肱动脉穿刺术并发症的预防与处理

目的 总结经皮肱动脉穿刺术的临床经验,探讨相关并发症发生的原因及其预防及处理对策.方法 回顾性分析2001年6月至2009年6月因行血管腔内诊疗而接受超声引导下肱动脉穿刺术87例患者的临床资料,总结发生并发症情况及其发生原因.结果 87例患者在超声引导下行肱动脉穿刺术均成功,成功率为100%,其中超声引导下一次穿刺成功有53例(61%),经多次穿刺成功有34例(39%).16例患者(19例次)发生了并发症,并发症发生率为18.4%.其中导丝进入血管周围间隙4例(4.6%),穿刺局部发生血肿11例(12.6%),其中3例合并局部神经损伤(1例为迟发型神经损伤),假性动脉瘤1例(1.2%).结论 熟悉肱动脉穿刺术部位的解剖特点,掌握相应的操作技巧并对其并发症有足够的认识和处理对策的充分准备可以减少并发症及其不良后果的发生.     

Brachial plexus compression due to subclavian pseudoaneurysm from cannulation of jugular vein hemodialysis catheter

Jugular venous cannulation is generally safer than subclavian cannulation. The traumatic complications associated with jugular vein hemodialysis catheters are rare. A jugular vein, therefore, has become the preferred site for hemodialysis catheter insertion. We describe the first case of brachial plexus compression attributable to delayed recognition of a right subclavian pseudoaneurysm as a complication of jugular venous cannulation of hemodialysis catheter. We advocate that any neck swelling, new bruit, and the symptoms of brachial plexopathy after jugular venous cannulation warrant an intensive investigation to exclude arterial injury. Because delayed diagnosis may lead to a worsened prognosis in patients with brachial plexus palsy, physicians should exercise vigilance to detect and manage early the potentially serious and fatal complications of subclavian artery pseudoaneurysm and brachial nerve injury.     

Influence of arterial access sites and interventional procedures on vascular complications after cardiac catheterizations.

The purpose of this study is to define the incidence of complications at the arterial access site after cardiac catheterization. The influence of the arterial access site on these complications was identified, as were the clinical characteristics of these problems. A total of 8,797 cardiac catheterizations were performed over the 3-year period of this study. Diagnostic catheterizations and percutaneous transluminal coronary angioplasties (PTCAs) were included, and the arterial access site was identified. Diagnostic catheterizations were performed via the brachial artery (group I, n = 3,137) or the femoral artery (group II, n = 4,055). PTCAs were also performed via the brachial artery (group III, n = 32) or the femoral route (group IV, n = 1,573). Ninety-five major vascular complications occurred during the course of this study. The frequency of complications was higher with brachial artery catheterization when compared with the femoral route. PTCA was associated with a higher complication rate than diagnostic studies. Brachial artery complications were primarily arterial thromboses, which were easily diagnosed and treated. Femoral artery complications were more complicated, difficult to identify, and associated with significant morbidity.     

Difficult catheterization of the radial artery. Comparison of a new arterial catheter and Seldinger's technic

Sixty difficult radial artery cannulations were carried out using either the Seldinger technique (Seldicath Plastimed, FG 3, 80 mm long; group S; n = 30) or a new arterial catheter (Arrow, Critikon, gauge 20, 44 mm long; group A; n = 30) in patients scheduled for coronary arterial surgery or cardiac valve replacement (age: 54.8 +/- 11.8 yr). The technique was chosen at random after failure of radial artery catheterization with a short intravenous catheter (Quick-Cath Travenol, gauge 20, 31 or 51 mm long, or Insite W Beckton-Dickinson, gauge, 20, 30 mm long). The second attempt was carried out on the same artery, a few centimeters higher up than the first one. Heparinized normal saline was infused through this arterial line. All the catheters were removed after extubation. There was no arterial thrombosis, nor any displacement of the catheter with loss of the arterial pressure curve. No difference was found between the two techniques regarding the number of catheterization failures, the duration of cannulation, and the quality of the blood pressure curve. For difficult radial artery cannulations, the arterial catheter Arrow associated the advantages of the Seldinger technique with those of short intravenous catheters.     

The impact of two arterial catheters, different in diameter and length, on postcannulation radial artery diameter, blood flow, and occlusion in atherosclerotic patients

Purpose  Arterial cannulation is a common intervention in anesthesia practice. However, the success rates and complications of radial arterial cannulation with 20-G or smaller catheters in patients with atherosclerosis have been underevaluated. The aim of this prospective randomized study was to compare the efficacy of and complications with 20- and 22-G catheters for radial arterial cannulation in atherosclerotic patients. Methods  Thirty patients with atherosclerosis, American Society of Anesthesiologists (ASA) III–IV, undergoing general anesthesia were enrolled in the study. Radial artery cannulation was performed in group 20G (n = 15) with a 20-gauge (20 × 1.1 × 33 mm; flow, 61 ml·min⁻¹) catheter and in group 22G (n = 15) with a 22-gauge (22 × 0.9 × 25 mm; flow, 36 ml·min⁻¹) catheter. Radial artery systolic blood flow (SBF) and radial artery diameter (RAD) were assessed by a Doppler ultrasound probe before cannulation and 24 h after decannulation for vascular complications. The number of puncture attempts, arterial blood gas samples, and manual flushes; total heparinized solution consumption; duration of cannulation; decannulated radial arterial systolic blood flow; postcannulation RAD; and vascular complications such as occlusion, hematoma, pseudoaneurysm, bleeding, and thrombosis were noted. The Mann Whitney U-test, χ² test, and one-sample t-test were used. Values are expressed as medians and quartiles and P < 0.05 was considered as significant. Results  The number of puncture attempts was greater in group 20G (range, 1 to 4) than in group 22G (range, 1 to 2; P = 0.02). In group 20G patients, postoperative RAD was larger than preoperative RAD (P = 0.02) and postoperative SBF was lower than preoperative SBF (P = 0.03). In group 22G patients postoperative SBF was higher than preoperative SBF (P = 0.03), while there was no significant difference between preoperative and postoperative RAD. The occlusion rate of atherosclerotic radial arteries was 6% with the 22-gauge catheter and 26% with the 20-gauge catheter (P = 0.02). Conclusion  A 22-gauge catheter for radial arterial cannulation in patients with atherosclerosis provides unchanged postcannulated radial artery diameter, decreases postcannulation complications, and improves the first-attempt success rate. Presented at the 20th International Congress of The Israel Society of Anesthesiologists.     

“Liquid stylet” for percutaneous radial artery cannulation

Radial artery catheterization in elderly patients may be difficult. The “liquid stylet” created by slow intra-arterial fluid injection facilitates insertion of arterial cannulae, and proved effective in 14 consecutive patients in whom percutaneous radial artery catheterization was otherwise unsuccessful. This technique is useful when difficulty in radial artery cannulation is encountered.     

Late complications after femoral artery catheterization in children less than five years of age

Fifty-eight children who underwent diagnostic femoral artery catheterization before 5 years of age, from 5 to 14 years before the study, were randomly selected from approximately 300 surviving patients undergoing diagnostic femoral artery catheterization at our institution during the interval. Each patient underwent vascular laboratory segmental pressure and waveform examination and arterial duplex scanning, as well as lower extremity bone length radiographs, which were considered positive if the catheterized leg was greater than or equal to 1.5 cm shorter than the opposite leg. Thirteen children who had only venous catheterization served as controls. No arterial abnormalities were present in the control patients (mean ankle/brachial index, 1.01). Arterial occlusion was present in both limbs of five patients who had bilateral diagnostic femoral artery catheterization and in 14 limbs of 51 patients who had unilateral diagnostic femoral artery catheterization. Thus arterial occlusion was present in 33% of patients (19 of 58) and in 37% of limbs (24 of 65). The mean ankle/brachial index in the catheterized limbs was 0.79. Leg growth retardation was present in four limbs (8%) of 51 children undergoing unilateral diagnostic femoral artery catheterization and in one (8%) control patient. The inverse relationship between ankle/brachial index and leg growth retardation was significant (R = 0.47, p less than 0.0005). Only one patient had symptoms of arterial occlusion (claudication), and one patient had symptoms of leg growth retardation (gait disturbance). We conclude that arterial occlusion is common after diagnostic femoral artery catheterization in children less than 5 years of age, but that excellent collateral supply prevents leg growth retardation and/or symptomatic arterial insufficiency in most children.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ulnar artery versus radial artery approach for arterial cannulation: a prospective, comparative study

STUDY OBJECTIVE: To compare the ease of cannulation, success/failure rate, and complication rate between ulnar and radial arteries. DESIGN: Randomized, controlled study. SETTING: Operating room. PATIENTS: 100 ASA physical status I, II, and III patients undergoing general anesthesia and requiring arterial cannulation. INTERVENTIONS: Patients were divided randomly into two separate groups of 50 patients each according to cannulation site: ulnar artery (group U) or radial artery (group R) group. MEASUREMENTS: The presence and fullness of the arterial pulses (strong/weak/absent), ease of cannulation (cases in which cannulation was successful on the first attempt and those that which required more than one cannulation attempt), success rate of cannulation, and complications (early/late) were all recorded. MAIN RESULTS: The radial artery was stronger in pulse (83% vs 73%). The success rates of cannulations for the ulnar and radial arteries were 82% and 90%, respectively (P > 0.05). The overall success rate of cannulation in the ulnar group with a strong pulse was 100%. There were significant differences in the success rate of cannulation between the patients with strong and weak pulses in the ulnar group (P < 0.0001). Ease of cannulation and complication rates of cannulations were not statistically different in both groups. CONCLUSIONS: The success rate of an arterial cannulation in a patient with a strong ulnar pulse is the same as for radial artery cannulation.     

Ultrasound-guided arterial cannulation in infants improves success rate

BACKGROUND AND OBJECTIVE: In small children, the placement of arterial catheters can be technically challenging for even the most experienced anaesthetist. We investigated whether ultrasound imaging would improve the success rate and reduce time demand and complications of radial artery cannulation. METHOD: In this prospective randomized study, we performed radial artery cannulation in 30 small children (age 40 +/- 33 months) using two different techniques for localization of the vessel. In Group 1 (n = 15), the traditional palpation method was used, while in Group 2 (n = 15) cannulation was directed by vascular ultrasound imaging. In addition, we used ultrasound to determine the cross-sectional area of the radial artery with and without dorsiflexion. For statistical analysis, the non-parametric U-test for non-paired data and the Wilcoxon signed rank sum test for paired data were used. Differences were considered significant, when P < 0.05. RESULTS: Ultrasound-guided puncture was successful in all children of Group 2 compared to only 12 of 15 (80%) children in Group 1. Fewer attempts with the imaging technique were required than with the traditional technique (20 vs. 34, P < 0.05). Dorsiflexion significantly reduced the mean cross-sectional area of the artery by 19%. CONCLUSION: The current pilot study suggests that ultrasound guidance is appropriate for radial artery catheter insertion, sharing many of the benefits of ultrasound-guided central vein catheter insertion.     

Long-term brachial artery catheterization: ischemic complications

The brachial artery is not used for long-term catheterization and routine hemodynamic monitoring because a high incidence of ischemic complications is anticipated. However, in a review of 157 patients who had 225 percutaneous transbrachial hepatic artery catheters placed for infusion of chemotherapeutic agents, catheters remained in situ from 1 day to 14 months (median 68 days). One hundred seventy-three catheters (77%) were removed electively and 52 catheters (23%) were removed because of complications. Diminution or loss of the radial pulses occurred on insertion of 88 catheters (39.1%) and 16 of these (8%) were removed after 24 hours because ischemic symptoms developed. Subsequently, 25 other catheters (11.1%) were removed because of complications such as paresthesia, eight (3.5%); brachial artery thrombosis, four (1.7%); microembolization, three (1.3%); claudication, two (0.8%); and pseudoaneurysm, one (0.4%). Seven catheters (3.1%) were removed because of a combination of pallor, diminished pulses, and muscle weakness. Hemorrhage from the arteriotomy site necessitated the removal of 11 other catheters (4.9%). Amputation, ischemic ulceration, major neuromuscular sequelae, and peripheral embolization to the head or lower limbs did not occur. This study suggests that long-term brachial artery catheterization is associated with a low incidence of permanent ischemic complications.     

Cardiovascular responses to pulmonary artery catheterization

This study compares prospectively the cardiovascular and catecholamine responses to central venous and pulmonary artery catheterization before and after induction of general anaesthesia. Twenty patients for elective coronary artery surgery were randomized into two groups. One group had central venous and pulmonary artery catheterization performed awake using local anaesthesia. The other group had these catheters inserted following induction of general anesthesia. In all patients heart rate, arterial blood pressure, ST segment analysis and epinephrine and norepinephrine levels were measured prior to central venous cannulation and at 2-min intervals until placement of the lines was achieved. There were no statistically significant changes in any cardiovascular or catecholamine variable with time compared with the base-line measurements. There were no statistically significant differences in plasma catecholamine levels between the awake and the anaesthetized groups.     

Axillary brachial plexus block for treatment of severe forearm ischemia after arterial cannulation in an extremely low birth-weight infant

Severe limb ischemia after arterial catheterization in neonates and premature infants is a well-recognized problem. The usual treatment of ischemic injuries includes removal of the catheter and elevation of the effected limb. If unsuccessful, tissue necrosis and loss may follow. We report the case of a 700 g infant with severe distal forearm ischemia after right radial and ulnar artery catheterization. Immediate removal of the arterial line did not improve ischemia. Thirty-six hours later a brachial plexus block via the axillary approach with 0.5 ml bupivacaine 0.125% was performed resulting in rapid improvement, restricting ischemia eventually to fingers II-V as well as the distal part of the thumb. Brachial plexus blockade and active vasodilatation in tiny neonates after severe local ischemia are discussed.     

Brachial artery cannulation facilitates lower ministernotomy cardiac surgery

BACKGROUND: Lower ministernotomy has become a more popular approach for many heart operations. However, cannulation of the ascending aorta may cause serious complications. Femoral and brachial arteries have been used for alternative arterial cannulation sites. MATERIALS AND METHODS: The lower ministernotomy approach was used in 65 patients. Ascending aortic cannulation was performed in group 1 (n = 38), femoral cannulation in group 2 (n = 12), and brachial cannulation in group 3 (n = 15) patients. Brachial artery diameter was measured preoperatively by Doppler ultrasound in the preoperative period. RESULTS: Average cross-clamp time for femoral and brachial artery cannulated patients was significantly shorter than in patients in group 1 (31 +/- 9 and 35 +/- 6 minutes, respectively) (p = 0.034). Total cardiopulmonary bypass (CPB) time was 56 +/- 11 minutes for group 1, 39 +/- 7 minutes for group 2, and 41 +/- 5.4 minutes for group 3 (p = 0.041). Operation time was 112 +/- 24, 88 +/- 12, and 91 +/- 11 minutes for the groups 1, 2, and 3, respectively. There was also statistically significant difference between group 1 and group 3 comparisons with regard to CPB time (p = 0.041). Difficult exposure from many cannulas impedes access and lengthens the operation in group I. Superficial wound infection developed in seven patients in group 1, one patient in group 2, and one patient in group 3. CONCLUSION: Cannulation of the brachial artery is superior to the femoral due to possible infection and lymph leakage with the latter and both are superior to central cannulation when lower ministernotomy is performed. By avoiding the difficulties of central aortic cannula placement the operative time is decreased and possible wound edge is protected as lesser exposure is required.     

A randomized-controlled study of ultrasound prelocation vs anatomical landmark-guided cannulation of the internal jugular vein in infants and children

Background: A specifically designed ultrasound scanner may be helpful in percutaneous cannulation of the internal jugular vein in pediatric patients. We report a new two‐dimensional (2D) ultrasound prelocation (UL) technique using a transesophageal echocardiography (TEE) intraoperative probe instead of the portable scanner, and have compared the new technique with conventional anatomical landmark method (AL) for central venous catheterization in infants and children. Methods: Sixty‐two infants (body weight <12 kg) undergoing elective surgery for congenital heart disease were randomized into two groups. In the AL group, the landmark for cannulation was the palpation of the common carotid pulsation or the sternocleidomastoid triangle. In the UL group, the central vein was located by 2D ultrasonic imaging using a TEE intraoperative probe for HP SONOS 4500. The number of cannulation attempts, success rate, and complication rate were recorded. Results: For the UL and AL groups, the cannulation success rate was 100% and 80% (P < 0.05), the incidence of arterial puncture was 3.1% and 26.7% (P < 0.025), and the number of attempts was 1.57 ± 1.04 and 2.55 ± 1.76 (P < 0.001), respectively. Conclusions: Two‐dimensional ultrasound prelocated central venous catheterization in infants and children is convenient and can markedly increase cannulation success rate and reduce the incidence of complications.     

Ultrasound-guided cannulation versus the landmark-guided technique for acute haemodialysis access

Background. The correct placement of large-bore venous catheters plays an important role in the management of haemodialysis patients. Whilst the procedure for landmark-based placement of these catheters is well known, the technique is not without significant morbidity and mortality. Complications include arterial puncture, haematoma, and pneumothorax. The procedure may be further complicated in these patients by venous thrombosis and abnormal vein position from multiple previous attempts at venous access. Methods. Data on the use of ultrasound guidance versus anatomical landmarks for the placement of internal jugular vein (n=69) and femoral vein (n=30) dialysis access was retrospectively analysed over a 13-month period. Data collected included age, sex, duration on dialysis, number of vein cannulation sets required, number of attempts for successful cannulation, salvage of failed cannulation using landmark-based technique by ultrasound guidance, and the complication rate. Results. Internal jugular vein cannulation using ultrasound was ultimately successful in 96.67% compared to 82% in the landmark group. The vein was entered on the first attempt in 83.3% of patients with ultrasound compared to 35.9% of the landmark group (P<0.0001). Seven patients in whom the landmark technique was unsuccessful had access placed under ultrasound guidance. There were fewer carotid artery punctures in the ultrasound group (7.7 versus 0%, P=n.s.). In the femoral vein group, the vein was entered on the first attempt in 85.7% of patients with ultrasound compared to 56.25% of the landmark group. (P=n.s.). Conclusions. The use of ultrasound guidance is associated with fewer complications and is more likely to lead to cannulation of the vein at the first attempt in haemodialysis patients.     

Risk of thrombosis in prolonged catheterization of the radial artery: comparison of 2 types of catheters

The thrombosis rate after long-term cannulation of the radial artery was assessed prospectively in 48 intensive care patients randomly assigned to groupe A (polyethylene Leader-Cath 115-09 catheter; n = 50, aged 55 +/- 20 years, 74% male patients) or groupe B (Teflon Viggo Floswitch 4441 catheter; n = 48, aged 58.6 +/- 16 years, 73% male patients). Bedside angiography was carried out with 10 to 15 ml Hexabrix before removal of the catheter. The two groups were similar with regard to anthropometric parameters, used drugs, pathological events during the stay in ICU, arterial cannulation technique and its duration. There was no case of clinically significant ischaemia. The rate of X-ray total arterial thrombosis was 20% in group A, and 2% in group B (p less than 0.01). There was no difference in the rate of partial thrombosis (54% vs. 41.7% respectively, NS) and of lack of thrombosis (26% vs. 56.3% respectively, NS). The overall rate of thrombosis was greater in group A than in group B, but not significantly (74% vs. 43.7% respectively). The duration of arterial cannulation did not influence the rate of thrombosis. However it was higher in males of Group A than in those of Group B (p less than 0.01), when heparin was not given (p less than 0.05); when vaso-active drugs were used (p less than 0.05); and when the time required for cannula insertion was greater than 5 min (p less than 0.01). It is concluded that Teflon catheters are more biocompatible than polyethylene catheters.     

A Prospective Randomized Study to Compare Ultrasound-Guided with Nonultrasound-Guided Double Lumen Internal Jugular Catheter Insertion as a Temporary Hemodialysis Access

Internal jugular venous catheters (IJVC) for hemodialysis are a commonly employed temporary vascular access for hemodialysis. Most hospitals still follow the use of blind technique, which uses anatomical landmarks. Even in the most experienced hands this procedure has a variable success rate. Ultrasound guidance can decrease the incidence of periprocedural complications and improve the success rate. In this randomized study we compared the procedure success rate and periprocedural complications in patients undergoing ultrasound guided vs. nonultrasound guided IJVC insertion for a temporary hemodialysis access. Methods. All patients subjected to insertion of an IJVC between March 2004 and June 2004 were enrolled into the study, randomized to either the blind (group A) or ultrasound guided (group B) procedure, which uses a portable ordinary ultrasound machine without a needle guide. The aseptic Saldinger technique was used for catheterization in both the groups. Baseline characteristics of patient and periprocedural events were recorded. Results. A total of 60 patients were randomized, 30 patients each in two groups. First attempt venous cannulation success rate was 56.7% in group A compared to 86.7% in group B. Chance of occurrence of adverse outcome was significantly more in the blind procedure (P = 0.020). A post-procedure chest radiograph done in all patient showed no complications. Conclusion. Ultrasound guided procedure for internal jugular vein catheter insertion using an ordinary ultrasound machine was significantly safer and more successful as compared to the blind technique.     

Zentrale Venenkatheter bei Neugeborenen, Säuglingen und Kindern

In neonates, infants and young children central venous catheters are of vital importance during surgery as well as postoperative care. The benefit of ultrasonography seems to be very important for vascular access of the internal jugular (IJV), subclavian (SCV), femoral and even peripheral veins. Ultrasound-guided cannulation of the IJV increases the success rate, reduces the time to the successful puncture and decreases the inadvertent puncture of the carotid artery in children in comparison to the landmark-guided technique. Due to compression of the vessel by the approaching needle in neonates transfixing the vein and aspirating blood on withdrawal of the needle may be the preferred technique. The lack of space may prevent ultrasound-guided puncture of the SCV in very low birth weight infants. However, the location of the vein and its patency should always be determined via ultrasound prior to cannulation. After catheterization of the SCV the homolateral IJV is screened by the use of ultrasound to detect wrong guide wire migration. A clear and rapid visualization of visceral pleura movement against the parietal pleura during respiration via ultrasound indicates the absence of pneumothorax after cannulation. In the case of haemodynamic instability, ultrasound should be used to exclude pericardial effusion.     

对比经远端桡动脉与肱动脉入路支架成形术治疗髂动脉慢性闭塞症的有效性及安全性

目的 对比经远端桡动脉入路与肱动脉入路支架成形术治疗髂动脉慢性闭塞症的有效性及安全性。方法 回顾性分析70例接受经左侧桡动脉远端入路（A组）与72例经左侧肱动脉入路（B组）支架成形术治疗髂动脉慢性闭塞症患者,其中B组18例因穿刺左侧桡动脉远端失败而改为穿刺左侧肱动脉;观察2种方法穿刺成功率、2组髂动脉开通成功率和穿刺并发症发生率。结果 穿刺桡动脉远端成功率为79.55%（70/88）,穿刺肱动脉成功率为100%（72/72）。髂动脉顺行开通成功率[78.57%（55/70）vs.80.56%（58/72）,<χ²=3.67,P=0.09]及总体开通成功率[94.29%（66/70）vs.95.83%（69/72）,χ²=2.34,P=0.10]组间差异均无统计学意义。A组穿刺并发症发生率低于B组[5.71%（4/70）vs.13.89%（10/72）,<χ²=3.24,P=0.02]。结论 相比经肱动脉入路,经远端桡动脉穿刺入路腔内支架成形术治疗髂动脉慢性闭塞症更为安全,而开通成功率相当。     

应用测压法减少中心静脉置管过程中的动脉损伤

背景中心静脉穿刺置管时误置入动脉的发生率约为2％-4．5％,导致动脉损伤的发生率为0．1％。0．5％。常规使用测压法可以成功鉴别出刺入动脉的情形,避免动脉置管和动脉损伤。方法我们进行了一项回顾性研究,统计了15年中执行安全计划并应用测压法验证中心静脉置管过程的所有病例。动脉损伤的定义为意外在动脉内置入7F或更大的导管或扩张器。动脉穿破的定义为18G导管或穿刺针意外穿入动脉。数据包括了15年中所有的动脉损伤。另外,在数据分析的最后1年,对穿破动脉和最终引起动脉损伤的数据进行评估。结果观察期内共完成9348例中心静脉穿刺置管。在整个15年的观察期间,没有患者发生动脉损伤。在研究的最后1年,进行了511例中心静脉置管,发生28例动脉穿破（5％）。其中24例动脉穿破没有经过测压法检验。而经测压法检验发生动脉穿破仅4例,没有发生动脉损伤。结论在15年的评估中,中心静脉置管时坚持应用测压法可有效确认置管于静脉,从而避免意外动脉置管导致动脉损伤的意外发生。