采用Seldinger技术锁骨下动脉穿刺插管的解剖学基础及临床应用研究

经皮锁骨下动脉（ＳＣＡ）穿刺是导管药盒系统植入术的难点之一。对１２例成人尸体标本双侧ＳＣＡ走行及毗临关系解剖学观察表明，ＳＣＡ的体表投影点（Ｄ点）位于胸锁关节与喙突连线中点偏外约１ｃｍ处。当动脉的穿刺靶点为Ｄ点内１．５ｃｍ上约１ｃｍ处时，在锁骨中外１／３下２～３ｃｍ处进针，角度额状面为（２０～３０）°，横断面为（１０～２０）°，深度为４～５ｃｍ。２０例患者穿刺成功并送入导丝后的Ｘ线照片测量显示左ＳＣＡ位于第一肋外缘中点处，可作为透视下定位点和靶点。ＳＣＡ穿刺先按体表标志进行，困难时按透视下骨性标志进行，不成功则采取经股动脉插管，入左ＳＣＡ，透视引导下穿刺。     

新法判断骶管穿刺成功60例

我们用 6 或 7号注射针头经骶裂孔行骶管穿刺时 ,以气 液注射试验作为判定穿刺成功与否的指标 ,介绍如下。1　临床资料1 1　一般情况　 60例中 ,男 49例 ,女 1 1例 ;年龄 1 5～ 59岁 ;ＡＳＡⅠ～Ⅱ级。1 2　方法　病人侧卧屈髋、屈膝 ,穿刺点以骶裂孔与左右骶后上棘的等边三角关系或以两侧骶骨角中点为定位标志。操作时 ,左手拇指定位穿刺点 ,右手持 6 或 7号注射针头与皮肤成 30°～ 40°直接穿刺 ,进针 2 5～ 3 0ｃｍ有一明显突破感时停止 (如刺入 2 5～ 3 0ｃｍ遇骨质 ,则稍退针 0 5ｃｍ) ,然后将注射针头柄后接一吸入 1 5ｍｌ…     

套管针穿刺抽气治疗少量气胸30例

我科于 1996年 10月～ 2 0 0 1年 10月采用套管针 (Ｂｒａｕｎ牌 ,1 7ｍｍ× 5 5ｍｍ)抽气治疗少量气胸 3 0例 ,使气胸吸收时间大大缩短 ,取得较好的疗效 ,现报告如下。1　临床资料1 1　一般情况　本组 3 0例 ,男 2 5例 ,女 5例 ;年龄 1768岁 ,平均 4 4 .2岁。均为我科住院的少量气胸或中大量气胸 ,经胸腔闭式引流治疗后遗留的少量气胸患者 ,其中肺组织压缩 10 %～ 2 0 %为 16例 ,2 0 %～ 3 0 %为 14例。1 2　治疗方法　根据胸片及胸部透视用回形针定位 ,利多卡因或普鲁卡因局麻 ,用套管针穿刺 ,抽出气体后 ,拔出套管内钢针 ,留住外套管针 ,…     

经皮穿刺椎体成形术治疗椎体骨质疏松性压缩骨折

目的　通过X线透视下进行经皮穿刺椎体成形术治疗椎体骨质疏松性压缩骨折 ,探讨该技术的临床疗效及应用注意事项。　方法　本组 2 3例 ( 44个椎体 ) ,男 8例 ,女 15例 ;年龄 48～ 83岁 ,平均 6 9岁。脊柱骨折部位为T5～L3,其中胸椎 2 0个椎体 ,腰椎 2 4个椎体。采用C形臂X线机透视引导下于俯卧位或侧卧位进行经皮穿刺椎体成形术 ,注射聚甲基丙烯酸甲酯 (骨水泥 )。在术前、术后 2d、随访期进行疼痛视觉类比评分 (VAS)、活动能力评分和止痛药使用评分。随访时间 1～ 7个月 ,平均 3.1个月。　结果　 2 1例 40个椎体手术成功 ,2例 ( 4个椎体 )因不能耐受俯卧位而手术失败。骨水泥注射量 1.0～ 8.0ml 椎体。VAS术前 ( 7.5± 1.2 ) ,术后 2d ( 2 .8± 1.0 )较术前显著下降 (P <0 .0 0 1) ;随访时为 2 .3± 0 .9,比术后 2d又略有下降。活动能力评分 ,术后 2d ( 1.6± 0 .3)较术前 ( 2 .3± 0 .8)明显改善 (P <0 .0 5 ) ;随访时为 1.4± 0 .4,行动能力进一步改善。止痛药使用评分 ,术后 2d ( 0 .6± 0 .6 )较术前 ( 2 .2± 0 .5 )显著改善 (P <0 .0 1) ;随访时为 0 .8± 0 .6 ,与术后比较无显著变化。　结论　经皮穿刺椎体成形术是治疗椎体骨质疏松性压缩骨折的有效微创技术 ,单平面C形臂X线机透视监视即可满足     

CT下经额颧角蝶腭神经节穿刺影像解剖测量

【摘要】 目的 为临床经额颧角穿刺蝶腭神经节（PPG）阻滞提供影像解剖数据。方法 在需行PPG阻滞 6例患者的MRI影像图像下定位蝶腭神经节并确定相关骨性标志。在142例（284侧）患者的CT影像资料中模拟穿刺，对穿刺相关的解剖数据进行影像学测量。 结果 额颧角位于距眶外缘（17.01±2.44） mm的平行线与距眶下缘（7.54±3.02） mm的平行线交点处。经额颧角穿刺针与穿刺平面的正中线的夹角为（68.41±4.19）°，冠状面观穿刺针与冠状面正中线的夹角为（83.67±5.99）°，穿刺深度约为（57.45±2.88） mm。结论 CT下可通过明显的骨性标志引导穿刺，为临床穿刺提供直观、有价值的解剖信息。     

留置导管引流治疗结核性心包炎的疗效观察

目的 :探讨留置导管引流术在治疗结核性心包炎伴大量心包积液中的作用。方法 :采用非同期回顾性研究 ,将常规心包穿刺的 2 6例患者作为对照组 ,用留置导管引流的 2 4例患者为试验组。结果 :对照组与试验组消除心包填塞症状时间分别为 ( 1 7± 0 9)d及 ( 1 1± 0 3)d ;两组积液消失时间分别为 ( 9 5± 2 0 )d及 ( 5 7± 1 5 )d。结论 :留置导管引流可迅速消除心包堵塞症状 ,减少穿刺次数 ,能及时、彻底地引流心包积液 ,降低缩窄性心包炎的发生率     

兔肝动脉化疗栓塞术实验方法学的对比性研究

目的　探讨兔肝动脉化疗栓塞的实验方法。材料与方法　大耳白兔 168只 ,随机分为股动脉插管组(n =2 0 )及剖腹下直视穿刺组 (n =148) ,比较两种实验方法的手术及X线下操作时间、手术成功率、动物存活率。结果　股动脉插管组平均手术操作时间 145 .4± 2 4.6min ,X线透视时间 44 .3± 10 .7min ,手术成功率为 2 0 % ( 4/ 2 0 ) ,动物在术后 3天内均死亡。剖腹直视下穿刺组平均手术操作时间为 49.8± 12 .7min ,X线透视时间 7.9± 4.3min ,手术成功率为 97.3 % ( 144 / 148) ,长期存活率为 91.2 % ( 13 5 / 148)。经统计学检验 ,两者间有极显著性差异 (P <0 .0 1)。结论　直视下兔肝动脉细针穿刺行化疗栓塞术是一种简便、有效的实验方法     

应用穿间隔技术射频消融老年复杂病例

目的　介绍在老年患者应用穿间隔 (transseptal,TS)技术进行左侧后间隔及位置较高的外侧游离壁旁道的消融是安全、易行的方法。方法　回顾分析 2 2例阵发性室上性心动过速 (SVT)的患者 ,年龄 (6 5± 6 )岁(6 0～ 85 )岁 ,14例经常规方法消融未成功 ,改用穿间隔的方法 ,另外 8例中 3例经判断为左后间隔旁道及 5例高位外侧游离壁旁路后直接应用穿间隔技术。将直接穿间隔患者分为一组 ,其余病例分为另一组。应用Dag 8F鞘或Mullin鞘和Brockenbrough穿刺针 ,取正位影像在左房影下缘上一个椎体水平与脊椎右中 1/ 3垂线交点处 (冠状窦口上一个椎体 ) ,右前斜位 4 5°在房室沟与心外缘正中间 ,在卵圆窝处进行房间隔穿刺 ,术中应用肝素 30 0 0～ 5 0 0 0U。选用Cordis普通射频大头或EPTTMP大头 ,通过房间隔进行消融。消融术后行电生理检查及超声心动图检查 ,比较两组病例手术时间有无差别。结果　标测穿刺间隔后房室瓣环 ,划分内中外上四个区。 15例为左后间隔旁路 (内区 ) ,7例为位置较高的外侧游离壁旁路 (上区 )。消融术后电生理检查旁路前传逆传阻断 ,未诱发SVT ,消融成功。输出功率 18～ 30W ,放电 (10 0± 2 0 )s ,改用穿间隔组X线透视时间为 (5 5± 8.2 )min ,直接穿间隔透视时间为 (30± 6 .5 )min ,后者     

CT引导下胰腺假性囊肿外引流术的临床应用

目的　探讨CT引导下经皮胰腺假性囊肿穿刺置管外引流术的临床应用价值。方法1 997年 1月至 2 0 0 1年 1月 ,对 2 9例 [男 2 1例 ,女 8例 ;年龄 2 2～ 71岁 ,平均 (48.2± 1 3 .6)岁 ]各种原因引起的假性胰腺囊肿患者进行了CT引导下的经皮穿刺置管持续外引流术。通过CT扫描确定假性胰腺囊肿的位置、穿刺途径、角度及深度后 ,进行穿刺、置管外引流 ,并对引流后的情况进行随访观察。结果　 2 9例穿刺 30次 ,穿刺成功率 1 0 0 % ,穿刺入路包括腹前壁 1 7例 (1 8次 ) ,侧壁 8例 ,背部 4例。共放置引流管 30根。 2 8例得到随访 ,失随访 1例 ,随访期 1～ 2 0个月 [平均 (8.0 7± 4 .0 4 )个月 ]。其中 1 9例囊肿消失后拔管 ,拔管后随访期 4～ 1 4个月 ,平均 (8.2 9± 4 .0 3)个月 ,除 2例复发后再穿刺 ,有 1 7例未复发。 5例外引流后 1～ 4个月转行手术治疗 ,4例仍在随访中 ,治疗有效率 65 .52 % (1 9/2 9)。结论　CT引导下胰腺假性囊肿穿刺外引流术手术损伤小 ,安全有效 ,成功率高 ,并发症少     

活检同步微波消融治疗肋胸膜下肺结节的安全性及有效性

目的 探讨CT引导下穿刺活检同步微波消融治疗肋胸膜下肺结节的安全性及有效性。方法 选取31例患者31个高度可疑恶性肋胸膜下肺结节行CT引导下穿刺活检同步微波消融的资料，采用消融-活检-再消融治疗模式，首先行低功率低温微波凝固技术预消融病灶，其次行经皮穿刺活检术，最后行根治性微波消融治疗。分析患者的临床资料、技术成功率、并发症及近期疗效，评价活检同步微波消融治疗肋胸膜下肺结节的安全性及有效性。结果 活检同步微波消融治疗肋胸膜下肺结节技术成功率为100%,穿刺活检阳性率为93.5%,完全消融率为93.5%。术后3、6和12个月随访，总体局部无进展生存期率(LPFS)分别为87.1%、77.4%和70.9%。术后1例出现重度疼痛，2例发生气胸，1例出现胸腔积液，5例出现发热，无针道转移及死亡发生。结论 CT引导下穿刺活检同步微波消融治疗肋胸膜下肺结节安全有效。     

A Comparative Study of CT Fluoroscopy Combined with Fluoroscopy Versus Fluoroscopy Alone for Percutaneous Transhepatic Biliary Drainage

Purpose: We compared CT fluoroscopy (CTF) for the initial puncture of bile ducts with conventional fluoroscopic guidance in patients with malignant jaundice in whom percutaneous transhepatic biliary drainage (PTBD) was planned. Methods: Forty consecutive patients were randomized to two study groups: group A underwent PTBD under CTF and fluoroscopic guidance, group B underwent PTBD under fluoroscopic guidance alone. CTF-guided PTBD was performed using a combination of a helical CT scanner of the latest generation and a mobile C-arm; conventional PTBD was performed under fluoroscopic guidance in the angiographic unit. End points of the study were the success (a puncture that enabled safe placement of a guidewire in a suitable bile duct) and the complication rate (hemobilia, bile fistula, biliary peritonitis), the number of punctures required, the time needed for successful puncture of a suitable bile duct, and the patient's radiation exposure. Results: CTF-guided puncture of peripheral bile ducts suitable for PTBD was successful at the first attempt in 16 cases, under conventional fluoroscopic guidance, in only two cases. We found a significantly different number of punctures (1.2 in group A vs 2.9 in group B), a significantly shorter time for puncture in group A (mean 39 sec), but also a significantly higher skin exposure dosage in group A (mean 49.5 mSv surface dosage). There was no significant difference regarding the total procedure time. Only one complication occurred in group B (portobiliary fistula). Conclusion: CTF-guided initial puncture of bile ducts allowed a significantly reduced number of punctures and puncture times compared with puncture under conventional fluoroscopic guidance for placement of percutaneous transhepatic biliary drainage catheters.     

实时超声引导静脉穿刺在增强CT检查肥胖患儿中的应用价值

 目的 探讨实时超声引导及动脉穿刺针用于肥胖患儿肘正中静脉穿刺置管进行增强CT检查的临床效果及优势。方法 选取2013-12至2015-10我院小儿骨科及骨肿瘤科收治年龄5~14周岁,体重指数BMI>24,拟行肘正中静脉穿刺置管的患儿共60例进行本研究,按计算机生成随机数字表分为传统操作方法组(TM组,n=30)及实施超声引导组(UG组,n=30)。观察并记录两组的穿刺准备时间、穿刺置管时间、总时间、进针次数及成功率,置管成功后即刻及置管后24 h观察并记录有无并发症的发生,置管后24 h随访家长对穿刺工作满意度。结果 US组穿刺置管前准备时间(3.4±0.7)min较TM组(1.9±0.7)min 较长,差异有统计学意义(P<0.01),穿刺置管时间明显短于TM组[TM组(3.8±4.9)min vs US组(1.4±0.5) min,P=0.041],两组患者总操作时间差异无统计学意义;US组进针次数均为1针,明显少于TM组(TM组2.0±1.8次 vs US组1.0±0.0次,P=0.028),两组患儿出现并发症情况、患儿配合度及家长满意度差异无统计学意义。结论 超声引导肘正中静脉穿刺可以明显缩短穿刺时间,明显减少反复进针次数,提高置管成功率,避免并发症发生。     

Complications associated with percutaneous nephrolithotripsy: supra- versus subcostal access. A retrospective study

Purpose: 
Percutaneous nephrolithotripsy is an essential procedure for treating complex urinary calculi. To achieve optimal access to a large and complicated stone, an upper calyx puncture is often preferable. However, when performing a puncture above the 12th rib there is risk of an increased number of complications. In this retrospective study, we assessed the kind and frequency of complications after sub- and supracostal punctures of the collecting system of the kidney. Material and Methods: 
Between 1996 and 2001, 85 patients were treated with percutaneous nephrolithotripsy. In 63 patients a subcostal track, below the 12th rib was established. Puncture was performed under ultrasonic or fluoroscopic guidance in 61 patients and CT-guided in 2 patients. In 17 patients a supracostal puncture, above the 12th rib, was performed under CT guidance and in 5 patients with US or fluoroscopic guidance. Result: 
The main difference regarding preoperative complications was the number of patients complaining of respiratory correlated pain, 7 (32%) in the supracostal puncture group compared with 3 (5%) in the subcostal puncture group. No significant difference regarding peroperative complications was found. Postoperatively, there were 2 major bleedings, one in each group, which had to be treated with arterial embolization. In the supracostal puncture group there were 2 patients with pleural effusion and 2 patients with pneumothorax. Conclusion: 
The complication rate was slightly higher after supracostal puncture as compared with a subcostal approach, especially regarding respiratory correlated pain. When performing a supracostal puncture there is an increased risk that the track passes through the pleural space, which might explain the difference in the panorama of complications.     

Use of a puncture needle for recanalization of an occluded right subclavian vein

We report a patient in whom we used a puncture needle to initiate percutaneous recanalization of a chronic occlusion of the junction between the right subclavian vein and the right brachiocephalic vein. Under fluoroscopic guidance, an 18-gauge needle was used to puncture the right subclavian vein. When contrast material injected through the needle confirmed intravascular location, the needle was advanced until it deflected and perforated an occlusion balloon target positioned within the right brachiocephalic vein. This technique may be useful in patients with central venous occlusions that are refractory to traversal using traditional catheter and guidewire techniques.     

Navigation-based needle puncture of a cadaver using a hybrid tracking navigational system

PURPOSE: The purpose of this study was to determine the puncture accuracy of a navigational system, Medarpa, in a soft tissue environment using augmented overlay imaging. MATERIALS AND METHODS: Medarpa is an optical electromagnetic tracking system, which allows tracking of instruments, the radiologist's head position, and the transparent display. The display superimposes a computed tomography scan of a cadaver chest on a human cadaver in real time. In group A, needle puncture was performed using the Medarpa system. Three targets located inside the cadaver chest were selected. In group B, the same targets were used to perform standard computed tomography-guided puncture using a single-slice technique. A total of 42 punctures were performed in each group. Postpuncture computed tomography scans were made to verify needle tip positions. RESULTS: Mean deviation from targets was 8.42 mm +/- 1.78 mm for group A and 8.90 mm +/- 1.71 mm for group B. No significant difference was found between group A and B in any target (P > 0.05). No significant difference was found between the targets of the same group (P > 0.05). Procedural time for 42 punctures was 160 minutes in group A versus 289 minutes in group B (P < 0.05). CONCLUSION: Needle puncture in a soft tissue environment using the navigational system Medarpa can be reliably performed and matches the accuracy achieved by a computed tomography-guided puncture technique.     

Transovale trigeminal cistern puncture: modified fluoroscopically guided technique

A simple, safe, and rapid radiologic technique is described for trigeminal puncture via the foramen ovale. A radiopaque marker is placed 3 cm lateral to the labial commissure. Then, under fluoroscopic guidance, the patient's head is turned until the marker is projected vertically, over the foramen ovale. The needle can be advanced along the anatomically safe line determined by the foramen ovale and the lateral labial puncture site. Needle or patient misalignment is detected readily and can be corrected using fluoroscopic guidance. The technique is learned easily, obviates multiple needle passes, and takes less than 5 min.     

J-tipped guidewire as a target for puncture of the subclavian artery in the placement of a reservoir port and catheter system

The aim of this study was to verify the feasibility of using a J-tipped guidewire as a target for puncture of the subclavian artery in the placement of a reservoir port and catheter system (RPCS). Twenty-five patients with various hepatic malignancies underwent percutaneous implantation of an RPCS through the left subclavian artery for regional chemotherapy. To successfully puncture the left subclavian artery, a J-tipped guidewire was used as a target with fluoroscopic guidance. Technical success and complication rates, and numbers of puncture failures, were retrospectively analyzed. Implantation of the RPCS was successful in all patients. Eight (32%) patients had minor complications and no patient had major complications. The number of puncture failures per patient was 0 to 1 (mean=0.32). The J-tipped guidewire is a safe and appropriate target for puncture of the subclavian artery in the placement of an RPCS.     

Feasibility of Augmented Reality–Guided Transjugular Intrahepatic Portosystemic Shunt

PurposeTo investigate an augmented reality (AR)–guided endovascular puncture to facilitate successful transjugular intrahepatic portosystemic shunt (TIPS).Materials and MethodsAn AR navigation system for TIPS was designed. Three-dimensional (3D) liver models including portal and hepatic vein anatomy were extracted from preoperative CT images. The 3D models, intraoperative subjects, and electromagnetic tracking information of the puncture needles were integrated through the system calibration. In the AR head-mounted display, the 3D models were overlaid on the subjects, which was a liver phantom in the first phase and live beagle dogs in the second phase. One life-size liver phantom and 9 beagle dogs were used in the experiments. Imaging after puncture was performed to validate whether the needle tip accessed the target hepatic vein successfully.ResultsEndovascular punctures of the portal vein of the liver phantom were repeated 30 times under the guidance of the AR system, and the puncture needle successfully accessed the target vein during each attempt. In the experiments of live canine subjects, the punctures were successful in 2 attempts in 7 beagle dogs and in 1 attempt in the remaining 2 dogs. The puncture time of needle from hepatic vein to portal vein was 5–10 s in the phantom experiments and 10–30 s in the canine experiments.ConclusionsThe feasibility of AR-based navigation facilitating accurate and successful portal vein access in preclinical models of TIPS was validated.     

Echocardiography-guided transseptal left atrial puncture: a safe approach to percutaneous transvenous mitral commissurotomy]

Transseptal left atrial puncture has generally been carried out under fluoroscopic control. In our experience, cardiac tamponade occurred in 3 of 83 cases during transseptal puncture for percutaneous transvenous mitral commissurotomy (PTMC) and percutaneous transvenous aortic valvuloplasty (PTAV). We tried to perform the puncture under simultaneous fluoroscopic and 2DE guidance to decrease the rate of complications. As a result, no complication has occurred in 55 cases. Furthermore, 2DE indicated that directing the puncture needle towards 4 or 5 o'clock was inappropriate, but that 3 o'clock was an appropriate direction for puncture of the fossa ovalis of a left atrium dilated because of mitral stenosis. In conclusion, transseptal left atrial puncture can safely and easily be carried out under a combination of fluoroscopic and 2DE guidance, as this procedure displays the correct position and direction of the needle tip for interatrial septal puncture.     

Magnetic resonance image-guided trans-septal puncture in a swine heart

PURPOSE: To test the feasibility of performing magnetic resonance (MR)-guided trans-septal punctures in the swine heart. MATERIALS AND METHODS: All procedures were performed in a 1.5-T MR scanner. A novel, active MR intravascular needle system was utilized for needle tracking and septal punctures. Trans-septal punctures were performed in five swine using electrocardiogram (ECG)-gated high resolution and non-ECG-gated, real-time MR imaging techniques. The intravascular needle was advanced over a guidewire from the femoral vein. Once the needle was in proper position, trans-septal punctures were made. RESULTS: Active tracking of the needle traversing the septum was possible. The location of the catheter tip was confirmed using real time gradient recalled echo (GRE). After a confirmatory ventriculogram with gadolinium-DTPA, a 0.014-inch guidewire was advanced into the left atrium and left ventricle. All punctures were made with no change in cardiac rhythm or rate; postmortem analysis was performed on all animals and demonstrated that 18/19 (95%) punctures were directly through the fossa ovalis. CONCLUSION: Using only MR guidance and a novel active intravascular needle system, we were able to repeatedly puncture the fossa ovalis in a swine heart from a transfemoral approach, with direct visualization of all components, including the needle, the atria, the fossa ovalis, and the surrounding vasculature.