基于CT评估解剖压迫性左头臂静脉狭窄的解剖学因素及临床意义

目的 探讨解剖压迫性左头臂静脉狭窄的解剖学因素及临床意义。方法 回顾性研究。纳入重庆医科大学附属第一医院2018年1月—2019年9月有左上肢功能性血透通路(自体动静脉内瘘或人工血管动静脉内瘘)且行胸部增强CT扫描的血液透析患者107例作为观察组,2019年7—9月行胸部增强CT扫描的非血透患者758例作为对照组。观测指标:左头臂静脉最小前后径(D1)、胸骨与主动脉弓(或头臂干)之间的最短前后距离(D2)、胸廓前后内径(D3)。分析:(1)D1、D2、D3之间关系;(2)D1、D2与身高、体质量、年龄、性别、高血压病史的关系;(3)左上肢功能性血透通路内瘘存续时间对D1、D2的影响;(4)D1≤2 mm患者的情况。结果 观察组患者较对照组年龄更大、高血压病史者更多,差异均有统计学意义(P值均＜0.01);性别、身高、体质量组间比较差异均无统计学意义(P值均＞0.05)。(1)观察组D1大于对照组,分别为(8.513±3.337)mm、(7.812±3.176)mm,差异有统计学意义(P＜0.05);两组D2比较差异无统计学意义(P＞0.05);观察组、对照组患者的D1与D2均呈正态分布、线性相关(r=0.663、0.694,P值均＜0.01),与D3均没有明显的线性关系。(2)身高、体质量与D1、D2均无明显的线性关系(P值均＞0.05)。男性的D1、D2均较女性大:观察组的D2以及对照组的D1、D2,男女差异均有统计学意义(t=3.323、2.048、5.721, P值均＜0.01)。对照组患者的D1、D2随着年龄增高而减小,差异均有统计学意义(F=14.025、11.822, P值均＜0.01)。(3)患者左上肢功能性血透通路内瘘存续的时间与D1、D2均无线性关系(r=0.471、0.223, P值均＞0.05)。(4)D1≤2 mm的患者在两组中比例相当,观察组2.8%(3/107)、对照组3.6%(27/758):观察组3例有左上肢功能性血透通路透析患者均未报告左上肢肿胀症状;对照组中有3例患者在经左侧置入导管后出现不同程度的左上肢肿胀症状,其中2例被诊断为深静脉血栓形成。结论 左头臂静脉最小前后径与同层面胸骨与主动脉弓(或头臂干)之间的最短距离密切相关,解剖压迫性左头臂静脉狭窄可能增加左上肢功能性血透通路建立后出现左上肢水肿以及静脉治疗导管置入后深静脉血栓形成的风险。

The anatomic factors and the clinical significance of left innominate vein stenosis due to anatomic compression on CT

Objective This study aimed to evaluate the anatomic factors and the clinical significance of left innominate vein(LIV) stenosis due to anatomic compression in the population detected by CT scan.Methods A retrospective study was conducted. A total of 107 hemodialysis patients with left upper limb functional hemodialysis access (i.e., arteriovenous fistula or arteriovenous graft) and chest enhanced CT obtained at the First Affiliated Hospital of Chongqing Medical University from January 2018 to September 2019 were enrolled as the observation group. Another 758 non-hemodialysis patients with chest enhanced CT obtained between July and September 2019 were enrolled as the control group. The observation indices were as follows: minimum anteroposterior diameter of the left brachiocephalic vein (D1), shortest anteroposterior distance between the sternum and aortic arch (or brachiocephalic trunk) (D2), and anteroposterior inner diameter of thoracic cage (D3). In this work: (1)the relationships among D1, D2, and D3 were analyzed; (2) the relationships between D1 and D2 and height, body weight, age, sex, and history of hypertension were determined; (3) the influence of the duration of functional hemodialysis access on D1 and D2 was explored; and (4) to analyzed the patients with D1≤2 mm.Results Compared with patients in the control group, those in the observation group were older and more likely to have a history of hypertension (all P values＜0.01). No significant difference in terms of gender, height, and body weight (all P values＞0.05) was observed among the groups. (1) D1 in the observation group ([8.513±3.337] mm) was greater than that in the control group ([7.812±3.176] mm), and the difference between groups was statistically significant (P＜0.05). D2 comparison showed no significant difference between the two groups (P＞0.05). D1 and D2 in the observation and control groups presented normal distributions and significant linear correlations (r=0.663, 0.694; all P values＜0.01), and no significant linear correlation with D3 was observed. (2) Height and body weight were not significantly related to D1 or D2 (P＞0.05). D1 and D2 in males were higher than those in females. D2 of the observation group and D1,D2 of the control group were compared between males and females, and the differences were statistically significant (t=3.323, 2.048, 5.721; all P values＜0.01). D1 and D2 in the control group decreased with age and history of hypertension, and differences observed were statistically significant (F=14.025, 11.822; all P values＜0.01). (3) D1 and D2 were correlated with the duration of functional hemodialysis access (r= 0.471, 0.223; all P values＞0.05). (4) The proportion of patients with D1 ≤ 2 mm was similar between the two groups (observation group, 2.8%[3/107]; control group, 3.6%[27/758]). Three patients in the observation group with left upper limb functional hemodialysis access did not report symptoms of left upper limb swelling. Three patients in the control group developed varying degrees of left upper extremity swelling after catheter placement through the left side, and two were diagnosed with deep vein thrombosis.Conclusions The minimum LIV diameter is closely related to the shortest distance between the sternum and aortic arch/brachial trunk. Anatomical compression LIV stenosis could increase the risk of left upper limb swelling after functional left hemodialysis access and promote deep venous thrombosis following catheter implantation from the left side.