覆膜支架植入术治疗短期复发性中心静脉狭窄的临床疗效观察(附3例病例报告)

正中心静脉狭窄(central venous stenosis,CVS)是维持性血液透析患者的严重并发症。目前CVS的首选治疗为经皮腔内血管成形术(percutaneous transluminal angioplasty,PTA)及血管腔内支架植入术(percutaneous transluminal stent,PTS)。本文报告3例覆膜支架植入术治疗短期复发性中心静脉狭窄临床疗效观察。     

超声引导下动静脉内瘘狭窄经皮腔内球囊扩张血管成形术治疗的应用分析

目的:探讨超声引导下经皮腔内血管成形术(PTA)在动静脉内瘘狭窄疾病治疗中的应用价值。方法:选取36例行PTA治疗动静脉内瘘狭窄的血液透析患者,于PTA术前、术后分别测量患者的狭窄处内径、峰值流速和肱动脉血流量;手术后采用CTA对治疗效果进行评价。结果:36例患者中,超声共发现50处外周血管狭窄,超声引导下经皮腔内血管成形术前,狭窄处内径、峰值流速和肱动脉流量相对于术后,差异(P<0.05),有统计学意义。结论:超声引导下经皮腔内血管成形术治疗动静脉内瘘狭窄,创伤比较小、疗效比较好、手术后患者恢复较快、在操作上也安全简便,建议临床治疗中推广应用。     

经狭窄或闭塞的中心静脉置入长期透析导管的临床研究

目的探讨血管资源已耗竭的血液透析患者永久性血管通路的建立方法。方法 6例无法建立动静脉内瘘并有多次多部位中心静脉导管留置史的维持性血液透析患者,经血管彩超及CT血管造影(CT angiography,CTA)证实存在多处中心静脉狭窄或闭塞,对其狭窄或闭塞的头臂静脉行经皮腔内球囊扩张血管成形术(percutaneous transluminal angioplasty,PTA),然后经颈内静脉途径置入长期中心静脉导管。结果术后应用导管透析,1例患者第2次透析时血流量仅达180ml/min,调整导管位置后血流量达到250ml/min以上,其余患者血流量均在250ml/min以上,随访2～6个月,所有患者均未出现导管功能不良及感染。结论对于血管资源耗竭的患者,通过介入治疗开通狭窄或闭塞的中心静脉留置长期透析导管,是一个安全有效的建立永久性血管通路的方法。     

超声引导下经皮腔内血管成形术治疗动静脉内瘘狭窄的应用价值

目的探讨超声引导下经皮腔内血管成形术(PTA)治疗动静脉内瘘狭窄的应用价值。方法 18例血液透析患者均行超声引导下PTA治疗动静脉内瘘狭窄,分别于PTA术前、术后测量其狭窄处内径、峰值流速及肱动脉血流量;术后行CTA评价治疗效果。结果 18例患者超声共发现25处外周血管狭窄。PTA术前狭窄处内径、峰值流速及肱动脉流量与术后比较,差异均有统计学意义(均P0.05)。术后CTA显示2例患者各遗留1处中心静脉狭窄。结论超声引导下PTA治疗动静脉内瘘狭窄创伤小、术后恢复快、疗效好、操作简便,可作为临床治疗的首选方法。     

自体动静脉内瘘失功后的血管通路选择

动静脉内瘘失功是血液透析患者血管通路常见的并发症。一旦动静脉内瘘失功,将面临进一步的血管通路选择问题。目前有8种技术可以解决自体动静脉内瘘失功后的血管通路问题,即经皮腔内血管成形术、静脉内膜增生物剥离/内瘘重建、远离狭窄部位的内瘘重建、重新建立自体内瘘(导管过渡)、移植物内瘘、中心静脉导管、手术切开取栓和内瘘血管搭桥。原则上能修复的内瘘尽最大可能修复,以保护血管资源,提高自体动静脉内瘘使用率。综合考虑,应优先选择手术修复,其次是经皮腔内血管成形术。其他的选择应根据患者的具体情况而定。     

血透患者内瘘阻塞后的处理方法

目的：探讨维持性血液透析患者内瘘阻塞后的处理方法。方法：血管通路急性血栓形成者采用局部药物溶栓和经皮腔内取检地，。血秋通路狭窄伴或不伴血栓形成者采用自体血管、人造移植血管和长期预内静脉托管重建。结果：10例血透患者12次发生血管通路急性血栓，3次经皮腔内取栓，9次局部尿激酶溶栓成功；13例26次发生血管通路部分或严重狭窄，其中8次伴有血栓形成。20例采用自体血管，4次人造移植血管和2次长期颈内静脉插管术成功。结论：对于于无血管狭窄的急性血栓形成，患者无活动性出血或高危出血倾向，局部尿激酶溶栓疗效较好，无出血、肺栓塞等并发症，值得临床试用，对于自体血管条件差或糖尿病肾病患者可直接选用人造移植血管或长期颈内静脉置管建立血管通路。     

腔内血管成形及支架植入术治疗缺血性脑血管疾病的并发症观察及护理

动脉粥样硬化引起的颈动脉狭窄是短暂性脑缺血发作(TIA)和脑梗死的主要原因之一,其造成的高致残率和死亡率严重威胁患者的生命与生存质量。所以近年来在开展颈动脉内膜剥脱术的同时,应用支架行血管内成形技术治疗颈动脉狭窄也已取得长足进步。经皮腔内血管成形及支架植入术(percutaneous transluminal angioplasty and stent- ing,PTAS)可通过解除颈部血管狭窄而治疗缺血性     

超声引导下经皮腔内血管成形术在血液透析患者动静脉内瘘狭窄中的应用

  目的  探讨维持血液透析患者自体动静脉内瘘狭窄行经皮腔内血管成形术的应用。  方法  对2018年1月~2019年12月在本院进行血液透析并发动静脉内瘘狭窄的40例患者的临床资料进行回顾性分析,所有患者均在术前采用超声评估血管,术中采用超声指导经皮腔内血管成形术治疗,统计手术技术成功率、临床成功率、并发症发生情况,比较手术前后患者的血流指标。  结果  介入超声可清晰显示狭窄部位,引导内瘘狭窄行球囊扩张手术进程。经皮腔内血管成形术后彩超显示40例患者血管狭窄及血栓消失,治疗技术成功率100%,临床成功率100%。仅2例患者出现穿刺点皮下轻度血肿,所有患者均无严重并发症发生。术后动静脉内瘘狭窄处内径、透析血流量、内瘘血流量均较术前明显增加（P < 0.05）。  结论  超声引导下内瘘狭窄行腔内血管成形术具有较高的成功率及开通率,可作为一种安全有效的引导方法,具有一定的临床应用价值。      

NKF-K/DOQI血管通路的临床实践指南第五部分并发症的处理:治疗并发症的合适措施

血管通路并发症的管理需要肾病医生、肾病护士、血管介入专家和外科医生的共同努力.管理的目的是延长血管通路使用寿命. 指南19 自体或血管移植物动脉-静脉内瘘不伴血栓形成的狭窄的治疗 狭窄的治疗 发生于血管移植物或自体AV内瘘的狭窄(静脉流出或动脉流入),如果内瘘的内径狭窄大于50%,并且有下列临床和生理异常,应当进行经皮腔内成型术,或请血管外科处理(证据):①血管通路此前发生过血栓;②透析时,静脉压力明显升高;③再循环测定明显异常;④体格检查异常;⑤无法解释的透析剂量下降;⑥血管通路血流量下降.     

经皮血管腔内成形术治疗自体动静脉内瘘狭窄的成功率及手术后1年内通畅率的影响因素

正自体动静脉内瘘(arteriovenous fistula,AVF)是维持性血液透析患者首选的血管通路~([1])。由于血流动力学发生明显改变,以及反复穿刺操作、压迫等影响,AVF可能会发生不同程度狭窄,导致AVF功能丧失。经皮血管腔内成形术(percutaneous transluminal angioplasty,PTA)是近年来被应用于临床治疗血管狭窄的一种新技术,逐渐成为AVF狭窄的一线治疗方法。本文旨在分析经皮腔内血管成形术治疗AVF狭窄的成功率及1年内通畅率的影响因素。     

CTA对诊断颈内静脉留置临时导管后功能异常的研究

目的 观察颈内静脉临时导管不同留置时间所引起的深静脉狭窄、闭塞情况。方法 因需解决血管通路问题来我院就诊的患者48例,按照留置导管时间不同分为3组：小于1月组、1～3月组、大于3月组,行CTA检查,观察深静脉情况,同时解决血管通路问题。结果 3组深静脉不同程度狭窄或闭塞发生率分别为75.0%、87.5%、100%,狭窄或闭塞涉及颈内静脉、头臂静脉、上腔静脉,部分患者血管通路耗竭。结论 临时导管留置时间大于1个月,血管狭窄率很高,减少留置导管,尽量缩短留置时间。     

The nature of a relationship of nitric oxide with angiotensin-converting enzyme and malonic dialdehyde in patients with atherogenic stenosis of the internal carotid artery

In patients with stenosis of the internal carotid artery (ICA), a relationship was studied between the level of nitric oxide (NO) and the activity of angiotensin-conversing enzyme (ACE) and malonic dialdehyde (MDA) in the blood serum taken from: 1) the cubital vein an hour before carotid endarterectomy; 2) ICA before surgery; 3) the internal jugular vein before surgery; 4) ICA 5 min after surgery; 5) the internal jugular vein 5 min after surgery; 6) the cubital vein an hour following surgery. There was a direct correlation between the level of NO and the activity of ACE and an inverse correlation between the content of NO and MDA in the sera taken from the cubital, internal jugular vein, and ICA before and after endarterectomy. There were significant increases in the level of NO, in the activity of ACE, and in the content of MDA and total cholesterol in the serum taken from the cubital vein before carotid endarterectomy, which is indicative of significant oxidative stress and the necessity of its pathogenetic correction.     

Needle directed re-entry to cross a subclavian occlusion following failed microdissection

Patients with existing internal cardioverter defibrillators (ICDs) often require upgrading to a biventricular ICD for treatment of congestive heart failure. Placement of a left ventricular (LV) lead can be technically challenging in the best of circumstances. A subclavian vein stenosis or occlusion related to previously placed leads adds a major obstacle to a successful implant. We report a technique to implant an LV lead from the same side as the existing ICD system despite failed microdissection of a complete occlusion of the subclavian vein.     

Opening an occluded subclavian vein with a screw-like flexible hollow guide-wire and venoplasty

Patients with existing internal cardioverter defibrillators (ICDs) often require upgrading to a biventricular ICD for treatment of congestive heart failure (CHF). Placement of a left ventricular (LV) lead can be technically challenging in the best of circumstances. A subclavian vein stenosis or occlusion related to previously placed leads adds a major obstacle to a successful implant. We report a technique of implanting an LV lead from the same side as the existing ICD system despite complete occlusion of the subclavian vein.     

Ultrasound‐guided subclavian venous catheterisation – is this the way forward? A narrative review

Central venous catheterisation is a commonly performed procedure in anaesthesia, critical care, acute and emergency medicine. Traditionally, subclavian venous catheterisation has been performed using the landmark technique and because of the complications associated with this technique, it is not commonly performed in the United Kingdom – where the accepted practice is ultrasound‐guided internal jugular vein catheterisation. Subclavian vein catheterisation offers particular advantages over the internal jugular and femoral vein sites such as reduced rates of line‐related sepsis, improved patient comfort and swifter access in trauma situations where the internal jugular vein may not be easily accessible. There is a growing body of evidence to suggest a potential emerging role for ultrasound‐guided subclavian vein catheterisation. Barriers to this approach include many physicians still believing that the clavicle obscures imaging of the vein. In this article, we review the evidence supporting ultrasound‐guided subclavian vein catheterisation and ask the question whether, in view of it potential advantages, it could be the way forward?     

门静脉瘤栓注射胶体_(32)磷酸铬的可行性研究

目的 :通过动物实验探讨超声导向门静脉瘤栓穿刺注射胶体32磷酸铬治疗门静脉瘤栓的可行性。方法 :分别将胶体32磷酸铬或生理盐水注入新西兰白兔门静脉左支及其邻近肝实质内 ,观察实验前后肝功能、外周血象及肝脏病理改变、32磷在体内的分布 ,了解门静脉有无狭窄。结果 :胶体32磷酸铬注入门静脉或肝实质后主要分布于肝内 ,未见门静脉狭窄 ,实验前后外周血象无显著变化 ,肝功能呈一过性升高 ,肝脏病理检查肝组织无明显坏死。结论 :超声导向门静脉瘤栓穿刺注射胶体32磷酸铬行内放疗具有可行性     

Color Doppler sonographic finding of retrograde jugular venous flow as a sign of innominate vein occlusion

Occlusion or stenosis of the superior vena cava, the innominate vein, or both is an important clinical problem that requires prompt diagnosis. To confirm a suspected occlusion, imaging studies revealing the obstruction and the presence of collateral venous routes are needed. Color Doppler sonography (CDUS) is widely used to evaluate suspected venous thrombosis and collateral pathways. We present the CDUS findings in 2 cases of innominate vein occlusion. In case 1, CDUS of the neck and left upper arm, which harbored a permanent hemodialysis access, showed engorged veins in the upper arm, a patent dialysis access, and some collateral veins in the axilla. The subclavian and internal jugular veins were patent, but the flow in the left internal jugular vein was reversed. The left innominate vein was occluded. In case 2, CDUS of the upper arms showed that the veins, the dialysis access in the left upper arm, and the subclavian and jugular veins were patent, but the flow in the left internal jugular vein and in the right subclavian vein was reversed. Collateral veins were seen in the right axillary region. Both innominate veins were occluded. The resulting collateral pathways, ie, retrograde flow in the ipsilateral jugular vein crossing to the contralateral jugular vein through dural sinuses, were confirmed by venography in both cases.     

Ultrasound‐guided central venous catheterization via internal jugular vein in a patient with subcutaneous neck emphysema: A case report

In patients with subcutaneous neck emphysema, ultrasound images of the internal jugular vein are unclear due to air bubbles. Central venous catheterization can be safely achieved by pushing the accumulated air laterally using an ultrasound probe.     

Pulmonary venous thrombosis and infarction complicating pulmonary venous stenosis following radiofrequency ablation

Pulmonary vein stenosis is a recently described complication of radiofrequency ablation. We report a patient who experienced thrombosis of the lingular vein and pulmonary infarction resulting from mild single-vessel pulmonary vein stenosis. This report extends available experience with complications of radiofrequency ablation, by demonstrating pulmonary venous thrombosis as a complication of relatively minor (approximately 50% luminal narrowing) stenosis of a single pulmonary vein, despite the fact that the patient was taking an anticoagulant. .     

肿胀手综合征介入治疗及复发分析

目的 探讨血液透析患者肿胀手综合征的发病特点、介入治疗方法和肿胀手复发影响因素.方法 88位肿胀手患者,按肿胀手在治疗后于观察期限内是否复发分为未复发组和复发组.采用介入下造影方式明确中心静脉病变位置,球囊扩张或植入支架治疗.考察透析患者置管史与中心静脉病变的关系,观察治疗方式和治疗后复发情况.结果 88位患者共行116例次介入检查治疗,15人因导丝无法通过或采用其他手术方式,3人未见中心静脉异常,其余70人中心静脉经过球囊扩张或支架植入后即刻开放;50位患者有同侧颈内静脉置管史,肿胀手症状出现距离内瘘手术时长26.4±32.5月,中心静脉病变的位置多位于锁骨下静脉和头臂静脉.经介入治疗后,观察期内23例患者35次肿胀手复发,再次复发距离上次治疗时间6.9±4.9月,复发组与未复发组一般资料上相比差异无统计学意义（P＞0.05）.虽然治疗上选择球囊扩张还是支架植入差别亦无统计学意义,但复发组支架植入的比例相对更高.结论 血液透析患者由于中心静脉置管、动静脉内瘘术后血流动力学改变等原因,导致中心静脉狭窄或闭塞,引起肿胀手综合征.球囊或支架植入治疗后,肿胀手综合征仍有较高的复发率,支架植入治疗者复发率可能更高.