透析瘻管之毒性(Arteriovenous fistula toxicity)、心衰竭、缺血性心臟病、洗腎

透析患者之洗腎瘻管用久後，可能因為功能不良而需要再重新在另一側開新的瘻管。然而，這舊的瘻管可能還有一點流量，怎麼處理它？不管它嗎？

若是患者的心臟功能尚可，可以支援兩條瘻管的血液需求量，都留著當然無妨。但若是心臟功能已經不佳了（大多數年紀大之透析患者都屬之），患者又合併喘或是胸悶之類症狀，這時就必須做檢查排除掉一些其他因素後，若是最後找不到一個特定造成以上症狀，就必須認真思考是否將那無作用，但是有流量之透析瘻管關閉以減少心臟之負擔。

診所內有兩位患者，一位三條冠狀動脈都有阻塞之糖尿病患者，也做過了心導管放支架，但是還是常說胸悶或是喘，血液學上或是透析體重設定也是沒問題，最後只剩下那多餘之瘻管未關閉。

另一位患者，之前是有右肺之不明原因腫瘤，因為年紀大了，不想檢查或是處理，也是有兩條透析瘻管，老是常常說胸悶，必須含NTG（救心錠），但也是效果不彰。近日住院後，家屬和病人下定決心做了完整檢查，發現那是肺腺癌第四期，同時，也關閉了那舊的瘻管。

手術報告單(OPERATION NOTE)                        
手術日期:2012/06/14          
生日:036/06/21 性別:女
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術後診斷:
               Congestive heart faiur with AVF overflow.
               End stage renal disease.
               Peripheral artery occlusive disease post left AK amputation
               Type II DM
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麻醉方法:L                 Surgeon:許俊傑          
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報告內容:
Operation: Excision, obliteration and repair of left elbow AVF aneurysm.
Operative indication: congestive heart failure with AVF overflow.
Operative procedure:
- The patient was put supine.
- Her left arm was sterilized, draped as usual.
- 2.5 cm incision was made over left antecubital fossa along the previous Op
scar.
- Then the wound was deepned to explore the previous AVF aneurysm.
- The basilic vein was explored, and looped.
- The vein was divided, and its arterial end was sutured with 5-O prlene in
two-row fashion.
- Then the venous end was tied over.
- The wound was closed in layers.

Blood Purif. 2011;31(1-3):113-20. Epub 2011 Jan 10.

Arteriovenous fistula toxicity.

Amerling R, Ronco C, Kuhlman M, Winchester JF.

Source

Department of Internal Medicine-Nephrology, Vivantes Klinikum im Friedrichshain, Berlin, Germany