心电图引导下非漂浮电极床旁心内起搏与起搏复律的临床应用

目的　探讨心电图引导下非漂浮电极床旁心内起搏与起搏复律的效果。方法　用改良的Seldinger方法穿刺左、右锁骨下静脉或右股静脉 ,置入 5F远端塑成直径为 10cmC型非漂浮起搏电极 ,进行床旁起搏和起搏复律。结果　床旁心脏起搏及起搏复律共 10 9例。进行床旁紧急心内起搏或保护性起搏 86例。其中 31例后来在植入埋藏式起搏器时 ,经X光透视证实临床起搏电极在心尖部 30例 ,在流出道 1例。 1例因心脏停搏 ,从右股静脉置入起搏电极进行起搏成功。进行床旁心内起搏复律 2 3例 ,其中室上性心动过速 17例 ,室性心动过速 6例。所有病例起搏及起搏复律成功。结论　心电图引导下非漂浮电极床旁心内起搏与起搏复律具有快速、简便、安全、有效和起搏稳定的优点 ,值得临床推广应用。     

普通电极经右颈内静脉床旁临时起搏12例

目的探讨使用普通电极经右颈内静脉在床旁快速、安全安置心脏临时起搏器方法。方法对12例患者在体表心电图指导下,经右颈内静脉途径,结合QRS波群在V1及Ⅱ导联主波方向及起搏阈值对临时起搏电极进行定位。结果临时起搏电极一次送入到位,成功率100%,无穿刺失败、血气胸、栓塞、心包填塞、心律失常等并发症。平均手术时间(11.1±3.4)m in;平均起搏阈值(0.9±0.2)V;临时起搏器保留时间(4.0±2.24)d。结论在体表心电图指导下,经右颈内静脉,使用普通电极床旁安置心脏临时起搏器,安全、快捷、有效。     

床旁球囊漂浮电极起搏在心脏术后缓慢性心律失常中应用

目的评估心脏外科术后缓慢性心律失常行床旁球囊漂浮电极导管紧急心脏起搏的可行性和有效性。方法心脏外科术后并发缓慢性心律失常患者21例,均给予漂浮电极导管临时起搏治疗,观察临时起搏手术入路、手术时间、电极导管放置部位及起搏阈值,评估治疗成功率和安全性。结果本组起搏器电极安置经右侧锁骨下静脉15例,经右侧颈内静脉6例;手术时间5-12min;电极导管置入右心室心尖部18例,右心室流出道3例;起搏阈值〈1.0mV;床旁球囊漂浮电极起搏治疗成功率100%,发生导管移位、感知起搏不良各2例,无严重并发症发生。结论床旁球囊漂浮电极起搏操作简单,用于治疗心脏术后缓慢性心律失常安全、可行,疗效确切。     

经皮血管穿刺插管单人操作技术及其临床应用

目的：探讨血管穿刺置管单人操作技术及临床价值。方法：采用单人操作、局麻下经皮穿刺股血管和置管的方法，进行血管内诊疗操作569例次，其中经股动脉穿刺置管561例次、股静脉8例次。结果：单人法经皮股血管穿刺、置管需要应用导管鞘，技术成功率达100％，其中一次穿刺成功率为98．07％，因该侧髂动脉极度扭曲或狭窄等而改插对侧者占1．93％。主要血管穿刺置管并发症包括髂动脉夹层2例（0．35％）、穿刺部位局部皮下少量渗血12例（2．11％）。结论：单人操作法股血管穿刺置管术安全、有效、极具实用价值。     

Very low complication rates with a manual, nurse-led protocol for femoral sheath removal following coronary angiography.

OBJECTIVE: We aimed to provide contemporary information on the complication rates after femoral artery sheath removal using a specific, nurse-led protocol, which is universally applicable and can be readily adopted by other units. BACKGROUND: Previous studies have reported a wide range of complication rates following femoral sheath removal after cardiac catheterisation. A variety of methods has been used for access site management and therefore it is difficult to compare complication rates between units. METHOD: Data were collected prospectively on patients undergoing diagnostic coronary angiography via the transfemoral route in a single centre. Sheaths were removed by trained cardiac nurses with direct application of manual pressure over the femoral artery in accordance with a specific protocol. We also investigated the same endpoints in patients who received an arteriotomy closure device (ACD) during the study period. RESULTS: None of the 516 patients who had their femoral sheaths removed with manual compression developed a major haematoma or complication. A minor haematoma developed in 1.6% of patients. Similarly, none of the 484 patients who received an ACD developed a major haematoma and 0.8% developed a minor haematoma. Mean arterial blood pressures were higher in patients that developed a haematoma. CONCLUSION: Our study shows that a manual, nurse-led system of femoral sheath removal following diagnostic coronary angiography is very safe and effective and that this remains a viable method of access site management.     

A new temporary atrial pacing catheter inserted percutaneously into the subclavian vein without fluoroscopy: a preliminary report

A permanently formed "J" shaped 6F bipolar electrode catheter specially designed to facilitate temporary atrial pacing was constructed and tested in 15 patients. A pair of rigid, "orienting wings" was fixed to the catheter 28 cm from a large spherical tip electrode to establish directional orientation of the "J" while in the right atrium. Rapid percutaneous introduction is possible with a peel-away sheath via the subclavian vein. Positioning in the right atrium can be accomplished without fluoroscopy. The catheter could be inserted and positioned against the right atrial wall generally in less than three minutes and required little or no additional manipulation for capture. No instance of loss of capture was documented during subsequent continuous monitoring as the catheter remained in place from one to thirteen days. Ease of insertion of this electrode catheter, as well as stability, provided an effective method for temporary atrial pacing without fluoroscopy. This novel catheter design warrants testing in a large patient population by others and could have a potential application to other types of catheter needs.     

Pulmonary artery catheter placement with two-dimensional echocardiographic guidance: a technique applicable in critically ill neonates

In nine critically ill neonates with persistent fetal circulation, femoral venous catheters were inserted at the bedside to initiate treatment and provide venous access. After femoral vein puncture or cutdown, a 5-F sheath was placed in the inferior vena cava through the femoral vein. With use of two-dimensional echocardiographic guidance, a 5-F balloon angiographic catheter was advanced through the inferior vena cava into the right atrium and subsequently manipulated through the tricuspid valve and into the main pulmonary artery. No major complications were attributable to the procedure. When performed by a pediatric cardiologist, this technique is as safe as umbilical catheter placement.     

Yoked catheter positioning in transseptal endocardial left ventricular lead placement

Background: Transseptal (TS) endocardial left ventricular (LV) lead placement may be needed for cardiac resynchronization therapy, and often requires crossing a preformed puncture in the interatrial septum (IAS) with a lead delivery catheter inserted from an upper body vein (UBV), which can be difficult or impossible to achieve by manipulation from its hub. Consequently, yoked superior approach TS catheterization was developed. Methods: A loop snare housed in a deflectable delivery catheter inserted from an UBV captured the guide wire extending out of a TS sheath inserted from the right femoral vein into the inferior vena cava (IVC). After the IAS had been punctured, the guide wire was left in the left atrium (LA) and the TS sheath withdrawn into the IVC. The delivery catheter was advanced over the snare onto the guide wire, and then pushed by the TS sheath across the IAS puncture into the LA. The snare released the guide wire and was withdrawn. The delivery catheter was manipulated to point toward the LV for lead deployment. If that was not possible, the IAS puncture was dilated with an electrophysiology (EP) catheter housed in a second TS sheath alongside the first one. The EP catheter was captured by the snare and manipulated across the IAS puncture into the LV. The delivery catheter was advanced over the EP catheter directly into the LV. Results: The technique was tried in four patients with challenging anatomy and allowed successful endocardial LV lead placement in all. Conclusions: Yoked catheter positioning facilitates TS endocardial LV lead placement. (PACE 2011; 34:884–893)     

Effectiveness of mechanical compression devices in attaining hemostasis after femoral sheath removal.

BACKGROUND: Cardiac interventions are widely accepted as a practical treatment option for coronary artery disease. However, few changes have occurred in the techniques used for percutaneous arterial cannulation and for attaining hemostasis after cardiac interventions. To date, researchers have focused on techniques to achieve optimal hemostasis at the time of removal of the arterial catheter and to minimize the impact and complications of arterial puncture. OBJECTIVE: To summarize the best available evidence on the effectiveness of mechanical compression devices used to obtain hemostasis following femoral sheath removal after cardiac interventional procedures. METHOD: An attempt was made to detect both published and unpublished reports of research evaluations of mechanical compression techniques used to attain hemostasis after femoral sheath removal. Methodological quality was assessed by using predesigned criteria. Data were extracted from information on randomized controlled trials and were statistically combined in meta-analysis where possible. Evidence was also synthesized by using narrative summaries. RESULTS: Twelve studies met the inclusion criteria; however, only 3 were included in the meta-analysis. The results of meta-analysis indicated that the mechanical compression technique was the most effective for preventing formation of hematomas. The prevalence of bleeding did not differ significantly for different methods of compression. CONCLUSION: A gap exists in the literature on quality randomized controlled trials of various devices used to attain hemostasis after femoral sheath removal.     

危重婴幼儿股静脉留置耐高压双腔PICC的应用研究

目的探讨危重婴幼儿股静脉留置耐高压双腔PICC导管的临床效果及并发症的发生率,为危重婴幼儿选取双腔导管建立有效的静脉通路提供临床依据。方法便利抽样选取我院PICU 2014年1月至2015年9月住院的PICC置管的危重婴幼儿140例,其中100例接受单腔PICC股静脉置管为对照组,40例接受双腔Power PICC股静脉置管为观察组,比较两组患儿的置管效果及导管留置期间并发症的发生率。结果观察组的出血量为(3.57±0.5)分高于对照组,差异有统计学意义(P0.05);两组间操作时间、留置时间以及导管堵塞、导管相关血栓、导管相关感染、误入动脉的发生率等方面比较,差异均无统计学意义(均P0.05)。结论股静脉留置耐高压双腔PICC导管安全可行,适用于危重婴幼儿使用。     

A Randomized Trial Assessing the Value of Ultrasound-Guided Puncture of the Femoral Artery for Interventional Investigations

Using a prospectively collected database of patients undergoing diagnostic or therapeutic angiography via transfemoral access, we sought to determine those patients who may benefit from ultrasound-guided puncture of the femoral artery. One-hundred-twelve patients with normal anticoagulation parameters were randomized in two groups. Fifty-six patients received ultrasound-guided puncture of the femoral artery, 56 patients underwent traditional palpation-guided vessel cannulation. Parameters assessed included procedure-time, number of attempts for successful puncture, intensity of the arterial pulse, previous ipsilateral punctures, history and risk factors of arteriosclerosis and leg circumference at the site of puncture. The data was analyzed by using outcome measures according to evidence-based medicine criteria. Only in patients with weak arterial pulse and thoses with a leg circumference of 60 cm or greater ultrasound guidance significantly decreased the number of attempts needed as well as the time for successful arterial puncture. In both patient subgroups, the number needed to treat (NNT) was 2, the absolute benefit increase (ABI) was 50 and 57%, respectively. In contrast, time for vessel cannulation was increased in patients with strong arterial pulse using ultrasound guidance. No significant differences were found with respect to diminished complications neither comparing both patient groups nor comparing risk subgroups. In conclusion ultrasound guidance for femoral artery access is recommended only in patients with a weak or absent arterial pulse and obese patients.     

Transradial versus transfemoral approach for cerebral angiography: A prospective comparison

ObjectivesTo evaluate the feasibility, efficiency, and safety of the transradial approach (TRA) for cerebral angiography versus the transfemoral approach (TFA) in patients.MethodsIn this trial, 2314 patients underwent cerebral angiography, with 1085 patients undergoing the procedure via radial access and 1229 via transfemoral access. The arterial puncture time, operation success rate, oppression time on puncture points, local vascular complication incidence (including bleeding, hematoma, and pseudoaneurysm), deep venous thrombosis of lower limbs (DVT), and bradycardia/hypotension were observed and compared between the two groups.ResultsOf the patients who underwent cerebral angiography via radial access, the procedure was successful in 1070 patients; compared with 1219 patients with transfemoral access, there was no significant difference (P > 0.05) in the success rate or the arterial puncture time. Radial access patients were less likely to present with oppression time on puncture points, local vascular complications, DVT, and bradycardia/hypotension compared with femoral access patients.ConclusionsFor patients undergoing cerebral angiography, radial and femoral approaches are both safe and effective. However, the lower rate of local vascular complications may be a reason to use the radial approach.     

Ambulation 1 hour after diagnostic cardiac catheterization: a prospective study of 1009 procedures

OBJECTIVE: To study the safety of a protocol that allows ambulation 1 hour after diagnostic cardiac catheterization with a transfemoral approach using a 5F catheter system. PATIENTS AND METHODS: A total of 1005 consecutive patients (1009 procedures) undergoing outpatient diagnostic cardiac catheterization with a transfemoral approach using a 5F catheter system at the Mayo Clinic in Rochester, Minn, were included in this study from January 1, 2004, to August 31, 2005. All patients underwent standard manual compression to achieve hemostasis and were ambulated after 1 hour of bed rest. RESULTS: The mean age of the patients was 64.5 years, and 62% were male. Minor vascular complications occurred in 33 procedures (3.3%), Including 14 hematomas (1.4%) less than 4 cm and 19 cases of rebleeding (1.9%) that required repeated manual compression. Only 1 patient (0.1%) had a hematoma greater than 4 cm. No patient had a major complication, such as surgical repair, red blood cell transfusion, retroperitoneal bleeding, formation of an arteriovenous fistula or pseudoaneurysm, arterial occlusion, or an infection. CONCLUSIONS: Ambulation 1 hour after diagnostic cardiac catheterization with a transfemoral approach using a 5F catheter system is safe and associated with low rates of vascular complications. This strategy may improve patient comfort, reduce resource utilization, and be preferable to use of vascular closure devices.     

几种深静脉置管方式的比较

目的：比较不同部位、不同方式深静脉置管的优缺点。方法：根据患者病情及能否配合操作,分别采用锁骨下静脉穿刺置管术、颈内静脉穿刺置管术、股静脉穿刺置管术并将三种术式的优缺点及所致的并发症进行比较。结果：276例深静脉置管术中（1）经锁骨下置管者220例,占79．71％。其中术后感染2例,占0．91％;误入动脉2例,占0．91％;纵膈血肿1例,占0．45％;（2）经颈内静脉置管者35例,占12．68％。其中术后感染3例,占1．40％;误入动脉者1例,占2．86％;气胸1例,占2．86％;术后导管脱落者1例,占2．86％;（3）经股静脉置管者21例,占7．60％。其中术后感染5例,占23．8％;误入动脉者1例,占4．76％。结论：几种深静脉穿刺术中,尤以经锁骨下穿刺者并发症相对较少,是深静脉置管方式中的首选。     

经桡动脉和股动脉两种途径行冠状动脉造影后即刻介入治疗的比较

目的比较经桡动脉和股动脉两种穿刺途径行冠状动脉造影术后即刻冠状动脉介入治疗的成功率、并发症以及近期疗效。方法选择因冠心病心绞痛入院行择期冠状动脉造影,且结果显示明确的冠状动脉病变,并选择即刻行冠状动脉介入治疗者。其中经桡动脉穿刺途径即桡动脉组134例,经股动脉穿刺途径即股动脉组427例。分析和比较两组靶血管病变特征、介入治疗成功率、疗效和并发症,并随访术后1月内主要心血管事件的发生率。结果桡动脉组男性患者和吸烟者所占的比例明显高于股动脉组(P<0.01)。桡动脉组PCI成功率为93.3%,与股动脉组(94.8%)相比差异无统计学意义。而桡动脉组病变血管的血运重建率为81.8%,低于股动脉组(93.4%),P<0.01。而且桡动脉组成功PCI者中慢性闭塞病变所占的比例(9.5%)也明显低于股动脉组(17.3%),P<0.05。但桡动脉组术后与穿刺有关的总的并发症发生率明显低于股动脉组,且术后平均卧床时间也明显短于股动脉组(P<0.01)。术后1个月期间主要心血管事件两组之间无明显差异。结论与经股动脉穿刺相比,经桡动脉穿刺冠状动脉造影后即刻行介入治疗的成功率和近期临床疗效基本相同,但术后与穿刺有关的并发症较少。对于复杂病变选择经股动脉PCI可能优于经桡动脉途径。     

皮下隧道股静脉穿刺置管用于重型颅脑损伤患者长期保持静脉通道的探讨

目的 :总结重型颅脑损伤患者长期静脉输液药物治疗、静脉高营养预防导管相关性感染的经验。方法 :随机将 137例重型颅脑损伤所致昏迷患者分为两组 ,实验组 (6 9例 )用经皮下隧道股静脉穿刺置管法建立静脉通道 ;对照组 (6 8例 )用传统股静脉穿刺置管法。两组均经此通道常规输液及补充静脉高营养素。穿刺点每周换药 2次 ,细菌培养 1次 ,发热患者行血培养 ,拔管时取导管尖端培养。观察导管阻塞、脱落、导管相关性感染等并发症以及留管时间等。结果 :实验组留管时间长于对照组 ,导管脱落及相关性感染、穿刺点感染等并发症的发生少于对照组 ,差异有显著性 (P <0 0 5或 0 0 1)。导管阻塞的发生率两组无差异 (P >0 0 5 )。结论 :经皮下隧道股静脉穿刺置管能有效降低导管相关性感染的发生率 ,延长留管时间 ,适合需长时间保留静脉通道的患者     

Dissection of the subclavian artery with mediastinal haemorrhage – an unusual complication of central venous catheterisation

Arterial cannulation is a recognised complication of attempted central venous cannulation. Arterial cannulation may cause haemorrhage, thrombosis, pseudoaneurysm formation, mycotic and true aneurysm formation and air embolism. We describe a case of subclavian artery dissection during attempted subclavian vein catheter placement resulting in a mediastinal haematoma and cardiac tamponade contributing to death. Inadvertent arterial cannulation may be difficult to diagnose in the hypoxic, hypotensive patient. The complications of arterial cannulation during attempted subclavian central venous catheter placement may be minimised by careful positioning, meticulous attention to technique and avoiding the use of large bore central venous catheters in unstable patients.     

Accidental mediastinal entry via left internal jugular vein cannylation

Two cases are reported in which mediastinal penetration by a pulmonary artery catheter and a temporary venous pacemaker wire occurred following cannulation of the left internal jugular vein and placement of an indwelling venous introducer sheath. The anatomy of the left internal jugular vein and possible mechanisms of accidental mediastinal penetration with this approach are discussed. Extreme caution must be exercised when using the left internal jugular venous access route and an indwelling venous introducer sheath.     

经桡动脉冠状动脉造影120例分析

目的 探讨经桡动脉冠脉造影术的临床应用价值。方法 120例病人术前均接受Allen＇s试验检查,选择右侧桡动脉作为穿刺插管的部位,依个人习惯我们使用5F桡动脉造影导管。结果 造影成功113例,成功率为94．2％,7例失败（为血管严重痉挛而无法进入导管）,局部血肿3例（2．5％）,2例（1．7％）术后发生桡动脉闭塞,无出血、夹层等血管并发症发生。结论 经桡动脉行冠脉造影与经股动脉同样安全、可行,经桡动脉的穿刺局部并发症少,病人更乐意接受。     

三种静脉插管行血液透析的临床比较

目的;比较股静脉,锁骨下静脉和颈内静脉插管留置双腔导管在血液透析中的应用。方法：１０６例尿毒症患者,４０例行股静脉插管,３６例行锁骨下静脉插管,３０例行颈内静脉插管进行血液透析（血透）。观察三种不同插管途径的血流速度,评估透析的充分程度,血尿素氮重复循环率,导管留置时间以及与导管相关的并发症。