Effect of local papaverine on arteriovenous fistula maturation in patients with end-stage renal disease

Abstract Background: Arteriovenous fistula (AVF) maturation is one of the main concerns in patients with end-stage renal disease (ESRD) and finding a strategy for increasing success rate and accelerating fistula maturation is valuable. The aim of this study was to evaluate the effects of papaverine injection on AVF maturation and success rate. Method: This study was a randomized clinical trial that involved 110 patients with ESRD that were referred for AVF construction. Patients were allocated in papaverine group and control group with block randomization according to age and sex. In the case group, papaverine (0.1 or 0.2 cc) was injected locally within the subadventitia of artery and vein after proximal and distal control during AVF construction and in the control group, AVF construction was done routinely without papaverine injection. Results: Maturation time in case and control groups was 37.94 ± 11.49 and 44.23 ± 9.57 days, respectively (p=0.004). Hematoma was not seen in the case group but occurred in one patient in the control group. One patient of the case group developed venous hypertension. Four functional fistulas, 1 (1.8%) in the case group and 3 (5.5%) in the control group, failed to mature (p=0.618). Maturation rate did not differ between the two groups statistically (p=0.101). Conclusion: Local papaverine injection increased vessel diameter and blood flow, increasing shearing stress in both arterial and venous segment of recently created AVF. In this way, papaverine probably can decrease AVF maturation time without an increase in complications.背景：动静脉内瘘（arteriovenous fistula, AVF）成熟是终末期肾病（end-stage renal disease, ESRD）患者临床关注的核心问题之一，探寻提升内瘘手术成功率、加速内瘘成熟的策略具有重要临床价值。本研究旨在评估局部注射罂粟碱（papaverine）对AVF成熟及手术成功率的影响。 方法：本研究为一项随机临床试验（randomized clinical trial），共纳入110例拟行动静脉内瘘构建术的终末期肾病患者。采用基于年龄和性别的区组随机化（block randomization）方案，将患者分为罂粟碱组与对照组。手术过程中，罂粟碱组患者在完成动静脉近远端阻断后，于动脉及静脉的外膜下层（subadventitia）局部注射0.1或0.2 cc罂粟碱；对照组则采用常规手术流程，未给予罂粟碱注射。 结果：罂粟碱组与对照组的内瘘成熟时间分别为37.94±11.49天与44.23±9.57天，组间差异具有统计学意义（p=0.004）。对照组有1例患者出现血肿（hematoma），罂粟碱组未发生血肿相关不良事件；罂粟碱组有1例患者出现静脉高压（venous hypertension）。共有4条具备功能的内瘘未实现成熟，其中罂粟碱组1例（1.8%），对照组3例（5.5%），组间差异无统计学意义（p=0.618）；两组内瘘成熟率比较，差异亦无统计学意义（p=0.101）。 结论：局部注射罂粟碱可增大新建AVF的动静脉管径、提升血流量，进而增加动静脉段的剪切应力。据此推测，罂粟碱或可在不增加并发症发生率的前提下缩短AVF成熟时间。