尿毒症患者动静脉内瘘术前超声评估及标记的价值

目的探讨终末期肾病血液透析患者建立动静脉内瘘术前彩色多普勒超声评估及定位对提高造瘘手术成功率的价值。方法纳入肾脏内科2012年1月-7月尿毒症终末期患者25例,均为多次造瘘失败或为临床建立动静脉造瘘较为困难的患者,术前超声行上肢动静脉及双侧大隐静脉评估,重点观察肱动脉、桡动脉、头静脉、贵要静脉及大隐静脉,寻找肘部及上臂段有无合适搭桥的血管,测量其管径并体表定位。结果14例术前多次造瘘失败患者,9例行再造瘘＋自体大隐静脉移植术,2例行人工血管置人术,1例行左上肢人工血管取栓＋动静脉内瘘成型术,2例放弃手术;11例术前未行动静脉造瘘的患者2例行人工血管置人术,6例行自体大隐静脉移植术,1例因桡动脉管径较细行肱动脉与肘正中静脉高位瘘,2例放弃手术。21例手术患者术后生命指征平稳,瘘口搏动震颤良好。术后～2周内复查彩色多普勒超声示所建通路通畅。结论尿毒症终末期患者动静脉内瘘术前超声评估及定位对提高临床手术成功率有重要价值。     

Femoral tibial bypass grafts.

The results of 53 femoral to tibial artery bypass grafts have been reviewed. All were carried out in an attempt to salvage severely ischemic extremities which resulted from arteriosclerotic occlusive disease involving the femoral, popliteal, and tibial arterial systems as demonstrated by arteriography. Most grafts were done with autogenous vein; however, composite grafts comprised of a Dacron prosthesis and an autogenous vein and homologous veins were used in several patients. The initial salvage rate in these pregangrenous extremities was 74%. Fifty-two percent of the grafts remain patent at this writing, a period of 56 months in some instances. This study indicates that most patients with a severely ischemic extremity are candidates for revascularization and should have angiographic studies before amputation is considered.     

化疗患者使用浅静脉留置针的血管选择

目的探讨化疗患者使用浅静脉留置针时置管反应的发生与血管管径的相关性.方法将套管针留置在头静脉、贵要静脉、正中静脉、大隐静脉设者为A组,置管于手背静脉网及四肢其他分支静脉者为B组,观察2组患者置管反应的发生率.结果 A组置管反应发生率为25.0%,B组置管反应发生率为70.4%,2组比较,P＜0.01,差异有显著意义.结论化疗患者使用浅静脉留置针时,其置管反应的发生与血管管径大小有关.为血液病患者留置套管针时,应尽可能选择直径较大的血管.     

患儿静脉滴注甘露醇最佳留置部位的临床观察

静脉滴注20%甘露醇是临床治疗颅内高压的重要方法之一。甘露醇作为一种高渗性脱水剂,常高浓度快速滴注进入体内,以迅速提高渗透压而发挥作用。由于药物的高渗及微粒等因素[1],可对局部血管产生较强刺激而发生疼痛、管壁变硬、外渗、红肿等静脉并发症,尤其是儿童和婴幼儿,由于血     

下肢股腘动脉搭桥术中应用复合移植物6例报告

目的：为寻求一种有效的长距离膝下移植物来治疗下肢动脉长段阻塞或动脉旁路 远端动脉阻塞,方法：自１９９５年２月～１９９９年２月采用复合移植物治疗下肢股Ｕｕｏ动脉硬化闭塞症共６例,包括（１）“直接式”吻合法;（２）“跳跃式”吻合法;（３）“连贯式”吻合法：即先做膝上股Ｇｕｏ动脉人造血管移植。再做人造血管－自体大隐静脉－膝下Ｇｕｏ动脉端侧吻合。结果：经术后３年随访,６例中４例症状消失,２例症状同术前,结论：当无法应用单一的大隐静脉或人造血管时,复合移植物对治疗下肢股瘤动脉长段闭塞,特别是病变累及膝下动脉时,是合适的血管代用品。     

The arm as an alternative site for vascular access for dialysis in patients with recurrent access failure

Patients with chronic renal failure requiring dialysis and in whom multiple attempts at vascular access have previously failed represent a challenge to vascular surgeons. In these difficult patients the arm offers an excellent site for either an autogenous fistula or a prosthetic shunt because of the relatively unharmed portion of the upper cephalic vein or the protected location of the brachial vein in most individuals. (The anatomic region of the arm by definition is the area between the shoulder and the elbow.) Over the last two years we have studied 15 patients with a mean of 2.5 previously failed shunts or fistulas who subsequently had vascular access procedures in the arm, with the brachial artery as the inflow and the cephalic vein or brachial vein as the outflow. The first choice was the cephalic vein transposition to the brachial artery because it involved only one anastomosis and is autogenous vein. The alternative was a prosthetic graft of polytetrafluoroethylene (PTEE) between the brachial artery and the cephalic vein or brachial vein in the arm. The patency rate of these arm access procedures has been 75%. None of these patients had had congestive heart failure, distal ischemia, or excessive hematoma formation. The arm represents an excellent source for fistula or shunt construction in those difficult patients in whom previous vascular access sites have already failed.     

Value of navigator echo magnetic resonance angiography in detecting occlusion/patency of arterial and venous, single and sequential coronary bypass grafts

Aim of our work was to validate magnetic resonance angiography (MRA) in detecting occlusion/patency of coronary artery bypass grafts. Twenty patients with previous history of bypass surgery and recurrent episodes of chest pain were enrolled. Two patients could not be studied (claustrophobia, erratic breathing). Thus, 18 patients with 51 bypasses were examined using a navigator echo sequence: 21 arterial grafts (six sequential) and 30 saphenous vein grafts (five sequential). All patients had undergone contrast conventional angiography 3–15 days before MRA. The magnetic resonance (MR) data set was analyzed by two independent readers blinded to the results of conventional angiography (occlusion of 12 of 51 grafts). At magnetic resonance, two bypasses of the posterior descending artery, patent at conventional angiography, could not be visualized because of imaging slab malpositioning. Interobserver concordance was 96% (47/49). Magnetic resonance and conventional angiography provided identical answers in 47 out of 49 (96%) of the examined grafts. Eleven out of 12 occluded grafts and 36 out of 37 patent grafts were correctly identified with MR. As far as occlusion is concerned, the sensitivity of MR was 91%, the specificity 97%. To summarize, a 30 min outpatient MR examination is highly reliable in determining occlusion/patency of arterial and venous, single and sequential bypasses.     

Circumferential deformation and shear stress induce differential responses in saphenous vein endothelium exposed to arterial flow.

Adaptation of saphenous vein to the hemodynamic stresses of the arterial circulation is critical to the maturation of vein bypass grafts. We have investigated early adaptive responses of venous endothelium by placing excised human saphenous vein in a bypass circuit with either venous or arterial flow conditions, using external stenting to resolve the effects of longitudinal (shear) from circumferential stress. Endothelial protein concentrations were assessed by immunostaining area (ratio of protein/CD31) and Western blotting of endothelial cell lysates (staining ratio protein/vWf). In both unstented and stented veins nitric oxide synthase increased after 90 min of arterial flow: twofold increase of immunostaining area (P = 0.001), four- to fivefold increase by Western blotting (P = 0.02), and increased A23187mediated maximum endothelium-dependent relaxation of vein rings (P = 0.01). In unstented veins, ICAM-1 concentration was increased after 45 min of arterial flow: twofold increase by immunostaining (P = 0.001) and Western blotting (P = 0.038), with maximum fibrinogen-mediated endothelium-dependent relaxation increasing from 55.9+/-4.9 to 97+/-2.1% (P = 0.01). In contrast, in unstented veins there was a threefold decrease of VCAM-1 and no change in P-selectin after arterial flow for 45 and 90 min, respectively. However, no changes in ICAM-1 and VCAM-1 were observed in stented veins. The flow-induced alterations in nitric oxide synthase, ICAM-1, and VCAM-1 were abolished when 3 mM tetraethylammonium ion (K+ channel blocker) was included in the vein perfusate. The very rapid changes in ICAM-1 and VCAM-1 expression are a response to circumferential stress, whereas the slower upregulation of nitric oxide synthase is a response to longitudinal (shear) stress. Similar changes could influence the adhesiveness of endothelium in newly implanted saphenous vein bypass grafts.     

Mapping of superficial extremity veins: normal diameters and trends in a vascular patient-population

Ultrasonic measurement of superficial extremity veins is a common procedure. To establish normal values for vein-size in a population of vascular patients and to assess if measurements remain unchanged over time, we analyzed a database with results of 28,130 measurements in 2420 separate saphenous and 3206 cephalic veins. Mean size of the great saphenous vein ranges from 2.3 mm to 4.4 mm but did not follow a tapering pattern as is often assumed. The distal calf segment is smaller than the ankle segment. The mean cephalic vein size in the upper arm (2.4 mm) was smaller than at the antecubital level (2.7 mm). A decrease in vein diameter over time was noted in many locations and this reached statistical significance (p < 0.005 for the thigh segment). The clinical significance of this is a need to repeat ultrasonic vein-mapping if more than a year elapses between ultrasound and surgical vein harvest.     

PICC置管在白血病静脉化疗中的应用

目的 为白血病患者建立良好的静脉通道，避免化疗药物对外周静脉和局部组织产生不良反应。方法 经患者贵要静脉、肘正中静脉或头静脉插入PICC导管至上腔静脉中、下1／3处行化疗。结果 20例患者19例置管成功，占95％(19／20)，置管时间最短为5日，最长超过300日。结论 PICC置管是一安全、简便、并发症少、保留时间长、能有效保护外周静脉网、避免局部组织损伤的静脉通道，值得推广。     

PICC置管机械性静脉炎产生的解剖因素及预防

目的 探讨经外周中心静脉置管(PICC)置管机械性静脉炎产生的人体形态学因素。 方法 对60具尸体上肢常规解剖观察头静脉、贵要静脉走向并测量其管径。 结果 头静脉缺如1例,在上臂中段头静脉直径最细。贵要静脉,在上臂直径粗且恒定,穿固有筋膜时存在潜在管腔。 结论 头静脉上段不易作为PICC置管通道;在利用贵要静脉通道置管进入固有筋膜时,应当避免导管前端挫伤血管内膜。     

不同部位注射造影剂对多层螺旋CT冠状动脉成像检查图像效果的影响

目的观察不同部位注射造影剂对多层螺旋CT冠状动脉成像检查图像效果的影响。方法选取115例拟行冠脉造影的患者,依造影剂注射部位,随机分为:左肘正中静脉组(20例)、右肘正中静脉组(49例)、右前臂贵要静脉组(23例)和右前臂头静脉桡侧组(23例)。观察各组冠状动脉成像质量。结果经右侧肘正中静脉团注成功后冠状动脉显影效果高于左侧,差异有统计学意义(P0.01)。右侧肘正中静脉和右侧前臂贵要静脉团注成功后冠状动脉显影效果好,其次是右侧前臂头静脉桡侧。三组注射部位之间图像质量差异有显著统计学意义(P0.01)。结论为提高冠状动脉成像质量,在进行增强CT检查时右侧肘正中静脉为首选注射部位。其次是右侧前臂贵要静脉,再次可以考虑右侧前臂头静脉桡侧。     

Technical considerations in aortocoronary bypass grafting

Since the inception of aortocoronary bypass surgery, many technical advances have been rapidly achieved. Early experience was limited to reversed saphenous vein grafting of single vessel coronary artery disease. Multiple grafts to several vessels soon became commonplace and sequential grafting techniques were developed. Expanded use of the internal mammary artery resulted after analysis of superior patency rates achieved with this conduit. Use of alternative conduits such as upper extremity veins, allogenic veins, synthetic graft material (polytetrafluorethylene), radial artery, splenic artery, and gastroepiploic artery have been explored. Apart from the gastroepiploic vessel, none of these alternative conduits have been suitable. A grat deal of effort has been directed at the mechanisms of saphenous vein occlusion including technical considerations, early thrombosis, intimal hyperplasia and graft atherosclerosis. Platelet inhibition and lipid reduction have shown promise in improving patency rates. Further work in these areas should lead to even better results.     

Infrainguinal revascularization for limb salvage in patients with end-stage renal disease

We studied the efficacy of infrainguinal bypass for limb salvage in patients with end-stage renal disease. The patency of 42 femoropopliteal and femorodistal bypasses, performed for limb salvage in 37 patients with end-stage renal disease, was assessed with Doppler ultrasonography and dye tests. Patency rates and limb salvage were determined by life-table analysis. Average age was 45 years (range, 28 to 61 years); 23 of the 37 were men. Twenty-three patients had diabetes mellitus, and 16 were smokers. Bypass procedures were done in 32 instances while the patients were maintained with chronic hemodialysis and in five instances with peritoneal dialysis; in five instances the patients had had successful renal transplantation. Indications for revascularization included pain at rest, nonhealing ulcer, or distal gangrene. Femoropopliteal bypass was done in 32 limbs; 10 were more distal procedures. Reversed saphenous vein was the conduit in 30 cases; prosthetic material was used in the remainder. Autogenous material was used in all distal bypasses. Four patients required graft revision during the initial hospitalization, but none thereafter. Two patients died within the operative period, nine within 18 months of operation. Nine major operations were required. Three-month cumulative graft patency was achieved in 41 cases and corresponding limb salvage in 33 cases; 18-month patency was achieved in 34 cases and overall limb salvage in 33 cases. Success of limb salvage most closely correlated with preoperative ankle-brachial ratio and level of bypass required.     

Ultrasonographic measurement of saphenous vein diameter compared to CEAP classification in patients with varicose veins

Introduction and ObjectiveUltrasound of the saphenous vein and measurement of the vein diameter may have a role in determining the severity of varicose veins. This study aimed to compare the saphenous vein diameter with the CEAP classification, as the reference standard in determining the severity of chronic venous diseases, in patients with lower limbs varicose veins free from saphenous vein reflux.MethodsIn this cross-sectional study, 100 patients with lower limbs varicose veins (saphenous vein) and free from saphenous vein reflux were enrolled. Demographic data (age, gender, body mass index (BMI)) were collected using a checklist. The severity of varicose veins was determined using the standard CEAP classification. The saphenous vein diameter was measured using ultrasonography.ResultsMean age of the patients was 43 years and there were 68 female patients. According to the CEAP classification, 13 patients had no varicose veins (CEAP class C0). However, 87 patients had varicose veins (65 patients with class C1, one patient with class C2, and 21 patients with class C3). Mean saphenous vein diameter in the whole sample was 6.7 mm. There was no significant relationship between the severity of varicose veins determined by CEAP classification and mean saphenous vein diameter measured by ultrasound. Mean saphenous vein diameter in C0, C1, C2, and C3 groups were respectively 1.7 mm, 6.7 mm, 8 mm, and 8.7 mm (P= 0.71). On the other hand, mean saphenous vein diameter was higher significantly in those with higher body mass index (BMI) and among older patients.ConclusionThe results of this study showed that saphenous vein diameter did not differ significantly between CEAP C0 through C4 classes. However, the severity of varicose vein was more prominent in older patients and those with higher BMI.     

Effects of Local Warming on the Peripheral Vein Cross-Sectional Area in Children Under Sedation

PurposePeripheral venous catheterization is challenging in small children. The local warming technique has been used to increase the peripheral vein cross-sectional area (CSA) and improve the success rate. However, there is limited evidence on the effect of local warming on venous CSA in children under sedation.DesignA pilot randomized controlled trial.MethodsEligible children aged 1 to 4 years undergoing ambulatory surgery were enrolled. At the bedside in the ambulatory surgery center, they were routinely sedated with 1 mcg/kg of intranasal dexmedetomidine. Through a computer allocation program, children were randomized into either a control group or a local warming group. Cephalic vein and basilic vein at 1 cm proximal to cubital fossa were scanned with ultrasound to measure venous CSA. Children in the control group received no intervention; those in the local warming group had a prepared hot pack of ~40°C applied to the target area on the arm for 5 minutes. A second ultrasound measurement was undertaken in both groups.FindingsA total of 35 from 40 children were analyzed. Cephalic vein CSA and basilic vein CSA increased significantly vs the first measurement within the local warming group (P < .05 for both) but not in the control group (P > .05 for both). Cephalic vein CSA was significantly different between groups at the second measurement (P < .05) but not at the first measurement (P > .05). Basilic vein CSA was significantly different between groups neither at the first measurement nor at the second measurement (P > .05 for both). The application of local warming resulted in an average of 34% increase (from 4.1 to 5.5 mm²) in cephalic vein CSA and an average of 21% increase (from 4.8 to 5.8 mm²) in basilic vein CSA.ConclusionsThe application of local warming induced mild venodilation in cephalic vein with an increase in CSA by 34% and had little venodilation effect on the basilic vein with an increase in CSA by only 21%.     

自体静脉移植建立的血液透析血管通路

背景：目前关于自体静脉移植建立内瘘的文章较少,尤其针对不同部位自体静脉移植效果的总结尚未见报道。目的：总结自体静脉移植内瘘的建立经验,探索提高手术成功率的方法。方法：回顾性分析40例自体静脉移植内瘘患者资料,对比上下肢静脉移植内瘘成功率、血流量和使用时间;分析合并糖尿病对自体静脉移植内瘘成功率的影响。结果与结论：自体静脉移植建立内瘘成功率由高到低依次为头静脉、大隐静脉、贵要静脉和小隐静脉;上肢移植静脉内瘘的血流量明显高于下肢移植静脉（P〈0.05）;比较使用时间,上肢移植血管内瘘长于下肢移植血管内瘘（P 〈0.01）;对于合并糖尿病的患者,进行自体血管移植的成功率明显低于不合并糖尿病者（P 〈0.01）。结果提示对于上肢浅静脉条件不佳的血液透析患者,自体静脉移植内瘘是其建立血管通路的较好方式;选择上肢静脉移植较下肢静脉移植内瘘的成功率高,使用时间长;而对于合并糖尿病的患者,不适宜行自体静脉移植内瘘。     

Correlation of preoperative ankle-brachial index and pulse volume recording with impaired saphenous vein incisional wound healing post coronary artery bypass surgery.

Patients undergoing coronary artery bypass surgery have vascular disease and, subsequently, the risk for impaired healing of their saphenous vein graft site. The purpose of this study was to identify the correlation of the preoperative ankle-brachial index (ABI) and pulse volume recording (PVR) with impaired saphenous vein incisional wound healing post coronary artery bypass grafting. A prospective, correlational research design was used to study 271 male and female adults undergoing coronary artery bypass surgery in which the saphenous vein was used for grafting. Arterial insufficiency was assessed preoperatively using patient history, physical examination, ABI, and PVR. Wound status was assessed postoperatively using the validated ASEPSIS tool for inpatients. A modified ASEPSIS tool, the Wound Healing Self Score, was used for telephone follow-up post discharge. Abnormal ABI and PVR measurements were positively correlated with impaired saphenous vein incisional wound healing (r = 0.72, P < .0001). Both tests also independently predicted impaired healing. Incisional infection correlated with impaired healing (P < .0001). Other clinical variables, including diabetes, hypertension, venous disease, and alcohol and cigarette use, were not found to be statistically significant independent predictors of impaired healing. Routine histories and physical examinations alone are insufficient in predicting risk for impaired saphenous vein incisional wound healing. The addition of noninvasive screening for the presence of arterial insufficiency before coronary artery bypass grafting using ABI and PVR tests is one method of predicting the likelihood of impaired healing.     

两种路径行PICC置管的效果探讨

目的探讨经贵要静脉与头静脉行PICC的效果比较。方法对24例经贵要静脉穿刺置管组和11例经头静脉穿刺置管组从一次穿刺成功率、留置时间、术后导管留置期间并发症三方面进行比较。结果两种路径行PICC置管者在这三方面均有显著差异。结论经贵要静脉行PICC置管者在穿刺一次成功率、留置时间、术后导管留置期间并发症发生率方面均显著优于经头静脉穿刺者。     

双源CT对冠状动脉桥血管的评价

【目的】评价双源螺旋CT对冠脉搭桥术后桥血管开通的诊断价值。【方法】对57例冠状动脉搭桥术后的患者行双源螺旋CT冠状动脉成像检查。【结果】所有141支桥血管均重建成功。其中内乳动脉桥39支,大隐静脉桥102支,通畅的桥血管102支（72．3％）,不同程度狭窄15支（10．63％）,完全闭塞24支（17．02％）。39支内乳动脉桥支33支通畅（84．62％）,102支大隐静脉桥支69支通畅（67．65％）,两种桥血管间相比较差异显著（P〈0．05）。【结论】双源螺旋CT是评价冠状动脉搭桥术后桥血管开通的有价值的无创检查方法。