長期血液透析廔管失能的處置

813 386

ၡāāࢋ

( Hemodialysis )

( PTA, percutaneous transluminal angioplasty )

ᙯᔣෟĈགྷϩҕგјݭఙ ( Percutaneous transluminal angioplasty, PTA ) ҕ୵౅ژ ( Hemodialysis )

જᐖਔ გεਕ ( Arterio-venous access dysfunction )

݈֏

ॲፂ઼࡚ඪ᝙ঽྤफ़൳ᐂր௚ ( USRDS ) 2006 ѐޘಡӘ޽΍Ă 45 ໐ͽ˯ඪ਽ა߾ඪ۞൴ Ϡத̈́஽Җதέ៉݄ٺБ஧Ă͍׎дέ៉̚ݑొ

гડՀߏځពĄ༊൒߾ඪ გΑਕ۞ள૱Ă˵

ಶՀࠎ೼࿆Ąགྷϩҕგјݭఙ ( PTA, percuta- neous transluminal angioplasty ) ࠎྋՙ߾ඪજᐖ ਔ გεਕ ( Arterio-venous access dysfunction )

૱ϡ۞щБѣड़͞ڱ̝˘

Ăᔵ൒ѣ̙Тࡊొ۞

ᗁरଂְ఺ีڼᒚ ( Β߁ٸडࡊă͕᝙̰ࡊă͕

᝙γࡊăඪ᝙ࡊඈ )Ăҭ઼̰дԫఙ˯ྵ͌ፋЪ

ّ۞ଣ੅ćώ௡Яѩаᜪ˘ֱ࠹ᙯ͛ᚥ̈́ॲፂ၁ ү۞གྷរĂଂԫఙᆸࢬ˯۞၁ᅫયᗟĂᕩৼፋந ͽ೩ֻણ҂Ă˵ഇ୕ਕΐˢՀкࡁտ׶ਫ਼ᜩĂֽ

൴ण̈́Լซ఺ีԫఙĂͽྋՙ઼̰γᇃ̂߾ඪଈ ۰̝൭ࡴ׶̙ܮĄ

ҕ୵౅ژ ( Hemodialysis ) გεਕ

۞ૄώᄮᙊ

д߉Җ გҕგјݭఙ̝݈Ăυื၆ҕ୵

౅ژ۞ გѣૄώ۞ᄮᙊĂ̖ਕү΍ϒቁ۞ҿ ᕝ̈́఍ཉĂ׎ᖎ̬т˭Ĉ

˘ăܜഇҕ୵౅ژ გ۞჌ᙷĈ

( ˘ )ăҋវ გ ( fistula )Ĉͽঽଈώ֗۞જ ᐖਔҕგүӚЪĂӚЪҜཉ૱֍ٺ͘ඦă͘օ

఍Ăߏͽ፠જਔă۴જਔۡତତЪᐖਔ҃јĄ ( ˟ )ăˠ̍ გ ( graft )ĈѣֱঽଈЯώ֗

ҕგ۞Ч჌Я৵ࢨטĂ̙ዋЪۡତүҋវજᐖਔ

ӚЪఙĂಶืͽˠ̍ҕგүࠎాତ፜ሇֽତЪજ

ᐖਔâਠˠ̍౅ژ გՄኳࠎ PTFE ( Polyte- trafluoroethylene )Ą

˟ăҕ୵౅ژ გΑਕள૱۞჌ᙷ̈́ҕგব৫ঽ ի۞ΞਕҜཉĈ

ధкېڶົᇆᜩ౅ژ࿅඀۞ึӀซҖ̈́Ԇ јĂкЯҕგგට̝ব৫ٙ࡭Ă૱൴Ϡٺ෹࿅

50% გश۞ব৫

Ąҋវҕგ౵ٽдҕ߹ᑅ˧म ព඾۞ҜཉயϠব৫ĂࣧЯֽҋٺᑅमயϠ۞ૻ

˧ҕ߹Ă̙ᕝ኏ᑝҕგጨֹ̰ቯᆧϠ҃யϠব ৫Ą౵૱֍۞ܡ๫ঽիҜཉдҋវٕˠ̍જᐖ ਔ გያܕᐖਔӚЪ఍Ąͽ˭ಶҕ୵౅ژ გ

Αਕள૱۞჌ᙷ̈́׎Ξਕ۞ব৫ঽիҜཉᄲځ

̝Ĉ

( ˘ )ă౅ژॡҲҕ߹ณ ( Low blood flow )

Ĉ

ଂତܕજਔӚЪ఍۞ᐖਔҕგ͔΍ҕ߹Ҍ౅ژ፟

ጡĂͽซҖҕ୵౅ژćҭ૱Я٩͔ొҜܕજਔბ

۞ҕგব৫Ăጱ࡭٩͔ҕ߹̙֖Я҃யϠҲҕ߹

ณېڶĂயϠ٩פ੫ྯજன෪่ٕਕͽྵҲҕ߹

ณซҖ౅ژĂֹ౅ژ࿅඀ॡมؼܜٕ̙ԆБ౅ژ ( тဦ˘ )ĄٙͽҲҕ߹ณΞਕ΃ܑд٩͔۞Ҝཉ ܕજਔბѣব৫ঽիĄ

( ˟ )ă౅ژॡ੼ᐖਔᑅ˧ ( High venous pres- sure )

Ĉҕ୵གྷ౅ژޢĂ͔ˢߙ఍ᐖਔҕგćЯ ᐖਔҕგব৫ጱ࡭ҕ߹៭᎕Ă൑ڱึၰކࠈĂ౅

ژ፟ጡЯѩពϯᐖਔᑅ˧࿅੼ன෪Ăซ҃አࢫ౅

ژҕ߹߹ณĂ˵ົֹ౅ژ࿅඀ॡมؼܜٕ̙ԆБ

౅ژĄٙͽ౅ژॡពϯ੼ᐖਔᑅ˧Ξਕ΃ܑҕ୵ ڦˢᐖਔ۞ܕ͕ბొҜѣব৫ঽիĄ

( ˬ )ă൑ҕ߹ ( no blood flow )Ĉ൑ҕ߹ېڶ

૱ͽ൑ڱຏᛇਔજ ( pulsation )ăͪ߹ຏ ( thrill )

׶᝘̙זဢᗔࢰ ( bruit ) ֽܑனĂ༊൒౅ژॡಶ

൑ڱ٩͔΍·֖ҕ߹ ( тဦ˟ )ć˘ਠྵ૱֍۞

ଐڶĂА݈̏хд۞ҕგব৫̈́ҕংયᗟĂ൑ኢ ߏ౅ژॡயϠҲҕ߹ณٕ੼ᐖਔᑅ˧ېڶĂޢᜈ

ࡶѣҕংং̄யϠĂटٽдব৫఍யϠܡ๫Ăጱ

࡭ҕ߹ഴٕ̈႖᎕Ă҃ԛјՀкҕং׶ҕ๴Ăซ

҃யϠ გ൑ҕ߹ன෪ĄΩγĂЧ჌ࣧЯֹҕ

߹ഴၙٕயϠ࿅̂ҕংং̄˵ਕౄј გ൑ҕ

߹Ą გ൑ҕ߹఼૱ߏ౵௣ඕڍĂࢋ࿰ീঽի ҜཉͧྵӧᙱĂ఼૱ืАֹϡҕং٩ӛన౯̈́ҕ

ংொੵԫఙΝੵҕং๴યᗟޢĂѣొ̶ҕ߹̖ट ٽͽҕგᛷᇆߤ΍ࣧώব৫ҜཉĂГͽঈ஧ᕖૺ

ඈ͞ڱ఍நব৫ঽիĄ

( α )ă౅ژॡҲҕ߹ณ̈́੼ᐖਔᑅ˧ඈ஄Ъ ݭĈࡗѣˬ̶̝˘ঽଈТॡѣк఍ҕგব৫

Ă

ٕயϠॡมѣАޢѨԔĄּтĈѣֱЪ׀Ҳҕ߹

ณ׶੼ᐖਔᑅ˧ېڶćΩѣֱ˘ฟؕ੼ᐖਔᑅ˧

՟ѣ఍நĂޢᜈҕংং̄ጱ࡭൑ҕ߹ېڶĄѣֱ

ঽଈЪ׀ѣк఍Ҝཉ۞ҕგব৫ొҜĂдҕგᛷ ᇆॡពன΍Ăҭ׎АΞਕ่ͽҲҕ߹ณଐԛܑ

னćЯࠎ߹ณ̈ॡĂᑅ˧఼૱̙ົ੼Ăੵܧҕგ ব৫ޝᚑࢦćЯѩ఍ந˞Ҳ߹ณயϠ۞ҕგব৫

ਔӚЪব৫఍(቏ᐝ఍)Ą

BĈҕგᛷᇆဦϯགྷ გјݭఙޢᐖਔӚЪব৫

఍გට̂̈̏ځពԼච(቏ᐝ఍)Ą

B

A

યᗟޢĂᑕڦຍߏӎѣЪ׀ѣ׎΁Ҝཉ۞ব৫ঽ իĄ

( ̣ )ă౅ژٕ̚౅ژޢѣ͘ᓖཚ൭াېĈ˘

ਠ౵૱൴Ϡд̚δᐖਔҕგܡ๫ॡĂ׎૱Яཉˢ Чᙷጱგ͔҃੓ć̚δᐖਔҕგܡ๫ጱ࡭౅ژॡ а߹צܡĂ̙ည׹ᙝব৫ҕგــѣ׎΁઎͚ҕ

გΞ͔߹Ăซֹ҃ᐖਔᑅᆧ੼͔҃੓͘ᓖཚ൭Ą ҭ൑াې۞̚δᐖਔҕგব৫̙֭ื఍ཉ

Ą

გҕგјݭఙ۞ఙ݈໤౯Ĉ

გјݭఙ࠹၆ٺ͘ఙڼᒚ۞р఍дٺܬ ˢّྵ̈ăఙޢূ൭̈ăΞܲ঻ᐖਔҕგ̈́̚δ ᐖਔҕგ˵Ξ఍ཉඈĄ׎ఙ݈۞໤౯̍үт˭Ĉ

˘ă͕࿪ဦăҕგᑅ˧̈́ײӛېڶႾീĈ

˘ਠጱგވ౯ѣ۞͕࿪ဦăҕგᑅ˧ăײӛ ېڶ۞ႾീᆇጡืְА౯ԁĂͽүࠎঽˠېڶă ঽի఍ཉ݈ޢෞҤ׶ѣ൑׀൴াඈႾീ̝ϡĄ

˟ăঽիҜཉ۞࿰ീ̈́ᕚҜĈ

ֶፂঽΫ׶நጯᑭߤֽෞҤ࿰ീঽիΞਕҜ ཉ

Ă༊൒˵Ξͽౌ˪ઙ෹ࢰگםӄؠҜĂຐؠ ڼᒚඉர֭ͷՙؠგᐘཉˢҜཉ̝ޢĂ૟ଈ઎͘

ᓖүዋ༊ᕚҜĂ͞ܮࡍו̈́ཉˢგᐘĄ ˬăА݈ᘽۏ۞໤౯Ĉ

( ˘ )ă౫ዕᄃͤ൭ĈΞֹϡ Midazolam ٕ Fentanyl үࠎ౫ዕͤ൭̝ϡ

ćώ͕̚ϫ݈Ᏼϡ Fentanyl ࡗ 1 Ҍ 2 cc ( 50 ɢ g/cc ) ᐖਔග̟Ăͽഴ

͌ঽଈఙ̚۞൏ᇋ׶ূ൭Ą͍׎дঈ஧ᕖૺјݭ ఙॡĂΞځពഴᅅঽˠ۞ূ൭޽ᇴĄืႾീঽˠ

۞ײӛېڶĄ

( ˟ )ăԩ጖ҕ጗Ĉ࿰ഇ఍ཉ࿅඀።ॡົྵ

˳ăঽիᇴྵкٕҕং๴ྵкଈ۰Ăֹϡ u n - fractionated heparin ׶ low molecular weight heparin ͽഇ୕ࢫҲఙ̚ҕংԛј۞፟ົĂҭ̙ืՏ࣎ঽ

ּ࠰૱ఢֹϡ

Ą

( ˬ )ăҕং໘ྋ጗Ĉ၆ٺಱӣҕგҕং۞ঽ իĂֹϡҕং໘ྋ጗ߏഴ͌ҕং۞͞ڱ̝˘Ăּ

т Urokinase Ă˵ื҂ᇋ΍ҕ۞ઘүϡ

Ą

ጱგგᐘ ( sheath ) ̂̈ܜޘăཉˢ Ҝཉ̈́͞Ш۞ᏴፄĈ

˘ăጱგგᐘ̂̈׶ܜޘ۞ᏴፄĈ

( ˘ )ăგश̂̈Ĉ˘ਠᄃ გεਕ۞ࣧЯă ঽիҜཉă࿰౯Ꮾਖ਼۞ጡୠ̂̈ăڼᒚ۞ඉரᄃ ϫᇾѣᙯĄᓝּᄲځĈҋវજᐖਔ გЯҲҕ߹

ณ۞ଈ۰Ă૱ߏӚЪ఍ᐖਔბѣব৫ٙ࡭Ă׎ણ

҂გටგश˘ਠྵ̈ĂΞֹϡྵ̈ঈ஧ĂٙͽΞ ϡྵ̈۞გᐘ ( т 6 French )ĄΩγĂЯᐖਔব̈

ဦ˟Ĉ A Ĉҕგᛷᇆဦϯν݈ᓖˠ̍જᐖ გԆБܡ

๫׀ѣҕং(቏ᐝ఍)Ą

BĈҕგᛷᇆဦϯν݈ᓖˠ̍જᐖ გགྷ გј ݭ ఙ ޢ ࢦ ޙ ҕ ߹ Ă ̪ ׀ ѣ ണ ঻ ҕ ং ( ቏ ᐝ

఍)Ą

B

A

ጱ࡭۞౅ژॡᑅ˧੼ٕঽիЪ׀ҕংҕ๴Ă҂ᇋ

ֹϡ٩ӛన౯ٕጡୠॡâਠౌົᏴϡྵ̂۞გ ᐘ ( 7-8 French )Ă༊൒გᐘດ̂Ăޢᜈಶດ̙ٽ

ͤҕĄֶ࣎ˠགྷរĂ 7 French გᐘಶ֖ૉ఍ந̂

ొ̶۞ঽիĄ

( ˟ )ăგᐘܜޘĈᚑॾֽᄲĂᑕߏཉˢҕგ

۞ܜޘĂЯࠎ˘ਠ֭Ϗ૟გᐘБొܜޘཉˢҕგ

̚ ( 7 Ƃ 10 cm )Ă҃ߏ঻˘߱ܜޘдγć఺ᆃઇ

۞ϫ۞дٺѣॡࣧ౅ژࡍוҜཉᄃঽի෼ᗓѣ ࢨĂื࿰঻఍ཉ۩มĂтঈ஧۞ᕖૺඈĂ༊൒ѣ ॡࡍוҜཉᄃঽի࠹ᗓޝᅈĂੵপঅ҂ᇋγĂಶ Ξ૟გᐘБొཉˢĄ

˟ăጱგგᐘཉˢҜཉ۞ᏴፄĈ

ᐌ඾ঽի۞ΞਕҜཉ̈́Ч჌̙Т۞ڼᒚඉ ரĂົᏴؠ̙Т۞გᐘཉˢҜཉâਠͽࣧА౅

ژࡍוҜཉࠎᐹАᏴፄćЯࠎྍҜཉྵਕͅߍ౅

ژॡ۞၁ᅫ გεਕېڶĂ͞ܮޢᜈ఍நĄּ

тĈࣧ౅ژࡍוҜཉ٩͔ҕ߹ณ̙֖ĂΞਕܑϯ дҕ߹˯ഫҜཉѣব৫ঽիĂϤࣧࡍוҜཉਗ਼඾

ҕ߹͞ШཉˢგᐘĂ֭ͷื࿰঻გᐘ౤ბᄃঽի มֱధ෼ᗓĂܮਕᖎಏг෧ᕝͷڼᒚঽիĄ ˬăጱგგᐘཉˢ͞Ш۞ᏴፄĈ

( ˘ )ăგᐘ͞ШົЯ඾ঽի׶გᐘ࠹ᙯҜཉ

̈́ڼᒚඉர҃ѣ̙ٙТĂֶҕ߹͞Ш̶ࠎึ߹

( antegrade ) ׶ਗ਼߹ ( retrograde ) ͞Шć׎मள͹

ࢋдҕგᛷᇆ෧ᕝॡĂᄲځт˭Ĉ

1 ăึ߹͞ШĈϤგᐘڦडពᇆ጗ᛷᇆĂព ᇆ጗ึ߹҃˭ĂۡତΞ֍˭ഫঽիćҭგᐘ۞˯

ഫঽիΞਕЯពᇆ጗Ш˭ഫଵᗓĂ҃൑ڱពϯ΍

ѣ൑ঽիĄѩॡΞд˭ഫ͔߹ᐖਔ૟ঈ஧ᕖૺٕ

ᑅ࢝ĂТॡڦडពᇆ጗࡭ਗ਼߹ז˯ഫ఍ֽពϯѣ

൑ঽիĂಶ̙ืЯѩГཉˢΩ˘გᐘĄ

2 ăਗ਼߹͞ШĈϤგᐘڦडពᇆ጗Яҕ߹ਗ਼

߹Я৵Ăдঽի෼ᗓგᐘྵܕĂٕдҕ߹ณ̈( Ϗ

఍ཉॡ) ٕϡ˧ڦडពᇆ጗ॡĂٕధΞពϯ΍˯ഫ ঽիćҭҕ߹ณ̂ॡ ( ܡ๫̙ᚑࢦٕ఍ཉޢ )ĂϤ ٺ֝ిଵᗓពᇆ጗Ă࡭ѣॡ൑ڱෞҤ˯ഫঽիĄ ѩॡΞֹϡጱቢ૟ጱგ ( ּтĈ Judkin's right catheter ) Ҍତܕঽի఍ĂϤጱგ̰ڦडពᇆ጗ֽ

ෞҤ˯ഫঽիĄ

( ˟ )ăᖎ҃֏̝Ăგᐘ͞Шᓁߏࢋ၆඾ঽ

իĂ͞ਕ఍நঽիĂ఺ߏ౵Аࢋ҂ᇋ۞ćҌٺҕ გᛷᇆ෧ᕝ˯Ă൑ኢึ߹ٕਗ਼߹͞ШĂᖣϤঈ஧

ᕖૺăᑅ࢝ҕგ̈́ጱგ۞ֹϡ׶ᑕϡĂౌΞҹڇ ҕგᛷᇆ෧ᕝ˯۞̙֖Ą

αăӧᙱጱგგᐘ۞ཉˢĈ

( ˘ )ăҕგ̚ࡶѣҕ߹ĂдࡍוॡΞགྷϤа ҕቁᄮдҕგට̚ćҭࡶ൑ҕ߹ॡĂࢋቁᄮࡍו ˢҕგට̚Ăಶߏ˘࣎ࢦࢋ۞Վូ׶ᙯᔣĄͽ˭

೩΍࣎ˠֹϡ۞ೀ࣎͞ڱֻણ҂Ĉ

1 ăࡍוॡ͘ຏĈ͍׎૱дࡍוˠ̍ გĂ ࡍו੫ซˢॡຏזҕგܡ˧ࡎ൒гঐεĂ̙࿅఺

ื੨Ъ׎΁͞ڱГቁᄮĂಏϡѩڱ̙֭ޝΞያĄ 2 ă޽͔ጱቢ۞֕ШĈซˢ޽͔ጱቢึၰ൑

ܡ˧ͷ׶ გ۞֕Ш˘࡭ĂՀΞቁᄮдგට̚Ą 3 ă࢑ᑅ٩ӛĈѣॡֹϡ 10cc ۩੫࢑ᑅ٩ӛ

͞ёΞਕົѣֱధаҕĂ͍׎дϏԆБܡ๫۞ঽ

ּĂΞͽᑀྏѩ͞ڱĄ

4 ă͌ณពᇆ጗ീྏĈΞͽଂࡍו੫ڦड͌

ณពᇆ጗Ăֽቁᄮߏӎдҕგට̚Ăҭ͉кពᇆ

጗ѣॡົᜨ΍ҕგĂซ҃ᇆᜩҿᕝĄ

5 ăՀೱࡍוҜཉĈЯࠎંටԛјĂࡍו֎

ޘᄃҕგ֕ШඈЯ৵ĂѣॡืՀೱࡍוҜཉĂ͍

׎Ᏼፄજਔბٕያܕਔજ۞Ҝཉࡍו

ĂΞϤа ҕቁᄮĂࡍוҋ൒ྵटٽјΑĄ

გҕგјݭఙ̝఍ཉ

გҕგјݭఙٕ͘ఙ۞ϫ۞дΝੵҕგඕ ၹّត̼Ăซ҃ޭೇ׎౅ژΑਕĂᄲځт˭Ĉ

˘ăҕგјݭఙన౯ăጡୠ׶̍׍ ( тဦˬ ) ̈́

׎ԫఙ

( ˘ ) ăጱ͔ጱቢĈώ͕̚ϫֹ݈ϡ 0 . 0 3 5

Fr ă( 0.89 ୮Ѽ௖௟ ) /150 ̶̳ܜޘጱ͔ጱቢĂϤ

͟ώ Te r u m o ̳ΦϠயĂೀͼౌΞึӀ఼࿅ঽ իĄ

( ˟ )ăঈ஧ᕖૺր௚ĈᖣϤ፟ୠّ۞ᑟᑅ̈́

ᇧෘᆧϠ̰ቯٕҕংĂͽᆧΐব৫఍გට̰शĂ

҃ྋՙЯҕგব৫͔੓Ч჌ გεਕ۞યᗟćϫ

ֹ݈ϡ fox plus ( Abbott ̳ΦϠய ) ׶ ATB AD- VANCE ( COOK ̳ΦϠய ) ׌჌׹ᙝҕგ۞ঈ஧ᕖ

ૺր௚Ăᓁܜ 80 cm Ăঈ஧ܜޘࠎ 40 mm Ăঈ஧̂

ֶ̈ঽիᏴؠâਠଂ 5 Ҍ 12 mm Ăдฉᙝᐖਔ

׶ˠ̍ҕგ૱ϡ 5 Ƃ 8 mm Ă̚δᐖਔ૱ϡ 9 Ƃ 12 m m ĄҌٺᕖૺᑅ˧ᐌঽիব৫ർޘ̙̂̈҃

Тâਠ૱ϡ 4 Ҍ 20 atm Ąࡶ̪൑ڱԆБᕖૺฟ

۞͌ᇴ࿱ԩّঽիĂΞֹϡ੼ᑅᕖૺঈ஧̷ٕ౷

ঈ஧఍ந

Ą

( ˬ )ăҕგ͚ߛ ( stent )Ĉ၆ٺঈ஧ᕖૺޢа ᇅّঽիĂٕൺഇ̰ ( ˬ̰࣎͡ ) ͅᖬгГܡ๫

̈́̚δᐖਔܡ๫ҜཉĂҕგ͚ߛཉٸߏ˘ีڼᒚ ᏴፄĂ̪ื҂ᇋঽիҜཉĂ̂̈׶ܜൺ̈́ߏӎᇆ ᜩޢᜈ͘ఙඈયᗟĂᐌ඾ࡁտᏴפ۞୉ཏѣ̙Т

۞ᓜԖඕڍĂߏӎѣр఍̪൒ѣۋᛉ

Ą ( α )ăҕং٩ӛన౯̈́ҕংொੵԫఙĈ д఍ந൑ҕ߹ঽּॡĂொੵҕং૱ߏ఍ந࿅

඀۞ௐ˘ՎូĂҕংொੵѣొ̶ҕ߹ޢĂ˵̖ਕ ତᜈ෧ᕝ֭఍ந׎΁ব৫ঽիĄ

1 ă࢑ᑅ٩ӛր௚Ĉֶனѣጡୠ૟ጱ͔ጱგ ( ˘ਠϡ 6 Fr ă Judkin's right guiding catheter ) ੨

˯̏٩ 10 ୮̿ࢴៃͪ۞ 50 ୮̿੫ඌĂ૟ጱ͔ጱ გਖ਼Ҍҕგҕং఍Ăͽ࢑ᑅ٩ӛҕং

Ą

2 ă͛ᚥ൴ܑ۞٩ӛր௚నࢍĈࠎொੵҕং๴

֭ᔖҺ࿅кҕং߹Ҍ۱ҕგĂԛј۱ং๫âֱ

͛ᚥಡጱֹϡপҾనࢍ۞٩ӛր௚ֽ྿זѩϫĂ

൴ܑ׎ड़ڍព඾

Ąώ͕̚ϫ݈੫၆ᇴ჌͞ڱϒ ซҖෞҤࡁտĂഇ୕ӀϡனѣΞ଀۞ጡୠĂ൴ण ѣड़۞͞ڱֽொੵҕং׶ᔖҺ۱ং๫׀൴াĄ

˟ăјΑத̈́ҕ୵౅ژ გΑਕ۞Гள૱Ĉ

͘ఙјΑதࡗ 80-98%

Ąҭ გεਕࣧ

ώಶхдЧ჌۞ΐࢦЯ৵Ă఍ཉޢ౅ژΑਕ۞ޭ

ೇ֭൑ڱ૟఺ֱЯ৵ԆБΝੵĂּтજᐖਔӚЪ ๕υѣព඾۞ᑅ˧मхдĂౄјૻ̂۞ҕ߹኏ᑝ

׶̰ቯ۞൴ۆன෪ĂΩγҕংԛј۞યᗟඈ˘ۡ

ౌົхдĂЯѩܜᅈֽᄲ გ۞Гεਕத༊൒

ޝ੼Ą˘ѨјݭఙπӮࡗჯ޺̱࣎͡Ăࡶˬ࣎͡

̰ืઇ׌Ѩјݭఙͽ˯Ăಶޙᛉ͘ఙڼᒚ

Ą ˬăγࡊ͘ఙ̬ˢĈ

ࡶ൑ڱᖣϤҕგјݭఙඈ͞ڱޭೇ׎ҕგ౅

ژΑਕॡĂಶื҂ᇋͽγࡊ͘ఙ̬ˢ͞ё఍நĂ

ּтĂᏴፄΩ˘఍үҕგӚЪ͘ఙĄ

ҕგјݭఙ݈ޢ۞ෞҤ

ҕგܡ๫ঽի۞ෞҤĂੵ˞౵ૄώ۞ҕგᛷ ᇆᇆညγĂ׎΁ѣధк۞͞ڱϺΞϡֽෞҤߏӎ ࠎѣຍཌྷ۞ঽի҃ืү఍ཉĂ҃఍ཉ۞ϫᇾͽޭ

ೇ გ۞౅ژΑਕࠎ͹Ă̙֭҃ߏͽ "ҕგ۞ፋ ԛ" ࠎϫᇾĂΞߏ఍ཉ̙ԆБϺߏ გГεਕ۞

ࣧЯ̝˘Ăͽ˭೩ֻᇴ࣎ෞҤ͞ڱүࠎણ҂Ăᑕ ტЪᑕϡĈ

˘ăҕგგशഴ̈Ă఍ཉޢᆧΐĈڦडពᇆ

጗ॡᛷᇆࡶҕგგशͧણ҂शځពഴ̈Ă͍׎Ъ

׀ѣҕ߹߹ిၙଐԛॡĂྍঽիᑕߏѣຍཌྷ۞ব ৫ঽիĄ఍ཉޢҕგგशᑕᆧΐͷ౺ዶܡ๫̈ٺ 30% Ă̖ߏѣड़఍ཉ

Ą

˟ăҕ߹߹ిഴၙĂ఍ཉޢᆧԣĈѣຍཌྷ۞

ব৫ঽիĂ૱࡭ҕ߹߹ిតၙĂࡶ߉χពᇆ጗۞

጗ณ̈́˧྽࠹༊ĂΞϡᛷᇆૺᇴ ( frame counts )

ࢍზពᇆ጗۞ଵੵֽෞҤ̈́ؠณҕ߹ిć༊൒ૺ

ᇴ෸кಶពϯҕ߹෸ၙĄܡ๫ٕব৫ঽի఍ந ޢĂҕ߹߹ిᑕតԣĂᛷᇆॡពᇆ጗ޝԣజଵ

ੵĂϤѩ˵Ξۢ఍ཉड़ڍрᗼĄ

ˬăҕგব৫఍׌઎ᑅ˧मᆧΐĂ఍ཉޢഴ

̈Ĉҕ߹఼࿅ҕგব৫఍ॡĂҕგ۞ܡ˧ᆧΐĂ ᑅ˧मᐌ̝ᆧΐĂЯѩব৫ঽի׌ბ۞ᑅ˧मΞ

ͅߍ΍ঽի۞ব৫඀ޘĄЯࠎ გ૱ԛјҕგ ሳĂֹҕგણ҂श̙ٽෞҤĂΞᖣϤব৫఍ᑅ˧

मԼត۞ณ̼͞ڱĂֽෞҤߏӎࠎѣຍཌྷ۞ব৫ ঽիĄব৫ঽի఍நޢĂব৫఍გशត̂Ăܡ˧

ត̈Ăᑅ˧मซ҃ഴ̈Ăҕ߹ᐌ̝ᆧΐĄ αă׎΁઎͚ᐖਔ͔߹ҕგᆧΐĂ఍ཉޢഴ

ٕ͌ঐεĈܡ๫۞ҕგጱ࡭͔߹ᐖਔᑅ˧ᆧΐĂ а߹ᐖਔᑅ˧ᆧΐĂֹ׎͔ˢ׎΁ᑅ˧ྵ̈ᐖਔ ҕგ̚ĂயϠధк͔߹۞઎͚̈ҕგតځពĂ఺

˵ߏҕგব৫ٕܡ๫۞ᇈЏĄܡ๫ٕব৫ঽի఍

நޢĂЯࠎҕ߹͔߹ᑅ˧ഴ̈Ă׎΁ᚮۋّҕგ

׶઎͚ೈᒖҕგᑅ˧࠹၆ྵ੼ॡĂҋ൒ົഴٕ͌

ঐεĄ

̣ăҕ߹ຏ ( thrill ) ̈́ဢᗔࢰ ( bruit ) ഴ̈Ă఍

ཉޢ΍னٕᆧΐĈ఺׌࣎ᇈЏͅߍ˞ҕ߹ి ( ณ ) ېڶĂࡶѣҕგব৫ᇆᜩҕ߹ॡĂѩ׌ᇈЏҋ൒

ഴ̈Ąܡ๫ٕব৫ঽի఍நޢĂҕ߹ᆧΐѩᇈЏ ಶົ΍னٕᆧΐĄ

̱ăౌ˪ઙ෹ࢰگĈͽҕგব৫யϠᑅ˧म

۞៍هĂϡౌ˪ઙ͞ڱֽؠҜҕგব৫ొҜĂࠤ ҌෞҤব৫۞ᚑࢦޘĂΞүࠎঽիؠҜ׶݈ޢෞ

Ҥ၆໰۞˘჌͞ڱĄ

׀൴া̈́ఙޢڦຍְี

ᓁ൴Ϡதࡗࠎ 1.15%

Ă૱֍׀൴াт˭Ĉ

˘ăᐖਔҕგ৔ෘĈѣࡁտ௚ࢍ൴Ϡதࡗ 0.9%

âਠ̶ࠎฉᙝݭ̈́̚δݭĂฉᙝݭͧྵ

टٽϡᑅֽ࢝ͤҕĂҭЯᄃજਔ࠹ତĂѣॡЯҕ გᑅ˧̂ົౄјᚑࢦҕཚĂࠤҌටވা࣏ཏĂಶ ᅮࢋγࡊ͘ఙ̬ˢڼᒚĄ̚δݭҕგ৔ෘĂ݋Я

൑ڱͽΐᑅֽͤҕâό൴Ϡᐖਔҕგ৔ෘĂ૱

ืࢋ͘ఙ̬ˢĂ߇఍ཉ˯ื˧ՐщБͷ࠹၆ܲч

ֱĄ

˟ăጱგგᐘཉˢ఍΍ҕ̈́ҕཚ

Ĉдგᐘ ཉˢॡĂ͍׎ߏ൑ҕ߹ېڶĂЯࠎࡍוॡྵᙱቁ ᄮдҕგට̚Ăጱ࡭ٽѣ΍ҕ׶ҕཚன෪யϠĂ

ֹϡԩ጖ҕ጗׶ҕং໘ྋ጗̈́ࢦᒔҕ߹ॡĂՀٽ

൴ϠĄ

ˬăާّҕংயϠĈ̙ኢߏ͘ఙ۞࿅඀ٕߏ ޢᜈͤҕᑅ࢝࿅ޘĂౌѣΞਕԛјާّҕংĂ҃

ᇆᜩҕ߹ĂҭּҖֹϡ Heparin ٕ low molecular weight heparin ߏӎΞѣड़࿰֨ާّҕং̪ѣޞ ซ˘ՎࡁտĂ Urokinase ݋ѣಡӘពϯΞѣड़ϡ

ֽڼᒚҕং׶۱ং๫۞׀൴া

Ą

αă۱ং๫Ĉѣֱࡁտ޽΍јݭఙ࿅඀Ξਕົ

யϠ۱ং๫Ăᓂֹ̂кᇴߏ൑াېٕ̙ᚑࢦ

Ăಶ ώ͕̚ϫ݈གྷរĂ˵֭൑ঽּѣځពাې҃ᅮࢋ

ڼᒚĂٕధЯࠎҕংณ̙к̈́۱ొ၆͌ณҕং۞

࡝צّඈࣧЯĄҭ఍ந࿅඀̚Ăቁ၁ົѣҕংа

߹Ҍ۱ొଐڶâ͞ࢬԧࣇనڱԼචԫఙͽഴ͌

ҕংং๫ଐԛâ͞ࢬԧࣇ˵ϒࡁտϡЧ჌͞ڱ

ֽෞҤ׎ᓜԖ۞ࢦࢋّĄ

̣ăֹϡ౫ዕͤ൭ঽଈĂᑕ͕̈៍၅ෞҤຍ ᙊېڶĂຍᙊԆБޭೇٕछᛳౖТ˭ؕΞᗓੰĂ ͽҺ̚౉൴ϠПᐍĄ

ඕኢ

Яᑕ߾ඪˠ˾̈́౅ژ გεਕঽּ۞ᆧ ΐĂдଈ۰ѣࢨ۞ҋវҕგᇴϫ݈೩˭Ăтңͽ ҕგјݭఙޭೇ გ۞ΑਕĂ֭ᔖҺঐਈҋវ ҕგ׶ӚЪ͘ఙ۞൭ࡴĂЯѩ൴ण׶Լซҕგј ݭఙѣ׎υࢋّĂҭ୕ЧҜᗁጯАซТрࣇ̙ӊ

޽ϔ́ଣ੅఺͟ᔌࢦࢋ۞ኝᗟĄ

ણ҂͛ᚥ

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Management of Hemodialysis Access Dysfunction

Chi-Cheng Lai

, Tung-Cheng Yeh

, Chun-Yao Lin

, Chih-Yang, Hsu

, Shih-Hung Hsiao

, Guang-Yuan Mar

, and Chun-Peng Liu

As the number of patients undergoing hemodialysis in Taiwan increases, the same increment has also been observed in the incidence of hemodialysis access dysfunction and this has lead to a demonstration of signifi- cance of the role of percutaneous transluminal angioplasty (PTA) in these lesions. After a review of the present literature along with a collaboration of our experience in angioplasty, we integrated and organized present data to serve as a clinical reference for other clinicians. In this review, we introduce the topics such as the basic con- cepts on arteriovenous access, types and sites of arteriovenous access dysfunction, prediction of sites of dys- function, preparations of puncture sites, directions and position of sheaths, options of angioplastic devices, meth- ods for evaluation of lesions before and after PTA along with their related complications. We hope that more physi- cians engage in studies and attempts to alleviate pain and inconvenience of patients undergoing hemodialysis.

( J Intern Med Taiwan 2008; 19: 197-204 )

1

Cardiovascular Medical Center,

2

Division of Nephrology, Department of Internal Medicine,

Kaohsiung Veterans General Hospital