慢性肾衰竭血液透析患者造瘘侧上肢肱动脉-指端微小动脉血流动力学变化特点分析

doi:10.3877/cma.j.issn.1672-6448.2023.12.010

目的

应用高频超声结合平面波超敏感血流显像（Angio PLUS）评估血液透析患者造瘘侧上肢肱动脉-指端微小动脉血流动力学变化特点。

方法

前瞻性选取2021年3月至2022年9月因慢性肾衰竭于川北医学院附属医院经自体动静脉内瘘长期规律血液透析的患者81例，同期纳入103例健康成人作为正常对照组。应用高频超声结合Angio PLUS观察2组上肢肱动脉、尺动脉、桡动脉、尺侧及桡侧指掌侧固有动脉血管解剖学结构，记录各段动脉内径、血流频谱波形、收缩期峰值速度（PSV）、舒张末期速度（EDV）、舒张期平均速度（MDV）、阻力指数（RI）、收缩期峰值血流加速度（Slope）及血流容积（V-Flow）等血流动力学参数，并行组间及组内比较分析。

结果

造瘘上肢肱动脉、尺动脉及桡动脉血流频谱单相波占比高于健康上肢（χ²=60.106、8.316、11.916，P均<0.05），而尺侧及桡侧指掌侧固有动脉单相波占比差异无统计学意义（P均>0.05）。造瘘侧上肢各段动脉频谱波形均为单相波，而健康上肢由近段动脉（肱动脉）经中段动脉（尺动脉、桡动脉）至远段动脉（尺侧及桡侧指掌侧固有动脉）血流频谱单相波占比逐渐增高。与健康上肢动脉相比，造瘘侧上肢肱动脉、尺动脉及桡动脉内径增大，PSV、MDV、EDV及V-Flow增高，RI降低（P均<0.05）；尺侧及桡侧指掌侧固有动脉内径减小，MDV、EDV及V-Flow降低，RI增高（P均<0.05）。造瘘侧上肢肱动脉、尺动脉及桡动脉之间RI差异无统计学意义（P均>0.05），但均低于尺侧与桡侧指掌侧固有动脉（P均<0.05）；造瘘侧上肢动脉内径、PSV及V-Flow与健康上肢动脉内径、PSV、RI、Slope及V-Flow自近段动脉（肱动脉）经中段动脉（尺动脉、桡动脉）至远段动脉（尺侧及桡侧指掌侧固有动脉）均呈逐渐降低的变化趋势（P<0.05）。

结论

高频超声联合Angio PLUS技术可在观察肱、尺、桡动脉的基础上，进一步定量检测指端微小动脉的内径及血流动力学变化特征；血液透析患者造瘘侧指端微小动脉RI高于肱、尺、桡动脉，其对血液透析患者造瘘侧肢体远端低灌注缺血现象的早期诊断有一定的临床价值。

关键词: 超声检查，多普勒，脉冲, 平面波超敏感血流显像, 慢性肾功能衰竭, 血液透析, 血流动力学, 动静脉瘘, 指端微小动脉, 上肢动脉, 肱动脉

慢性肾衰竭血液透析患者造瘘侧上肢肱动脉-指端微小动脉血流动力学变化特点分析

Objective

To evaluate the hemodynamic changes of the brachial artery to fingertip arterioles in hemodialysis (HD) patients with chronic renal failure by high frequency ultrasound combined with Angio planewave ultrasensitive imaging (Angio PLUS).

Methods

Eighty-one chronic renal failure patients with autogenous arteriovenous fistula (AVF) on long-term regular hemodialysis were prospectively selected at the Affiliated Hospital of North Sichuan Medical College from March 2021 to September 2022, and 103 healthy adults were selected as a control group during the same period. Artery anatomical structures, internal diameter, monophasic waveform, peak systolic velocity (PSV), end diastolic velocity (EDV), mean diastolic velocity (MDV), resistance index (RI), peak systolic blood flow slope (Slope), and blood flow volume (V-Flow) of the brachial artery, ulnar artery, radial artery, ulnar proper palmar digital artery, and radial proper palmar digital artery on the upper limb were acquired by high frequency ultrasound combined with Angio PLUS and compared between and within groups.

Results

The proportion of monophasic waveforms in the flow spectrum of the brachial, ulnar, and radial arteries of the upper limb on the side of the fistula was higher than that of the healthy adult upper limb (χ²=60.106, 8.316, and 11.916, respectively; P<0.05), but there was no statistically significant difference between the ulnar and radial palmar proper digital arteries (P>0.05). The waveforms of all level arterial spectrum on the fistula side upper limb were monophasic; however, the proportion of monophasic waveforms gradually increased from the proximal artery (brachial artery) to the middle artery (ulnar artery and radial artery) to the distal artery (ulnar and radial palmar proper digital artery) on the healthy upper limb. Compared with healthy upper arteries, the internal diameter, PSV, MDV, EDV, and V-Flow of the brachial, ulnar and radial arteries on the fistula side upper limb were increased and RI was decreased (P<0.05), while the internal diameter, MDV, EDV, and V-Flow of the ulnar and radial proper palmar digital artery on the fistula side upper limb were decreased and RI was increased (P<0.05). There was no statistically significant difference in RI between the brachial and ulnar and radial arteries on the fistula side upper limb (P>0.05), but they were all lower than those of the ulnar and radial proper palmar digital artery (P<0.05). The internal diameter, PSV, and V-Flow of arteries on the fistula side upper limb were gradually decreased from the proximal artery (brachial artery) to the middle artery (ulnar artery and radial artery) to the distal artery (ulnar and radial palmar proper digital artery) (P<0.05), which was consistent with the trend of internal diameter, PSV, RI, Slope, and V-Flow of arteries on the healthy upper limb.

Conclusion

By combining high-frequency ultrasound with Angio PLUS technology, the inner diameter and hemodynamic changes of fingertip arterioles can be further quantitatively detected on the basis of observing the brachial, ulnar, and radial arteries on the fistula side in HD patients with chronic renal failure, which could provide a more comprehensive analysis of changes in hemodynamics. The RI of fingertip arterioles is higher than that of the brachial, ulnar, and radial arteries, which has appreciated clinical value for early diagnosis of distal limb hypoperfusion/ischemia on the fistula side in HD patients.

Key words: Ultrasonography, Doppler, pulsed, Angio planewave ultrasensitive imaging, Chronic renal failure, Hemodialysis, Hemodynamics, Arteriovenous fistula, Fingertip arterioles, Upper limb artery, Brachial artery

图1 动脉血流频谱形态脉冲多普勒超声图像。图a示造瘘侧上肢肱动脉呈单相低阻力型动脉血流频谱；图b示造瘘侧上肢尺侧指掌侧固有动脉血流呈单相高阻力型动脉血流频谱；图c示健康上肢肱动脉呈非典型外周动脉三相波血流频谱（收缩期正向，舒张中晚期负向、正向不连续性低速血流频谱）；图d示健康上肢肱动脉呈典型外周动脉三相波血流频谱（收缩期正向，舒张中晚期负向、正向连续性低速血流频谱）

表1 造瘘侧上肢动脉与健康成人上肢动脉血流频谱波形占比[例（%）]

动脉波形	BA	UA	RA	UPPDA	RPPDA
造瘘侧上肢（n=81）
单相波	81（100）	81（100）	81（100）	81（100）	81（100）
非单相波
典型三相波	0	0	0	0	0
非典型三相波	0	0	0	0	0
健康上肢（n=103）
单相波	49（47.57）	93（90.30）^a	89（86.41）^a	103（100）^abc	102（99.03）^abc
非单相波
典型三相波	34（33.01）	5（4.85）	6（5.82）	0	1（0.97）
非典型三相波	20（19.42）	5（4.85）	8（7.77）	0	0

表1 造瘘侧上肢动脉与健康成人上肢动脉血流频谱波形占比[例（%）]

动脉波形	BA	UA	RA	UPPDA	RPPDA
造瘘侧上肢（n=81）
单相波	81（100）	81（100）	81（100）	81（100）	81（100）
非单相波
典型三相波	0	0	0	0	0
非典型三相波	0	0	0	0	0
健康上肢（n=103）
单相波	49（47.57）	93（90.30）^a	89（86.41）^a	103（100）^abc	102（99.03）^abc
非单相波
典型三相波	34（33.01）	5（4.85）	6（5.82）	0	1（0.97）
非典型三相波	20（19.42）	5（4.85）	8（7.77）	0	0

表2 造瘘侧上肢与健康成人上肢动脉血流动力学参数（

）

动脉	内径（mm）	PSV（cm/s）	MDV（cm/s）	EDV（cm/s）	RI	Slope（cm/s²）	V-Flow（ml/min）
造瘘侧上肢（n=81）
BA	6.24±0.99^*	133.29±48.08^*	59.18±22.02^*	63.33±24.42^*	0.53±0.10^*	641.91±370.00^*	875.69±462.05^*
UA	2.52±0.61^*a	107.32±42.68^*a	47.65±30.61^*a	50.51±32.10^*a	0.58±0.18^*	649.57±315.79^*	121.28±101.91^*a
RA	2.85±0.86^*ab	104.90±63.31^*a	54.19±40.94^*	56.66±40.63^*	0.53±0.23^*	411.39±335.73^*ab	172.73±158.85^*a
UPPDA	0.76±0.23^*abc	26.78±14.60^abc	7.67±5.57^*abc	7.91±5.64^*abc	0.74±0.13^*abc	200.30±170.49^abc	2.67±2.07^*abc
RPPDA	0.76±0.29^*abc	17.46±9.41^*abc	5.27±3.73^*abc	5.37±3.81^*abc	0.73±0.13^*abcd	107.46±87.30^*abcd	2.20±1.32^*abc
F值	685.15	131.17	78.87	89.08	34.40	64.27	214.47
P值	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01
健康上肢（n=103）
BA	3.72±0.65	74.01±17.47	6.95±6.89	7.63±7.10	0.90±0.09	787.20±239.05	68.44±31.85
UA	1.85±0.38^a	65.43±15.57^a	13.56±9.38^a	14.50±9.32^a	0.79±0.10^a	601.12±150.38^a	31.61±26.63^a
RA	2.09±0.30^ab	58.09±14.02^ab	11.90±7.34^a	12.64±7.48^a	0.79±0.10^a	541.57±152.53^ab	29.53±18.44^a
UPPDA	0.93±0.14^abc	30.05±15.95^abc	11.17±8.03^ab	11.56±6.28^ab	0.64±0.11^abc	182.31±86.51^abc	4.88±3.89^abc
RPPDA	0.86±0.14^abc	24.99±12.37^abcd	8.67±5.96^bcd	8.91±6.03^bcd	0.66±0.11^abc	153.20±86.18^abc	3.42±2.76^abc
F值	991.18	210.59	12.35	13.34	105.07	223.57	172.09
P值	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01

表2 造瘘侧上肢与健康成人上肢动脉血流动力学参数（

）

动脉	内径（mm）	PSV（cm/s）	MDV（cm/s）	EDV（cm/s）	RI	Slope（cm/s²）	V-Flow（ml/min）
造瘘侧上肢（n=81）
BA	6.24±0.99^*	133.29±48.08^*	59.18±22.02^*	63.33±24.42^*	0.53±0.10^*	641.91±370.00^*	875.69±462.05^*
UA	2.52±0.61^*a	107.32±42.68^*a	47.65±30.61^*a	50.51±32.10^*a	0.58±0.18^*	649.57±315.79^*	121.28±101.91^*a
RA	2.85±0.86^*ab	104.90±63.31^*a	54.19±40.94^*	56.66±40.63^*	0.53±0.23^*	411.39±335.73^*ab	172.73±158.85^*a
UPPDA	0.76±0.23^*abc	26.78±14.60^abc	7.67±5.57^*abc	7.91±5.64^*abc	0.74±0.13^*abc	200.30±170.49^abc	2.67±2.07^*abc
RPPDA	0.76±0.29^*abc	17.46±9.41^*abc	5.27±3.73^*abc	5.37±3.81^*abc	0.73±0.13^*abcd	107.46±87.30^*abcd	2.20±1.32^*abc
F值	685.15	131.17	78.87	89.08	34.40	64.27	214.47
P值	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01
健康上肢（n=103）
BA	3.72±0.65	74.01±17.47	6.95±6.89	7.63±7.10	0.90±0.09	787.20±239.05	68.44±31.85
UA	1.85±0.38^a	65.43±15.57^a	13.56±9.38^a	14.50±9.32^a	0.79±0.10^a	601.12±150.38^a	31.61±26.63^a
RA	2.09±0.30^ab	58.09±14.02^ab	11.90±7.34^a	12.64±7.48^a	0.79±0.10^a	541.57±152.53^ab	29.53±18.44^a
UPPDA	0.93±0.14^abc	30.05±15.95^abc	11.17±8.03^ab	11.56±6.28^ab	0.64±0.11^abc	182.31±86.51^abc	4.88±3.89^abc
RPPDA	0.86±0.14^abc	24.99±12.37^abcd	8.67±5.96^bcd	8.91±6.03^bcd	0.66±0.11^abc	153.20±86.18^abc	3.42±2.76^abc
F值	991.18	210.59	12.35	13.34	105.07	223.57	172.09
P值	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01	<0.01

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Hemodynamics changes of the brachial artery to fingertip arterioles on the fistula side upper limb in hemodialysis patients with chronic renal failure

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Hemodynamics changes of the brachial artery to fingertip arterioles on the fistula side upper limb in hemodialysis patients with chronic renal failure