经腋静脉和锁骨下静脉途径植入或拔除心内膜电极的对比研究

目的 探讨经皮腋静脉穿刺植入与拔除心内膜电极导线的可行性与安全性.方法 538例具有起搏器或植入式心律转复除颤器（implantable cardioverter defibrillator,ICD）植入指征的患者分为实验组与对照组,分别经腋静脉途径和经锁骨下静脉途径植入心内膜电极导线.对比分析两种途径植入心内膜电极导线的穿刺成功率和并发症.对同期入院因起搏器囊袋感染拔除心内膜电极导线的47例患者和81例起搏器升级患者的手术情况进行回顾分析,对比不同植入途径心内膜电极导线拔除成功率和增加心内膜电极导线的成功率.结果 实验组与对照组穿刺成功率及并发症发生率比较,差异无统计学意义98.5％（268/272） vs.98.9％（263/266）,P＞0.05; 13.2％（36/272） vs.13.9％ （37/266）,P＞0.05].其中,对照组发生锁骨下静脉挤压综合征1例,气胸5例,实验组无一例发生气胸和锁骨下静脉挤压综合征.经腋静脉途径植入心内膜电极导线的拔除成功率及新增电极导线的植入成功率均高于经锁骨下静脉途径,差异有统计学意义94.4％（17/18）vs.86.2％（25/29）,P＜0.05；97.2％（35/36）vs.88.9％（40/45）,P＜0.05].结论 经腋静脉途径植入心内膜电极导线安全可行,并为可能的电极导线拔除和起搏器升级增加心内膜电极导线预留更大的解剖空间,值得在临床推广应用.

A comparative study on implantation and extraction of endocardial electrode via axillary vein and subclavian vein approaches

Objectives To compare the safety and efficacy of axillary vein and subclavian vein approaches for implantation and extraction of endocardial electrode. Methods A total of 538 patients were randomized to undergo placement of pacemaker or implantable defibrillator leads via axillary vein approach （experiment group） or subclavian vein approach （control group）. Success rate of lead placement and incidence of complications were compared between the two groups. During the same period, pacemakers were upgraded in 81 patients and the leads were extracted from 47 patients due to pacemaker pocket infection. Initial success rate and success rate of implantation of new electrode were compared between the different approaches. Results Lead placement was accomplished in 268 of the 272 patients （98.5%） randomized to the axillary vein approach as compared to 263 of 266 patients （98.9%） using the subclavian vein approach, and it had no obvious difference between the two groups （P〉0.05）. There was no significant difference in the incidence of complications between experiment group and control group 13.2% （36/272） vs. 13.9% （37/266）, P〉0.05 ]. There was 1 patient with subclavian vein crush syndrome and 5 patients with pneumothorax in control group, but no patients with such complications in experiment group. Initial success rate and success rate of implantation of new electrode were significantly higher via axillary vein approach than via subclavian vein approach 94.4% （17/18） vs. 86.2% （25/29）, P〈0.05; 97.2% （35/36） vs. 88.9% （40/45）, P〈0.051. Conclusions Axillary vein approach is safe and feasible for placement of endocardial leads, especially for patients with electrodes to be removed or addedendocardial electrode for cardiac pacemaker upgrade.