå ïîçâîëÿåò â
ïîëíîé ìåðå ñ÷èòàòü òàêîé âèä ñîñóäèñòîãî äîñòóïà
äîëãîâðåìåííûì.
Ôîðìèðîâàíèå ÀÂÔ íà áåäðå ïóòåì òðàíñïîçèöèè
áîëüøîé ïîäêîæíîé âåíû íîãè ïîëó÷èëî íåîäíîçíà÷íûå îöåíêè èññëåäîâàòåëåé. Îäíè ñ÷èòàþò åãî
ïðèîðèòåòíûì ïî îòíîøåíèþ ê èìïëàíòàöèè ñîñóäèñòûõ ïðîòåçîâ íà íèæíåé êîíå÷íîñòè [16]. Äðóãèå
ïîëàãàþò, ÷òî îáëàñòü ïðèìåíåíèÿ ìåòîäà ñóùåñòâåííî îãðàíè÷åíà ïî ïðè÷èíå âûñîêîé ÷àñòîòû ðàçâèòèÿ
ñîïóòñòâóþùèõ îñëîæíåíèé (äåãåíåðàöèÿ âåíîçíîé
ñòåíêè âñëåäñòâèå íàðóøåíèÿ åå êðîâîñíàáæåíèÿ,
àíåâðèçìû è ïñåâäîàíåâðèçìû, äëèòåëüíûå êðîâîòå÷åíèÿ èç ïóíêöèîííûõ îòâåðñòèé, èíôèöèðîâàíèå,
ñèíäðîì «îáêðàäûâàíèÿ»), íåèçáåæíî âîçíèêàþùèõ
ïðè ýêñïëóàòàöèè ýòîãî âèäà ñîñóäèñòîãî äîñòóïà è
òðåáóþùèõ äîïîëíèòåëüíûõ ðåêîíñòðóêòèâíûõ âìåøàòåëüñòâ [15, 18].
Ïðèìåíåíèå òîííåëüíûõ ÖÂÊ, ïîëó÷èâøåå ðàñïðîñòðàíåíèå â ïîñëåäíèå ãîäû, ÿâëÿåòñÿ îïðàâäàííûì, à âî ìíîãèõ ñëó÷àÿõ è åäèíñòâåííî ïðèåìëåìûì
äëÿ ïðîâåäåíèÿ ïðîãðàììíîãî ãåìîäèàëèçà ïðè íåâîçìîæíîñòè èëè íåöåëåñîîáðàçíîñòè ôîðìèðîâàíèÿ ÏÑÄ ó îïðåäåëåííîé êàòåãîðèè ïàöèåíòîâ (ïîñëå èñ÷åðïàíèÿ ðåñóðñà íàòèâíûõ ñîñóäîâ äëÿ ñîçäàíèÿ ÏÑÄ è â ñâÿçè ñ íåâîçìîæíîñòüþ ïðîâåäåíèÿ ïåðèòîíåàëüíîãî äèàëèçà; ó ìàëîëåòíèõ äåòåé; ó ïàöèåíòîâ ñ âûðàæåííûì ïîðàæåíèåì ñîñóäîâ; ó áîëüíûõ
ñ äèëàòàöèîííîé êàðäèîìèîïàòèåé èëè îíêîëîãè÷åñêèìè çàáîëåâàíèÿìè â òåðìèíàëüíîé ñòàäèè) [3, 8, 11,
20, 33]. Îäíàêî òîëüêî îêîëî 30–40% òîííåëüíûõ ÖÂÊ
îñòàþòñÿ ôóíêöèîíàëüíî ïðèãîäíûìè ÷åðåç 1 ãîä,
äàæå ñ ó÷åòîì âûïîëíåíèÿ êîððèãèðóþùèõ âìåøàòåëüñòâ [1], êðîìå ýòîãî, ÷àñòîòà ðàçâèòèÿ èíôåêöèîííûõ îñëîæíåíèé è ñìåðòíîñòü ñóùåñòâåííî ïðåâûøàþò òàêîâóþ ïðè ôîðìèðîâàíèè ÀÂÔ èëè èìïëàíòàöèè ÑÑÏ [5, 6, 37]. Âñå ýòî íå ïîçâîëÿåò â ïîëíîé
ìåðå îòíåñòè äàííûé âèä ñîñóäèñòîãî äîñòóïà ê êàòåãîðèè ïîñòîÿííîãî.
Òðàíñïîçèöèÿ v. basilica (v. brachialis) íà ïëå÷å, â
ñèëó òîïîãðàôî-àíàòîìè÷åñêèõ îñîáåííîñòåé ýòèõ
âåí (îòíîñèòåëüíî áîëüøàÿ ãëóáèíà ðàñïîëîæåíèÿ,
îáùèé ôàñöèàëüíûé ôóòëÿð ñ ïëå÷åâîé àðòåðèåé), âûïîëíÿåòñÿ â öåëÿõ îáåñïå÷åíèÿ óäîáñòâà è áåçîïàñíîñòè èõ ïóíêöèé äëÿ âûïîëíåíèÿ ãåìîäèàëèçà (ðèñ. 2).
Ýôôåêòèâíîñòü ìåòîäà äîñòàòî÷íî âûñîêà, áîëüøèíñòâî èññëåäîâàòåëåé íà îñíîâàíèè äàííûõ î ñóùåñòâåííî ëó÷øåé ñîõðàííîñòè ôóíêöèè è ìåíüøåé
÷àñòîòå îñëîæíåíèé ñ÷èòàþò åãî ïðÿìîé àëüòåðíàòèâîé èìïëàíòàöèè ÑÑÏ [17, 23, 26, 36]. Ïî äàííûì çà-
Îðèãèíàëüíûå ñòàòüè
Ðèñ. 1. Òðîôè÷åñêèå íàðóøåíèÿ, ðàçâèâøèåñÿ ÷åðåç
6 ìåñÿöåâ ïîñëå ôîðìèðîâàíèÿ «ðåòðîãðàäíîé» ÀÂÔ
Ðèñ. 2. Ñõåìà îïåðàöèè ïî òðàíñïîçèöèè ïëå÷åâîé âåíû
ðóáåæíûõ èññëåäîâàòåëåé, ïîêàçàòåëè 1-ãîäè÷íîé âûæèâàåìîñòè ÀÂÔ ñ òðàíñïîçèöèåé âåí ïëå÷à íàõîäÿòñÿ â ïðåäåëàõ 74–100% [13, 38].
Ôîðìèðîâàíèå ÀÂÔ ìåòîäîì òðàíñïîçèöèè âåí
ïëå÷à ìîæåò îñóùåñòâëÿòüñÿ êàê â îäèí ýòàï (òðàíñïîçèöèÿ âûïîëíÿåòñÿ îäíîâðåìåííî ñ ñîçäàíèåì àðòåðèîâåíîçíîãî àíàñòîìîçà), òàê è äâóõýòàïíî (ïîñëå «ñîçðåâàíèÿ» âåíû) [9, 13, 39]. Ñîñóäèñòîå ñîóñòüå
ôîðìèðóåòñÿ ìåæäó a. brachialis è v. basilica (èëè v. brachialis) â ëîêòåâîé ÿìêå èëè äèñòàëüíîé òðåòè ïëå÷à
[7, 10]. Ïðåèìóùåñòâà äâóõýòàïíîãî ìåòîäà òðàíñïîçèöèè çàêëþ÷àþòñÿ â òîì, ÷òî ìîáèëèçàöèè ïîäâåðãàåòñÿ óæå «ñîçðåâøàÿ» ôèñòóëüíàÿ âåíà ñ óòîëùåííîé
(ãèïåðïëàçèðîâàííîé) ñîñóäèñòîé ñòåíêîé, âñëåäñòâèå ýòîãî áîëåå óñòîé÷èâàÿ ê òðàâìàòèçàöèè [4].
Êðîìå ýòîãî, II ýòàï ìîæåò âîîáùå íå ïîòðåáîâàòüñÿ,
òàê êàê îêîëî òðåòè ÀÂÔ ïî òèïó «êîíåö â áîê – v. basilica – a. brachialis» ìîãóò áûòü ôóíêöèîíàëüíî ïðèãîäíûìè äëÿ ïðîâåäåíèÿ ãåìîäèàëèçà áåç âûïîëíåíèÿ
òðàíñïîçèöèè âåíû. Ïðîòÿæåííîñòü ïåðåìåùåííîãî
ó÷àñòêà âåíû ïëå÷à äîëæíà áûòü äîñòàòî÷íîé äëÿ îñóùåñòâëåíèÿ ýôôåêòèâíîãî ãåìîäèàëèçà, íî íå ìàêñèìàëüíî âîçìîæíîé, òàê êàê ñ óâåëè÷åíèåì äëèíû ìîáèëèçîâàííîãî ñåãìåíòà ðàñòåò âåðîÿòíîñòü ðàçâèòèÿ
òðîìáîçà, à òàêæå äåãåíåðàòèâíûõ èçìåíåíèé ñîñóäèñòîé ñòåíêè [35].
Îïåðàöèè ïî òðàíñïîçèöèè ãëóáîêî ðàñïîëîæåííûõ âåí ïëå÷à â Ðîññèè ïîêà íå ïîëó÷èëè ðàñïðîñòðàíåíèÿ. Íàø ïåðâîíà÷àëüíûé îïûò ïðèìåíåíèÿ ìåòîäà ñâèäåòåëüñòâóåò î âîçìîæíîñòè åãî ãàðàíòèðîâàííîãî òåõíè÷åñêîãî âûïîëíåíèÿ è ýôôåêòèâíîñòè
â ïëàíå îáåñïå÷åíèÿ àäåêâàòíîãî ïðîãðàììíîãî ãåìîäèàëèçà.
Ò. 10, ¹ 2 2008 · Íåôðîëîãèÿ è äèàëèç
131
Îðèãèíàëüíûå ñòàòüè
À.Þ. Áåëÿåâ
Ðèñ. 3. Ðàñïîëîæåíèå ôèñòóëüíîé (ïëå÷åâîé) âåíû äî åå
òðàíñïîçèöèè
Ðèñ. 4. Ôîðìèðîâàíèå ïîäêîæíîãî ëîæà äëÿ ôèñòóëüíîé
(ïëå÷åâîé) âåíû
Ìàòåðèàëû è ìåòîäû
Âñåãî âûïîëíåíî 17 îïåðàöèé ïî òðàíñïîçèöèè
ãëóáîêèõ âåí ïëå÷à ñ öåëüþ îáåñïå÷åíèÿ ÏÑÄ. Âñå
îïåðàöèè âûïîëíÿëèñü äâóõýòàïíûì ìåòîäîì.
Ïàöèåíòàìè â 14 ñëó÷àÿõ áûëè æåíùèíû, â 3 – ìóæ÷èíû (ñðåäíèé âîçðàñò 54,5 ± 4,3 ãîäà).
Ñîñóäèñòûé àíàñòîìîç â 14 îïåðàöèÿõ ôîðìèðîâàëñÿ â ëîêòåâîé ÿìêå, â 3 – â äèñòàëüíîé òðåòè ïëå÷à
(â 10 ñëó÷àÿõ – ìåæäó a. brachialis è v. basilica, â 4 – ìåæäó a. è v. brachialis). ×åðåç 3–7 íåäåëü ïîñëå ñîçäàíèÿ
ñîñóäèñòîãî àíàñòîìîçà âûïîëíÿëñÿ II ýòàï – ìîáèëèçàöèÿ è òðàíñïîçèöèÿ ôèñòóëüíîé âåíû (ðèñ. 3–5).
Ðåçóëüòàòû
Âî âñåõ íàáëþäåíèÿõ äîñòèãíóòà 100% òåõíè÷åñêàÿ ýôôåêòèâíîñòü, ò. å. äî ìîìåíòà íà÷àëà ýêñïëóàòàöèè â êà÷åñòâå ÏÑÄ äëÿ ãåìîäèàëèçà (â ñðåäíåì
62,7 ± 13,4 äíÿ ïîñëå îïåðàöèè I ýòàïà) íè îäíà ÀÂÔ
íå óòðàòèëà ñâîåé ôóíêöèè. Ïðè ýòîì ïîñëå âûïîëíåíèÿ II ýòàïà âî âñåõ ñëó÷àÿõ äîñòèãíóòû ïîñòàâëåííûå öåëè: ïîâåðõíîñòíîå (è ñîîòâåòñòâåííî äîñòóïíîå äëÿ ïóíêöèé) ðàñïîëîæåíèå ôèñòóëüíîé âåíû,
àäåêâàòíûé êðîâîòîê ïî íåé, áåçîïàñíîñòü ïóíêöèé
ÀÂÔ (ðèñê òðàâìèðîâàíèÿ ïëå÷åâîé àðòåðèè ìèíèìàëåí).
Ê ìîìåíòó íàïèñàíèÿ ñòàòüè ïîëó÷åíû äàííûå îá
èñïîëüçîâàíèè äëÿ ãåìîäèàëèçà 11 ÀÂÔ ïîñëå òðàíñïîçèöèè ãëóáîêèõ âåí ïëå÷à (èç íèõ ó îäíîé ÀÂÔ ôóíêöèÿ áåçâîçâðàòíî óòðà÷åíà ïî ïðè÷èíå òðîìáîçà).
Ïðè ôîðìèðîâàíèè ÀÂÔ ñ òðàíñïîçèöèåé ãëóáîêî ðàñïîëîæåííûõ âåí âåðõíèõ êîíå÷íîñòåé ìîæåò
áûòü äîñòèãíóòî îïòèìàëüíîå ñîîòíîøåíèå ýôôåêòèâíîñòè è áåçîïàñíîñòè ïî ñðàâíåíèþ ñ ðåòðîãðàäíîé ÀÂÔ, èìïëàíòàöèåé ÑÑÏ èëè òîííåëüíîãî ÖÂÊ.
Íè â îäíîì ñëó÷àå ïîñëå òðàíñïîçèöèè ÀÂÔ íå áûëî
îòìå÷åíî îñëîæíåíèé, ñâÿçàííûõ ñ èíôèöèðîâàíèåì ñîñóäèñòîãî äîñòóïà èëè ïîñëåîïåðàöèîííîé ðàíû
ëèáî ñ íàðóøåíèåì êðîâîñíàáæåíèÿ êîíå÷íîñòè.
Òðàíñïîçèöèÿ ÀÂÔ, ñ îäíîé ñòîðîíû, ïðîëîíãèðóåò
âîçìîæíîñòü ýêñïëóàòàöèè ïîòåíöèàëà íàòèâíûõ ñîñóäîâ è îòäàëÿåò íåîáõîäèìîñòü èìïëàíòàöèè ÑÑÏ, ñ
132 Íåôðîëîãèÿ è äèàëèç · Ò. 10, ¹ 2 2008
Ðèñ. 5. Ðàñïîëîæåíèå ôèñòóëüíîé (ïëå÷åâîé) âåíû
ïîñëå åå òðàíñïîçèöèè
äðóãîé – îáåñïå÷èâàåò ëó÷øèå òåõíè÷åñêèå è ãåìîäèíàìè÷åñêèå óñëîâèÿ äëÿ ïîñëåäíåé â ñëó÷àå åå
íåèçáåæíîñòè (àíàñòîìîç ÑÑÏ ìîæåò áûòü âûïîëíåí
ñ óæå «ñîçðåâøåé» äèëàòèðîâàííîé âåíîé). Äîïîëíèòåëüíûì ïðåèìóùåñòâîì ìåòîäà ÿâëÿåòñÿ òî, ÷òî ñîõðàíÿåòñÿ ðåàëüíûé âàðèàíò (åñëè ïîòðåáóåòñÿ) ïîñëåäóþùåé èìïëàíòàöèè ÑÑÏ íà ãëóáîêèå ñîñóäû
âåðõíåé êîíå÷íîñòè. Êðîìå ýòîãî, âîçìîæíî óñïåøíîå ñîçäàíèå ÀÂÔ ñ èñïîëüçîâàíèåì äëÿ ïîñëåäóþùåé
òðàíñïîçèöèè âåíû îòíîñèòåëüíî íåáîëüøîãî äèàìåòðà (äî 3 ìì â äèàìåòðå), ò. å. íåàäåêâàòíîé ïî ðàçìåðó äëÿ èìïëàíòàöèè ÑÑÏ.
Òàêòèêà ôîðìèðîâàíèÿ ÀÂÔ ñ ïîñëåäóþùåé åå
òðàíñïîçèöèåé ó ïàöèåíòîâ ñ èñ÷åðïàííûì ðåñóðñîì
íàòèâíûõ ïîâåðõíîñòíûõ âåí ïîçâîëèëà óìåíüøèòü
äîëþ èìïëàíòàöèé ÑÑÏ â ñòðóêòóðå îïåðàöèé ïî
îáåñïå÷åíèþ ÏÑÄ ñ 22,2% (2001–2006 ãã.) äî 2,2%
(2007 ã.).
Îñíîâíûì íåäîñòàòêîì ñïîñîáà äâóõýòàïíîãî
ôîðìèðîâàíèÿ ÀÂÔ ñ òðàíñïîçèöèåé âåí ïî ñðàâíåíèþ ñ äðóãèìè ìåòîäàìè ñîçäàíèÿ ÏÑÄ ÿâëÿþòñÿ
áîëüøèå ñðîêè îò ìîìåíòà ñîçäàíèÿ ñîñóäèñòîãî àíàñòîìîçà äî íà÷àëà ýêñïëóàòàöèè ÀÂÔ äëÿ ãåìîäèàëè-
Ôîðìèðîâàíèå àðòåðèîâåíîçíûõ ôèñòóë ìåòîäîì òðàíñïîçèöèè âåí âåðõíåé êîíå÷íîñòè
Ðèñ. 6. Èñïîëüçîâàíèå äëÿ ãåìîäèàëèçà ïëå÷åâîé âåíû
ïîñëå åå òðàíñïîçèöèè
çà, ÷òî òðåáóåò äîëãîâðåìåííîãî ïðèìåíåíèÿ ÖÂÊ è
óâåëè÷èâàåò ðèñê ðàçâèòèÿ ñîîòâåòñòâóþùèõ îñëîæíåíèé. Äðóãîé íåäîñòàòîê ÀÂÔ ïîñëå òðàíñïîçèöèè
ôèñòóëüíîé âåíû ñâÿçàí ñ âîçìîæíûìè òåõíè÷åñêèìè ïðîáëåìàìè ïðè åå ïóíêöèÿõ íà íà÷àëüíîì ýòàïå
èñïîëüçîâàíèÿ äëÿ ãåìîäèàëèçà. Ýòî îáúÿñíÿåòñÿ îïðåäåëåííîé òðóäíîñòüþ òî÷íîé ïàëüïàòîðíîé èäåíòèôèêàöèè ïðîåêöèè è ãëóáèíû ðàñïîëîæåíèÿ ôèñòóëüíîé âåíû ïî ïðè÷èíå âûðàæåííûõ ðóáöîâûõ èçìåíåíèé ìÿãêèõ òêàíåé âîêðóã íåå. Ïîýòîìó êàðòèðîâàíèå ôèñòóëüíîé âåíû ìåòîäîì ÓÇÈ ïðåäñòàâëÿåòñÿ
îïðàâäàííûì ðóòèííûì ìåòîäîì ïåðåä íà÷àëîì åå
ïóíêöèé.  íåêîòîðûõ ñëó÷àÿõ ïðîåêöèÿ ôèñòóëüíîé
âåíû ìîæåò ñîâïàäàòü ñ ëèíèåé ïîñëåîïåðàöèîííîãî ðóáöà, ÷òî òàêæå óñëîæíÿåò åå ðóòèííóþ ýêñïëóàòàöèþ (ðèñ. 6).
Ïî ðåçóëüòàòàì íàøèõ îïåðàöèé àíàëèç äîëãîâðåìåííîé âûæèâàåìîñòè ÀÂÔ ñ òðàíñïîçèöèåé ãëóáîêèõ âåí ïðåäïëå÷üÿ íå ïðèâîäèòñÿ â äàííîé ðàáîòå èççà îòíîñèòåëüíî íåáîëüøîãî ñòàòèñòè÷åñêîãî ìàòåðèàëà è äëèòåëüíîñòè íàáëþäåíèé. Íî ïðåäâàðèòåëüíûå äàííûå îäíîçíà÷íî ñâèäåòåëüñòâóþò â ïîëüçó
ýòîãî ìåòîäà ïî ñðàâíåíèþ ñ èìïëàíòàöèåé ÑÑÏ.
Âûâîäû
Ñîçäàíèå ÀÂÔ ñ òðàíñïîçèöèåé ãëóáîêî ðàñïîëîæåííûõ âåí âåðõíèõ êîíå÷íîñòåé îòêðûâàåò ðåàëüíûå ïåðñïåêòèâû äëÿ ìàêñèìàëüíîãî èñïîëüçîâàíèÿ
ïîòåíöèàëà íàòèâíûõ ñîñóäîâ äëÿ ôîðìèðîâàíèÿ
ÏÑÄ. Ïîëó÷åííûå ðåçóëüòàòû ïðèìåíåíèÿ ìåòîäà âñåëÿþò îïðåäåëåííûé îïòèìèçì â ïëàíå äîïîëíèòåëüíîé âîçìîæíîñòè âûïîëíåíèÿ òåõíè÷åñêè îòíîñèòåëüíî íåñëîæíîé îïåðàöèè, êîòîðàÿ ìîæåò èìåòü
àáñîëþòíûé êëèíè÷åñêèé óñïåõ ïðè ìèíèìóìå îñëîæíåíèé è ýêîíîìè÷åñêèõ çàòðàò.
Ëèòåðàòóðà
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Ïèòåðà Äæ. Áëåéêà, Òîääà Ñ. Èíãà. Ïåð. ñ àíãë. ïîä ðåä. À.Þ. Äåíèñîâà è Â.Þ. Øèëî. Òðåòüå èçäàíèå. Ì.: Öåíòð äèàëèçà – Òâåðü:
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Ñóáúåêòèâíûå ïîêàçàòåëè ôèçè÷åñêîãî
çäîðîâüÿ, ñâÿçàííûå ñ âûæèâàåìîñòüþ
áîëüíûõ íà ãåìîäèàëèçå
И.А.Васильева1,В.А.Добронравов1,Е.В.Бабарыина2
1
НИИнефролоииСант-Петерб$рсооос$дарственноомедицинсоо
$ниверситетаим.аад.И.П.Павлова,.Сант-Петерб$р;
2
Oбластнаялиничесаябольница,.Омс
Subjective measures of physical health associated
with survival in hemodialysis patients
I.A.Vasilieva,V.A.Dobronravov,E.V.Babarykina
Êëþ÷åâûå ñëîâà: êà÷åñòâî æèçíè, âûæèâàåìîñòü, ãåìîäèàëèç.
Ïðîâåäåí ðåòðîñïåêòèâíûé àíàëèç âûæèâàåìîñòè 125 áîëüíûõ, ïîëó÷àâøèõ ëå÷åíèå ãåìîäèàëèçîì (ÃÄ). Èñõîäíîé âðåìåííîé òî÷êîé ñ÷èòàëîñü ïðîâåäåíèå èññëåäîâàíèÿ êà÷åñòâà æèçíè ïî ìåòîäèêå SF-36 â ñî÷åòàíèè ñ ðåãèñòðàöèåé êëèíèêî-äåìîãðàôè÷åñêèõ ïàðàìåòðîâ. Îöåíèâàëàñü ïðîãíîñòè÷åñêàÿ çíà÷èìîñòü ýòèõ ïîêàçàòåëåé â îòíîøåíèè âûæèâàåìîñòè. Ãðóïïà óìåðøèõ áîëüíûõ (n = 46)
èñõîäíî îòëè÷àëàñü äîñòîâåðíî áîëåå íèçêèì óðîâíåì ïîêàçàòåëåé êà÷åñòâà æèçíè. Óñòàíîâëåíî, ÷òî
ïîêàçàòåëü ôèçè÷åñêîãî ôóíêöèîíèðîâàíèÿ è ñóììàðíûé èíäåêñ ôèçè÷åñêîãî çäîðîâüÿ, áàçèðóþùèåñÿ íà ñàìîîöåíêå áîëüíîãî, ÿâëÿþòñÿ âàæíûìè íåçàâèñèìûìè ïðåäèêòîðàìè âûæèâàåìîñòè ÃÄ-ïàöèåíòîâ íàðÿäó ñî ñðåäíèì îáúåìîì óëüòðàôèëüòðàöèè, êàëüöèé-ôîñôàòíûì ïðîèçâåäåíèåì, ñðåäíèì
óðîâíåì àëüáóìèíà. Ïîêàçàòåëè ïñèõè÷åñêîãî çäîðîâüÿ îáñëåäîâàííîé ãðóïïû áîëüíûõ ñ âûæèâàåìîñòüþ ñâÿçàíû íå áûëè.
A retrospective analysis of survival of 125 haemodialysis patients was carried out. Evaluation of quality of life
(using the SF-36 scoring method) and assessment of clinical and demographic variables have been performed the
initial time point of the study. The aim of the work was to assess the predictive value of quality of life scores and
clinical data. Quality of life scoring correlated significantly with survival rate. In the group of patients who died
during the period of observation (n = 46) the baseline quality of life scores were significantly lower than in the group
of survivals. Patient’s self-assessed physical functioning and physical summary score were found to be significant
independent predictors of survival as well as the mean ultrafiltration volume, serum albumin level and Ñà-Ð product. No significant correlation was found between the mental health scores and survival rate.
Àäðåñ äëÿ ïåðåïèñêè: 197022, ã. Ñàíêò-Ïåòåðáóðã, óë. Ë. Òîëñòîãî, ä. 17. ÑÏáÃÌÓ èì. àêàä. È.Ï. Ïàâëîâà, ÍÈÈ íåôðîëîãèè. Âàñèëüåâîé È.À.
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134 Íåôðîëîãèÿ è äèàëèç · Ò. 10, ¹ 2 2008