研究背景與目的：
台灣的末期腎臟疾病（ESRD, end stage renal disease）不論就其發生率或是盛行率而言皆是名列「世界第一」， 其中90 %的患者選擇血液透析治療，而血管通路（vascular access）對於這些病患是非常重要的第二條生命線。台灣的全民健康保險每年花費龐大的醫療費用在血液透析的相關治療上，維持好這些病患的血管通路便可以減少相關醫療的耗用。
本研究以南部某區域教學醫院為例，當其接受血液透析的末期腎臟疾病患者之動靜脈瘻管狹窄或阻塞時，分析比較其接受動靜脈瘻管重建手術或者是經皮穿腔血管成形術（PTA）的長期通暢時間以及其醫療花費組成，以提供醫師日後對於類似病患選擇治療時之參考依據。
研究材料與方法：
本研究設計採用回溯性病歷回顧及統計。收集南部某區域教學醫院自2008/1/1至2013/12/31為止，6年來因為進行血液透析的動靜脈瘻管產生狹窄或阻塞性疾病而接受動靜脈瘻管重建手術或者是PTA的末期腎臟疾病患者資料，共計252人、384人次，並追蹤至2014/8/31為止，分別記錄其人口學特質、共病症、接受治療的手術方式、治療時的動靜脈瘻管之種類及其部位、相關醫療資源耗用等，利用SPSS 20統計軟體進行分析。統計分析包括描述性統計及迴歸分析。
研究結果：
在人口學特質與共病症中，重建手術相較於PTA除男性比例較高（53.5% vs 42.5%）外，其他的變項在統計上並無明顯差異。由單因子變異數分析與多因子變異數分析各個變項後發現，不同的手術介入治療方式與動靜脈瘻管種類對於治療之暢通時間與醫療費用有明顯的影響。其中動靜脈瘻管重建手術之平均暢通時間優於PTA（951.8天 vs 474.9天），平均每日血管通路維持費用少於PTA（19.7健保點數vs 43.3健保點數），且衛材費用比例亦低於PTA（26.9% vs 43.6%）。自體動靜脈瘻管利用PTA治療之平均暢通時間少於重建手術（528.2天 vs 1011.2天），平均每日血管通路維持費多於重建手術（38.8健保點數vs 17.1健保點數），且衛材費用比例亦高於重建手術（44.1% vs 25.1%）。人工動靜脈瘻管利用PTA治療之平均暢通時間同樣少於重建手術（344.6天 vs 750.4天），平均每日血管通路維持費高於重建手術（60.1健保點數vs 31.6健保點數），且衛材費用比例亦高於重建手術（42.6% vs 31.6%）。
結論與建議：
治療動靜脈瘻管狹窄阻塞性疾病時，不論何種動靜脈瘻管或瘻管所處部位為何，利用動靜脈瘻管重建手術來進行治療不僅有較佳的暢通時間，每日的血管通路維持費也比較低。另外，即使在總醫療費用上動靜脈瘻管重建手術與PTA沒有統計上的意義，但在花費的組合上，動靜脈瘻管重建手術的服務費用佔有較高的百分比，且有統計學上的意義。綜合以上的研究結果，不論就減少醫療成本的支出上，或者就增加醫院的獲利觀點而言，動靜脈瘻管重建手術還是比較佳的治療選項。

Background and purposes:
The end stage renal disease (ESRD) in Taiwan, either the incidence or prevalence are all ranked as "world first", also topped the 2011's tenth leading cause of death in Taiwan. In Taiwan, 90% of the ESRD patient received hemodialysis and vascular access is a very important second lifeline for these patients. Taiwan's National Health Insurance (NHI) spends huge medical expenses to treat the hemodialysis associated problems, so maintain good vascular access to these patients can reduce the associated medical consumption.
This study we chose a south regional teaching hospital, for example, when the hemodialysis patients with end-stage renal disease suffered from arteriovenous fistula（AVF） stenosis or occlusion. When the patients received AVF reconstruction or percutaneous transluminal angioplasty (PTA ), we analyse and compare the time of patency and consisting of medical costs. Thus we can provide physician a reference of treatment to similar diseases.
Materials and Methods:
In this study, we use retrospective chart review design and statistics. We collect the ESRD patient’s general data, when they received AVF reconstruction or PTA to treat AVF stenosis or occlusion in a south regional teaching hospital from 2008/1/1 to 2013/12/31. A total of 252 peoples received 384 therapies was included in this study and was tracked up to 2014/8/31. We recorded their demographic characteristics, comorbidities, type of interventional therapy, kind and location of arteriovenous fistula, and other related medical resource consumption, and use SPSS 20 statistical software for analysis. Statistical analyses include descriptive statistics and regression analysis.
Results:
In the patient’s demographic characteristics and comorbidities, reconstruction as compared with PTA except higher proportion of males (53.5% vs 42.5%) , other variables are not statistically significant. After analysis with ANOVA and multi-factor analysis of various variables, different types of interventional therapy and different kinds of AVF has significant impact in the time of patency and the medical expenses. The average time of patency of AVF reconstruction was superior to PTA (951.8 vs 474.9 days), the average daily vascular access maintenance fee was lower than PTA (19.7 vs 43.3 NHI points), and the proportion of the cost of Eisai also was below the PTA (26.9% vs 43.6%). In autogenous AVF, the average time of patency of PTA was below to reconstruction (528.2 vs 1011.2 days), the average daily vascular access maintenance fee was higher than reconstruction (38.8 vs 17.1 NHI points), and the proportion of the cost of Eisai also was higher than reconstruction (44.1% vs 25.1%). In artificial AVF, the average time of patency of PTA also was below to reconstruction (344.6 vs 750.4 days), the average daily vascular access maintenance fee was higher than reconstruction (60.1 vs 31.6 NHI points), and the proportion of the cost of Eisai also was higher than reconstruction (42.6% vs 31.6%).
Conclusions and recommendations:
When treating AVF stenosis or occlusion, regardless which kind of AVF or which position of AVF, using AVF reconstruction not only has better time of patency, the average daily maintenance of vascular access fee also is relatively low. In addition, even in the total medical expenses AVF reconstruction and PTA has no statistical significance, but in reconstruction the service charges occupy a higher percentage of the cost , and there is statistically significant. Based on the above findings, for the aim not only to reduce the health care costs, but also to increase the hospital's profit, AVF reconstruction is still relatively a better treatment options.

口試委員會論文審定書 i
誌謝 ii
摘要 iii
Abstract v
目錄 vii
圖次 ix
表次 x
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的與問題 8
第二章 文獻探討 9
第一節 末期腎臟疾病的診斷與治療 9
第二節 末期腎臟疾病透析的種類 12
第三節 永久性血管通路之選擇原則 16
第四節 永久性血管通路之評估 21
第五節 動靜脈瘻管之狹窄阻塞與治療 23
第五節 治療方式之趨勢 26
第三章 研究方法 32
第一節 研究設計與研究架構 32
第二節 研究對象與資料來源 34
第三節 研究變項操作型定義 38
第四節 資料處理與統計分析 41
第四章 研究結果 42
第一節 描述性統計分析 42
第二節 單因子相關因素分析 49
第三節 多重因子相關因素分析 59
第五章 討論與建議 82
第一節 研究討論與建議 82
第二節 研究貢獻 88
第三節 研究限制與未來研究 90
參考文獻 91
一、中文文獻 91
二、英文文獻 91
三、網站資訊 93
附錄 94
人體試驗委員會核准函 94

一、中文文獻
王水深、詹志洋、吳毅暉等編著 (2011) ‧血液透析血管通路的建立與合併症的治療‧靜脈疾病與血管通路 （pp. 37-78）‧台北市：合記圖書。
台灣腎臟醫學會編著 (2005) ‧血管通路併發症之處理‧台灣血液透析臨床診療指引（pp.24-34）‧台北市：台灣腎臟醫學會。
范思善 (2012) ‧長期血液透析患者血管通路阻塞後接受血管重建手術或經皮血管內成型術治療之比較研究(未出版碩士論文) ‧高雄市：高雄醫學大學健康科學院。
洪燕妮、吳肖琪、吳義勇、柯博仁 (2009) ‧採用動靜脈瘻管或人工血管之血液透析病人住院醫療利用之分析‧臺灣公共衛生雜誌，28(2)，144-154。
賴麗英 (2010) ‧血液透析病患動靜脈瘻管使用年限與PTA治療之分析‧腎臟與透析，22(3)，210-215。
二、英文文獻
Ayez N, Fioole B, Aarts RA, et al. (2011). Secondary interventions in patients with autologous arteriovenous fistulas strongly improve patency rates. Journal of Vascular Surgery, 54(4), 1095–1099.
Bethesda, MD (2008). U.S. Renal Data System, USRDS 2008 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.
Brescia MJ, Cimino JE, Appel K, et al. (1966). Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. The New England Journal of Medicine, 275, 1089–1092.
Georgiadis GS, Lazarides MK, Lambidis CD, et al. (2005). Use of short PTFE segments (<6 cm) compares favorably with pure autologous repair in failing or thrombosed native arteriovenous fistulas. Journal of Vascular Surgery, 41(1), 76-81.
Levowitz BS, Flores L, Dunn I, et al. (1976). Prosthetic arteriovenous fistula for vascular access in hemodialysis. The American Journal of Surgery, 132(3), 368–372.
Lipari G, Tessitore N, Poli A, et al. (2007). Outcomes of surgical revision of stenosed and thrombosed forearm arteriovenous fistulae for haemodialysis. Nephrology Dialysis Transplantation, 22, 2605-2612.
Long B, Brichart N, Lermusiaux P, et al. (2011). Management of perianastomotic stenosis of direct wrist autogenous radial-cephalic arteriovenous accesses for dialysis. Journal of Vascular Surgery, 53(1), 108–114.
Mallik M, Sivaprakasam R, Pettigrew GJ, et al. (2011). Operative salvage of radiocephalic arteriovenous fistulas by formation of a proximal neoanastomosis. Journal of Vascular Surgery, 54(1), 168–173.
National Kidney Foundation (2006). DOQI Clinical practice guidelines for vascular access: Updates (2006). American Journal of Kidney Diseases, 148, 188-217.
Tessitore N, Mansueto G, Bedogna V, et al. (2003). A prospective controlled trial on effect of percutaneous transluminal angioplasty on functioning arteriovenous fistulae survival. Journal of the American Society of Nephrology, 14, 1623–1627.
Tessitore N, Mansueto G, Lipari G, et al. (2006). Endovascular versus surgical preemptive repair of forearm arteriovenous fistula juxta-anastomotic stenosis: Analysis of data collected prospectively from 1999 to 2004. Clinical Journal of the American Society of Nephrology, 1, 448-454.
三、網站資訊
行政院衛生署 (2013)‧民國100年國人十大死因及透析治療簡介‧2013.4.21摘自http://www.doh.gov. tw。
中央健保局 (2013)‧101年第3季門診透析總額報告‧2013.4.21摘自http//:www.nhi.gov. tw。