{"id":5843,"date":"2023-08-28T13:42:18","date_gmt":"2023-08-28T18:42:18","guid":{"rendered":"https:\/\/ami.advancedrenaleducation.com\/wparep\/?post_type=article&p=5843"},"modified":"2025-05-09T11:01:19","modified_gmt":"2025-05-09T16:01:19","slug":"injertos-arteriovenosos-iav-sp","status":"publish","type":"article","link":"https:\/\/ami.advancedrenaleducation.com\/wparep\/article\/injertos-arteriovenosos-iav-sp\/","title":{"rendered":"Injertos arteriovenosos (IAV)"},"content":{"rendered":"

Los injertos de puente prot\u00e9sico o IAV son conductos artificiales creados quir\u00fargicamente que conectan una arteria a una vena y se tunelizan superficialmente debajo de la piel para permitir una f\u00e1cil canulaci\u00f3n1<\/sup>. El conducto puede ser recto o en bucle y tiene un di\u00e1metro de entre 4 y 8 mm2<\/sup>. Una configuraci\u00f3n com\u00fan para IAV es el injerto de asa de antebrazo que conecta la arteria braquial y la vena cef\u00e1lica en la fosa antecubital. Generalmente, se prefiere el injerto de asa de antebrazo a una configuraci\u00f3n recta porque se cree que tiene una mejor permeabilidad2,3<\/sup>. Los IAV tambi\u00e9n se colocan con frecuencia en la parte superior del brazo desde la arteria braquial o axilar hasta la vena braquial o axilar. Los cirujanos creativos han colocado injertos en lugares tan diversos como el muslo, a trav\u00e9s del t\u00f3rax en forma de collar, asas desde la arteria axilar o subclavia hasta la vena yugular y la colocaci\u00f3n axilar-femoral1<\/sup>.<\/p>\n

Hist\u00f3ricamente, el material m\u00e1s utilizado para la construcci\u00f3n de IAV era el politetraflueileno o PTFE. Este material sint\u00e9tico se utiliz\u00f3 con preferencia a otros materiales sint\u00e9ticos o biol\u00f3gicos, en base a su disponibilidad, facilidad de implantaci\u00f3n, integridad estructural, facilidad de canulaci\u00f3n, mayor permeabilidad y menor riesgo de desintegraci\u00f3n con infecci\u00f3n3. Otros materiales org\u00e1nicos, semiorg\u00e1nicos o sint\u00e9ticos que se han utilizado para crear injertos de puentes prot\u00e9sicos incluyen vena car\u00f3tida o mesent\u00e9rica bovina, col\u00e1geno ovino con malla, vena safena hom\u00f3loga, poliuretano (PU), silicio y dacr\u00f3n3,4<\/sup>. Ninguno de estos ha mostrado una supervivencia mejorada o una mejor permeabilidad que los injertos de PTFE. Los injertos de PTFE se pueden canular t\u00edpicamente en 2-3 semanas. El injerto de compuesto\/PU tiene la ventaja de una propiedad de autosellado que le permite canularse en tan solo 24-48 horas e incluso dentro de las horas posteriores a la colocaci\u00f3n, si es necesario, para di\u00e1lisis3,5<\/sup>. Como resultado, el injerto de compuesto\/PU se puede colocar en algunos casos sin tener que usar un cat\u00e9ter para iniciar la terapia de di\u00e1lisis.<\/p>\n

Las tasas de fracaso primario pueden variar significativamente entre IAV y f\u00edstula arteriovenosa (FAV)2,5,6<\/sup>. El fallo primario se define como un acceso que nunca proporcion\u00f3 una hemodi\u00e1lisis fiable2<\/sup>. Aunque las tasas de falla primaria se correlacionan con factores demogr\u00e1ficos, comorbilidad y posici\u00f3n anat\u00f3mica, el porcentaje de falla primaria de IAV de aproximadamente el 15% es considerablemente m\u00e1s bajo que el l\u00edmite superior aproximado del porcentaje de falla primaria del 40% para la FAV2,5,6<\/sup>. Sin embargo, las IAV tienen serias desventajas a largo plazo que incluyen trombosis e infecciones m\u00e1s frecuentes que las FAV. La trombosis es la principal causa de fracaso del injerto y representa aproximadamente el 80% de los casos5<\/sup>. Un metan\u00e1lisis que abarc\u00f3 1849 FAV y 1245 IAV extra\u00eddos de 34 estudios demostr\u00f3 que la FAV ten\u00eda una permeabilidad (primaria) sin asistencia significativamente mejor (72% a los seis meses, 51% a los dieciocho meses) que IAV (58% a los seis meses, 33% a los dieciocho meses). La permeabilidad asistida (secundaria) tambi\u00e9n fue superior en la FAV (86% a los seis meses, 77% a los dieciocho meses) que en la IAV (76% a los seis meses, 55% a los dieciocho meses) 7<\/sup>. Los injertos de PTFE tienen una tasa de infecci\u00f3n significativamente mayor que la de AVF1<\/sup> y se asocian con un riesgo de muerte un 41% mayor en los pacientes diab\u00e9ticos prevalentes8<\/sup>. La canulaci\u00f3n repetida de IAV en combinaci\u00f3n con estenosis proximal puede resultar en el desarrollo de pseudoaneurismas que pueden tener fugas o infectarse.<\/p>\n

Estas complicadas y costosas complicaciones han relegado cada vez m\u00e1s a IAV a seleccionar pacientes que son malos candidatos para una FAV y han puesto \u00e9nfasis en la vigilancia del acceso y el desarrollo de nuevas tecnolog\u00edas. Un desarrollo reciente fusiona la tecnolog\u00eda de injertos y cat\u00e9teres. La sangre arterial se deriva de la arteria braquial a trav\u00e9s de un segmento de injerto superficial y posteriormente al sistema venoso central, a trav\u00e9s de un segmento similar a un cat\u00e9ter que ingresa a la vena yugular interna con descarga en la aur\u00edcula derecha9,10<\/sup>. Aunque es demasiado pronto para evaluar su tasa de complicaciones y permeabilidad a largo plazo, los resultados preliminares con esta tecnolog\u00eda se han mostrado prometedores.<\/p>\n

<\/div>
<\/div>\n

Referencias:<\/h4>\n
    \n
  1. Huber TS, Carter JW, Carter R, Seeger JM. Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: A systematic review. J Vasc Surg<\/em> 38:1005-1011, 2003<\/li>\n
  2. Oliver MJ. Chronic hemodialysis vascular access: Types and placement. Retrieved from www.uptodate.com<\/a> on January 14, 2008<\/li>\n
  3. KDOQI Clinical Practice Guidelines for Vascular Access. Am J Kidney Dis<\/em> 48(Suppl 1):S176-S273, 2006<\/li>\n
  4. Berardinelli L, Vegeto A. Lessons from 494 permanent accesses in 348 haemodialysis patients older than 65years of age:29 years of experience. Nephrol Dial Transplant<\/em> 13(Suppl 7):S73-S77, 1998<\/li>\n
  5. Maya ID and Allon M. Core curriculum in nephrology vascular access: Core curriculum 2008. Am J Kidney<\/em> Dis<\/em> 51:702-708, 2008<\/li>\n
  6. Polo JR, Tejedor A, Polo J, Sanabia J, Calleja J, G\u00f3mez F. Long-term follow-up of 6-8mm brachioaxillary polytetrafluorethylene grafts for hemodialysis. Artif Organs<\/em> 19:1181-1184, 1995<\/li>\n
  7. Sands JJ. Vascular access 2007. Minerva Urol Nefrol<\/em> 59:237-249, 2007<\/li>\n
  8. Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int<\/em> 60:1443-1451, 2001<\/li>\n
  9. Katzman HE. The HeROTM<\/sup> vascular access device: A new long-term dialysis access option for access challenged patients. 36th Annual Symposium for the Society for Clinical Vascular Surgery, Las Vegas, NV, March 2008<\/li>\n
  10. Hemosphere Product Information<\/em>. Available from: www.hemosphere.net.<\/li>\n<\/ol>\n

    P\/N 101041-01S Rev A 02\/2023<\/p>\n

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