中国血液净化

中国血液净化 ›› 2018, Vol. 17 ›› Issue (07): 476-480.doi: 10.3969/j.issn.1671-4091.2018.07.011

• 血管通路 • 上一篇    下一篇

血液透析患者中心静脉狭窄的治疗及报销方式对治疗方法选择的影响

王自强1,王雅静1,赵淑丽1,付立平2,杜书同1   

  1. 沧州市人民医院1. 肾内科 2.介入科
  • 收稿日期:2018-01-15 修回日期:2018-04-26 出版日期:2018-07-12 发布日期:2018-07-12
  • 通讯作者: 杜书同 346240010@qq.com E-mail:346240010@qq.com

Treatment of central venous stenosis in hemodialysis patients and the effect of reimbursement on the selection of treatment mothod

  • Received:2018-01-15 Revised:2018-04-26 Online:2018-07-12 Published:2018-07-12

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摘要： 【摘要】目的探讨血液透析患者中心静脉狭窄治疗(central vein stenosis，CVS)的临床效果、治疗费用、对通路血管资源的节省与保护，并依据当地患者报销方式的不同，初步探讨报销方式对治疗方法选择的影响。方法以2013 年1 月～2016 年10 月期间在沧州市人民医院首次确诊中心静脉狭窄的血液透析患者为研究对象，病变侧均伴有通畅的动静脉内瘘，临床综合评估，分别予经皮腔内球囊扩张术(percutaneous transluminal angioplasty，PTA)、支架置入术(percutaneous transluminal stenting，PTS)、选择合适血管重建通路3 种方案治疗，记录不同治疗方案的临床效果，并进行3 个月、6 个月、12 个月通畅率的随访，记录不同治疗方案的住院时间、总住院费用、报销方式及报销后患者自付费用，同时记录3 种治疗方法对患者血管资源的使用情况。结果共有27 例患者纳入本研究，男12 例，女15 例，96.30%存在中心静脉置管史，其中12 例行单纯PTA 治疗，4 例行PTS 治疗，11 例选择合适血管重建通路。①从通畅率分析，PTA、PTS 3、6、12 个月初级通畅率分别为91.67%、58.33%、41.67%和100%、75%、50%；次级通畅率为100.00%、83.33%、58.33%和100.00%、100.00%、75.00%；从再次通路干预时间分析，PTA、PTS、重建通路分别为(6.36±2.69)月、(9.00±4.24)月、(1.73±0.26)月，重建通路者均因应用动静脉内瘘后拔除导管进行住院干预。②从住院时间、总住院费用及报销后患者自付费用分析，血管腔内治疗(PTA 及PTS)者与重建血管通路者相比，因治疗后不影响血管通路的使用，故住院时间较短[(6.58±0.67)天、(9.00±0.82) 天、(11.45±1.75)天]，差异存在统计学意义(t=-8.657，P＜0.001；t=-3.675，P=0.003)，其总治疗费用高[(21788.16±1246.29)元、(33853.50±1524.99)元、(12966.36±902.44)元]，差异存在统计学意义(t=19.557，P＜0.001；t=25.800，P＜0.001)，但PTA 及重建血管通路者相比，其自付部分费用相当[(5056.36±1795.27)元比(4510.09±916.26)元]，差异无统计学意义(t=0.930，P=0.366)。③从通路资源的节省及保护方面来看，PTA、PTS 治疗者医源性干预仅涉及1 处血管资源，重建血管通路者涉及4 处血管资源。④因医保报销比例差异，报销比例高者，在治疗方式的选择上多倾向于PTA 或PTS 治疗
(72.73%、100.00%、33.33%)，而报销比例低者则倾向于选择合适的血管重新建立动静脉内瘘。结论从临床效果、治疗费用、通路血管资源的节省与保护方面综合分析，介入治疗具有明显的优势，其中以单纯PTA 治疗临床效价最佳，报销方式影响患者对治疗方式的选择，随着医保报销比例的提高，腔内治疗仍是CVS治疗的首选方法。

关键词: 血液透析, 中心静脉狭窄, 经皮血管内治疗, 治疗花费, 报销方式

Abstract: 【Abstract】Objective We investigated the clinical effect, medical expenses and protection of vascular resources in the treatment of central venous stenosis in maintenance hemodialysis (MHD) patients. We also explored the effect of reimbursement ratio by medical insurance on the choice of treatment methods. Method The MHD patients with central venous stenosis first diagnosed in the period from Jan. 2013 to Oct. 2016 were recruited in this study. The lesion side was accompanied by an arteriovenous fistula. They were treated with percutaneous transluminal angioplasty (PTA), percutaneous transluminal stenting (PTS) or pathway reconstruction. They were followed up for 3, 6 and 12 months. Hospitalization duration, total expenses, the payment part by patients, treatment methods, and the use of blood vessel resources were recorded. Results A to-tal of 27 patients (12 males and 15 females) were enrolled in this study. A history of central venous catheterization was found in 96.30% of patients. PTA, PTS and pathway reconstruction were adopted in 12, 4 and 11 patients, respectively. (a) After PTA for 3, 6 and 12 months, the primary patency rates were 91.67%, 58.33% and 41.67%, respectively, and the secondary patency rates were 100%, 83.33% and 58.33%, respectively. After PTS for 3, 6 and 12 months, the primary patency rates were 100.00%, 75.00% and 50.00%, respectively, and the secondary patency rates were 100.00%, 100.00% and 75.00%, respectively. PTA, PTS or pathway reconstruction had to be conducted after central venous catheterization for 6.36±2.69 months, 9.00±4.24 months and 1.73±0.26 months, respectively. Patients treated with pathway reconstruction were hospitalized after removal of the catheters. (b) Hospitalization duration was shorter in patients with PTA and PTS (for PTA, 6.58±0.67 vs. 11.45±1.75 days, t=-8.657, P＜0.001; for PTS, 9.00±0.82 vs. 11.45±1.75 days, t=-3.675, P=0.003). However, the medical expenses for PT and PTS were higher than those of pathway reconstruction (compared to PTA, 21788.16±1246.29 vs. 12966.36±902.44 Yuan, t=19.557, P＜0.001; compared to PTS, 33853.50±1524.99 vs. 12966.36±902.44 Yuan; t=25.800, P＜0.001). The payment part by patients was similar in patients treated with PTA and those with pathway reconstruction 5056.36±1795.27 vs. 4510.09±916.26 Yuan, t=0.930, P=0.366). (c) PTA and PTS had the advantage of vascular resource preservation and protection, and only one blood vessel was used for PTA and PTS. In contrast, 4 blood vessels had to be used for pathway reconstruction. (d) Patients with higher payment ratio by medical insurance tended to choose PTA or PTS (72.73%,100.00% vs. 33.33%), while those with lower payment ratio by medical insurance chose pathway reconstruction. Conclusions Endovascular treatment had the advantages of better effects, lower expenses and preservation of blood vessel resources, especially the endovascular treatment of PTA. The payment ratio by medical insurance affected the treatment method. With the increase of reimbursement ratio by medical insurance, endovascular treatment is the first choice for the treatment of central venous stenosis.

Key words: Hemodialysis, Central venous stenosis, Percutaneous endovascular treatment, Treatment expense, Reimbursement way