双侧股静脉入路在左下肢深静脉血栓介入治疗中的应用

目的 探讨采用双侧股静脉入路介入插管溶栓方法治疗左下肢深静脉血栓的可行性.方法 对18例从右股静脉或右颈静脉入路行左髂股静脉插管失败的急性左下肢深静脉血栓患者.采用左侧股静脉顺行法穿刺,注射埘比剂证实穿刺成功后将导丝插入至下腔静脉,将导丝从右侧股静脉或颈静脉穿出或拉出后建立导丝轨道,冉沿导丝将导管自右向左逆行插入左侧髂...     

数字减影血管造影辅助B超引导下行PICC的临床应用

 经外周静脉穿刺置入中心静脉导管（peripherally inserted central catheter,PICC）是指经贵要静脉、肱静脉、头静脉或肘正中静脉穿刺置管,导管的末端位于上腔静脉的下1/3处或上腔静脉与右心房交界处^［1］。PICC 因其明显的优点已被临床广泛应用,但由于临床插管多为在床边盲穿,穿刺成功后再至放射科行胸片检查,可能存在导管不能到达理想位置的情况。目前,临床多采用B超引导取代传统的盲穿置管术,明显提高了穿刺和置管的成功率,降低了并发症的发生。但对于临床上不适合盲穿的患者,单纯采用B超引导效果并不是很好,笔者尝试采用数字减影血管造影机（digital subtraction angiography,DSA）辅助下B超引导PICC 置管术,取得了良好的临床效果。     

DSA引导下调整中心静脉置管头端异位的尝试

目的 探索调整经外周中心静脉置管(PICC)头端异位的新方法.方法 在X线透视下,应用DSA技术,将异位导管的头端按血管走行重新置入上腔静脉与右心房交界处的理想位置.结果 本组共13例PICC头端异位患者采用DSA引导下调整,成功率100%,调整所需平均时间为15.5 min,与床边盲调比较所需时间显著缩短.结论 临床上PICC导管头端异位发生率高,且难以避免.采用DSA引导下调整PICC头端异位,具有成功率高、安全性强和操作时间短等优点,值得在临床上推广.     

深静脉置管

深静脉穿刺留置导管,是目前临床上输血、补液、静脉内营养支持、给药和测定中心静脉压的公认的重要诊疗措施。随着深静脉穿刺定位的解剖学研究的不断深入和临床工作者的广泛实践,积累了较多的经验,大大提高了穿刺成功率;但穿刺成功并不等于置管成功。置管能否成功还与置管方法、导管的种类等密切相关。1　导管的选择与操作要领11　导引钢丝置管　导引钢丝置管,目前临床应用较多的是美国生产的ＡＲＲＯＷ中心静脉导管,这种导管质量可靠,不会发生导管尖端裂开,该种导管将穿刺与置管两项操作合二为一,注射器针柄内有1根钢制管道直通前端,管道内…     

应用输液测压法减少深静脉置管过程中的动脉损伤

目的深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%4.5%,导致动脉损伤的发生率为0.1%⁰.5%。使用输液测压法可以成功鉴别穿刺针是否刺入动脉,从而避免动脉置管和动脉损伤。方法回顾性统计分析我科5年来所有深静脉置管病例的穿刺过程和结果。结果观察期内共完成12 021例深静脉穿刺置管。其中应用输液测压法958例。在5年观察期内,没有患者发生动脉损伤。结论深静脉置管时应用输液测压法可有效确认置管是否于静脉,从而避免动脉置管导致动脉损伤。     

恶性输尿管梗阻的综合介入治疗18例

【摘要】 目的 探讨膀胱镜下输尿管支架置入失败或无法置入的恶性输尿管梗阻患者介入治疗策略。方法 收集2016年1月到2019年9月因恶性输尿管梗阻行膀胱镜下输尿管支架置入失败患者18例,共22条梗阻输尿管,先采用经皮穿刺肾盂,常规或改良的微导丝贯通技术建立贯通通道,然后利用交换导管导丝技术,逆行置入输尿管支架,对常规及改良法都无法建立微导丝贯通的患者行经皮肾盂造瘘术。 结果 所有的22条梗阻输尿管均采用介入方法得到了治疗,18例患者22条梗阻输尿管中,常规微导丝贯通术成功18条,4条常规微导丝贯通失败患者,均行改良微导丝贯通术,成功3例,其中2例为膀胱全切术后回肠代膀胱、回肠造瘘患者,均成功放置输尿管支架,1例改良微导丝贯通术通过输尿管重度狭窄段并成功逆行置入输尿管支架,1例改良微导丝贯通失败患者改行经皮肾盂造瘘术。所有微导丝贯通成功患者术后均未见肉眼血尿;术后第7天所有患者肾盂输尿管扩张较术前明显好转,术后第7天患者肌酐水平（88.89±22.19） μmol/L,较术前（233.44±125.63） μmol/L有明显下降,差异有显著统计学意义（T=5.329 P＜0.001）。结论 对于膀胱镜下输尿管支架置入失败的恶性输尿管梗阻患者,介入术中首先采用经皮穿刺肾盂,利用常规或者改良微导丝贯通技术逆行置入输尿管支架,若无法行微导丝贯通,则行经皮穿刺肾盂造瘘术。综合介入方法能够解除恶性输尿管梗阻患者的梗阻症状,明显降低患者的肌酐水平,改善患者的肾功能,值得推广。     

超声引导特殊体位下颈内静脉穿刺置管56例临床效果分析

目的探讨超声定位对特殊体位下颈内静脉穿刺置管的临床价值。方法对特殊体位下超声定位颈内静脉穿刺置管56例进行回顾性分析。结果本组56例经颈内静脉成功置管55例,其中半卧位穿刺置管52例,端坐位穿刺置管4例,成功率98.21%,失败1例改行超声定位经同侧锁骨下静脉穿刺置管成功,全程操作时间7-15min,平均10min;其中并发局部血肿1例,无气胸、神经损伤、空气栓塞发生。结论超声定位下特殊体位颈内静脉穿刺置管高效、准确、安全,可作为提高一次性穿刺成功率及降低特殊体位深静脉穿刺置管风险的有效措施,具有较好的临床实用价值。     

超声引导在颈内静脉穿刺置管困难时的应用价值

目的探讨彩色多普勒超声实时引导对颈内静脉置管困难患者的应用价值。方法将80例颈内静脉置管困难患者采用完全随机方法分为盲探穿刺组(A组)和超声引导组(B组),观察两组病人的置管率。结果 40例颈内静脉穿刺置管术在盲探穿刺下,27例穿刺成功,13例穿刺失败,置管成功率为67.5%;40例颈内静脉穿刺置管术在超声引导下,39例成功,1例穿刺失败,置管成功率97.5%。结论彩色多普勒超声实时引导颈内静脉置管有重要的应用价值。     

老年患者对PICC置管认同性调查分析

目的了解老年患者对外周静脉穿刺置入中心静脉导管(PICC)相关知识的认知度,分析PICC在老年患者中推广使用的难度,便于PICC的普及和开展。方法采用自行设计的调查问卷表,对116例老年患者进行调查,其内容包括:患者的个人情况及对PICC相关知识的认知度。结果患者对PICC的认知度均存在较大盲区,仅有11.2%患者熟悉PICC置管概念,21.6%的患者认为PICC安全性高,45.6%的患者认为PICC置管对血管有保护作用,83.6%的患者愿意承担PICC相关费用,另外13.8%的患者认为PICC置管对日常生活没有影     

老年重症病人深静脉置管术的护理

经皮穿刺外周中心静脉置管(PICC)在静脉高价营养、中心静脉压监测、危重病人抢救等方面得到广泛应用。但临床上由于老年患者血管壁硬,弹性差,易滑动,周围循环差,使穿刺难度和并发证的发生率增加,使其应用受到一定的限制。为了解决老年病人深静脉置管的特殊性,特别是对于需要长期输液而表浅静脉穿刺困难以及肿瘤化疗的老年病人,合理的保护好静脉,避免每天穿刺给患者带来的痛苦,现将48例老年重症病人深静脉置管术的术前准备、穿刺要点及术后并发证预防体会报告如下:     

Managing peripherally inserted central catheter-related venous thrombosis: How I do it

Imaging-guided insertion of central venous catheters, either in the form of a peripherally inserted central catheter (PICC) or through a subclavian or a jugular approach, is becoming the preferred method of acquiring long-term venous access for a variety of therapeutic purposes. The most significant complication from central venous catheters is thrombosis of the catheterized vein. Venous thrombosis related to the insertion of PICC lines is conventionally treated with line removal followed by anticoagulation. Direct thrombolysis with urokinase, using the lumen of the PICC line to facilitate the insertion of the infusion catheter is a simple, safe and effective treatment option. In this article, we describe our experience with this procedure and the technique used.     

Peripherally inserted central catheters and upper extremity deep vein thrombosis

The purpose of the study was to determine the incidence and risk factors for venous thrombosis in patients with a peripherally inserted central catheter (PICC). A retrospective study of all upper extremity venous duplex scans was carried out in the Vascular Medicine department from year 2000 to 2002 inclusive. A chart review of positive scans was undertaken to identify possible thrombotic risk factors. Of 317 upper extremity venous duplex scans carried out, 115, or 32%, were positive for upper extremity deep vein thrombosis. Three main risk factors were identified - presence of a central line, malignancy and administration of chemotherapy. PICC were the most common central line present. Symptomatic thrombosis occurred in 7% of PICC inserted for chemotherapy compared with 1% of PICC inserted for other reasons. Ten per cent of the patients receiving chemotherapy through a PICC developed a thrombosis. The post-thrombotic syndrome was infrequent following upper extremity deep vein thrombosis. Patients receiving chemotherapy through a PICC are at increased risk of thrombosis. There may be a role for prophylactic low-dose anticoagulation in these high-risk patients.     

Venous thrombosis associated with the placement of peripherally inserted central catheters

PURPOSE: Peripherally inserted central catheters (PICCs) have become an essential component of the management of an increasing number of patients, including patients who may require hemodialysis. Reported symptomatic venous thrombosis rates associated with PICC lines are based on clinical signs and symptoms and range from 1% to 4%. The purpose of this study is to evaluate the true rate of thrombosis of upper extremity veins after the placement of PICCs and the potential impact on future access in hemodialysis patients. MATERIALS AND METHODS: A retrospective analysis was performed. Patients who had (i) normal findings during initial venography, (ii) PICC placement, and (iii) who underwent subsequent repeated venography were included. Age, sex, vein cannulated, catheter size, location, and incidence of thrombosis were analyzed. RESULTS: Three hundred fifty-four PICCs were placed in 119 patients. Of the 144 extremities, 137 had normal findings during initial venography. Of the 137 extremities, 32 developed thrombosis of the cannulated vein (or central veins) after initial PICC placement (23.3%). When all extremities with multiple PICC lines placed were considered, 52 developed thrombosis, for an overall thrombosis rate of 38%. The incidence of thrombosis by site was cephalic 57%, basilic 14%, and brachial 10%. No significant differences were noted in the rates of thrombosis by age, sex, or catheter size. CONCLUSIONS: There is a relatively high rate of venous thrombosis associated with PICCs, particularly cephalic thrombus. Because of the high rate of thrombosis associated with these catheters, an alternative mode of access should be considered in current or potential hemodialysis patients. All patients with a history of PICC line placement requiring dialysis access should undergo upper extremity venography prior to the placement of permanent access.     

A nurse led peripherally inserted central catheter line insertion service is effective with radiological support

AIM: Peripherally inserted central catheters (PICC) are increasingly used as a route of chemotherapy administration. Our aims were to assess a collaborative approach to PICC placement, with radiological support for a nurse led line insertion service in a minority of cases, and to determine whether PICC provided a safe and reliable method of chemotherapy administration. MATERIALS AND METHODS: Prospective data on 100 consecutive patients undergoing PICC placement for chemotherapy were collected. Lines were inserted by ward based nurses or under ultrasound guidance by radiologists. End points were successful completion of treatment or patient death. RESULTS: One hundred and forty-four lines were placed for 118 courses of chemotherapy. 107 (74%) were placed by nurses and 37 (26%) by radiologists. Ninety-five percent of patients completed therapy with either one or two lines. Seventy percent of lines were removed on achieving the primary end points. In two additional patients PICC could not be placed radiologically. Twelve patients were unable to complete treatment with PICC alone, nine of these required an alternative administration route. The catheter related sepsis rate was 4.9%. CONCLUSION: The majority of PICC can be successfully placed by trained nurses, reserving image guidance only for more difficult cases. PICC have an acceptable complication profile, and decrease the need for tunnelled central lines.     

Incidence of upper limb venous thrombosis associated with peripherally inserted central catheters (PICC)

The objective of this study was to prospectively determine the incidence of venous thrombosis (VT) in the upper limbs in patients with peripherally inserted central catheters (PICC). We prospectively investigated the incidence of VT in the upper limbs of 26 patients who had PICC inserted. The inclusion criteria were all patients who had a PICC inserted, whilst the exclusion criterion was the inability to perform a venogram (allergies, previous contrast medium reaction and inability of gaining venous access). Both valved and non-valved catheters were evaluated. Prior to removal of the PICC, an upper limb venogram was performed. The number of segments involved with VT were determined. The duration of central venous catheterization was classified as; less than 6 days, between 6 days and 14 days and more than 14 days. VT was confirmed in 38.5% (10/26) of the patients. The majority 85.7% (12/14) were complete occlusive thrombi and the majority of VT only involved one segment. There was no statistical correlation between the site of insertion of the PICC and the location of VT. Neither was there any observed correlation between the occurrence of VT with the patient's history of hypertension, hypercholesterolaemia, coronary artery disease, diabetes mellitus, cardiac insufficiency, smoking or cancer. There was also no statistical correlation with the size of the catheter. In conclusion, PICCs are associated with a significant risk of upper extremity deep vein thrombosis (UEVT).     

Prospective evaluation of PICC line related complications

PURPOSE: To report the occurrence of complications following placement of peripherally inserted central catheters (PICC). Materials and methods. A total of 127 PICC lines were placed in 115 patients for TPN (n=54), long-term antibiotics (n=29), chemotherapy (n=14) or miscellaneous intravenous therapy (n=18). RESULTS: All PICC lines were successfully inserted. PICC lines were used for a mean duration of 16 days (1-166 days). The following complications were recorded: occlusion (7%), rupture (1.6%), accidental withdrawal (2.4%), infection (3.1%) and venous thrombosis (2.4%). CONCLUSION: PICC lines are a simple, safe and effective alternative to conventional central venous catheters. The occurrence of complications, typically "mechanical", must be reduced and prevented by strict management of this type of central line by the treating team.     

Outcomes of Venoplasty-Assisted,Peripherally Inserted Central Catheter Placement in Patients with Upper-Arm Venous Stenosis: Comparison with Midlines and Contralateral Placement

PurposeTo compare the effectiveness and safety of percutaneous transluminal angioplasty and peripherally inserted central catheter (PTA + PICC), contralateral PICC, and midline catheterization (MC) in patients with venous stenosis.Materials and MethodsA total of 7,327 PICC procedures were performed in 5,421 patients at a single institution between 2013 and 2019. Among them, 87 patients had upper-arm venous stenoses and were managed with PTA + PICC, contralateral PICC, or MC. Data on catheter-dwell time, clinical success rate, and adverse events were recorded. The procedure was considered to have clinically succeeded when a PICC was removed from the patient just before discharge or after the completion of therapy. Catheter survival time and the chance of adverse events were compared among the groups using the Kaplan-Meier method and log-rank test.ResultsPTA + PICC, contralateral PICC, and MC procedures were performed for 57 (65.5%, 57/87), 10 (11.5%, 10/87), and 20 (23.0%, 23/87) patients, respectively. The mean catheter-dwell time in the PTA + PICC, contralateral PICC, and MC groups was 49.7, 28.7, and 15.1 days, respectively, and the clinical success rate of each group was 86.0% (49/57), 80.0% (8/10), and 50.0% (10/20). The PTA + PICC group had a significantly longer catheter survival time than the MC group (P < .001). The chance of a catheter-related infection (P = .008) was significantly lower in the PTA + PICC group than in the MC group.ConclusionsPTA + PICC or contralateral PICC should be considered prior to ipsilateral MC when venous stenosis is encountered during PICC procedures.     

Venous thrombosis related to peripherally inserted central catheters

PURPOSE: To determine factors that may lead to venous thrombosis in patients with peripherally inserted central catheters (PICC). MATERIALS AND METHODS: The medical records of 678 patients with 813 PICCs during 1997 were cross-referenced with all patients receiving venous duplex examinations (1,631) during the same time period. Multiple factors were examined in the patients with catheter-related thrombosis, including diagnosis, solution infused, catheter tip position, vein accessed, and catheter diameter. RESULTS: Nurses placed 269 PICCs with 12 venous thromboses, for a rate of 4.5%. Radiologists placed 544 PICCs with 20 venous thromboses, for a rate of 3.7%. There was no significant difference in these rates. The overall thrombosis rate was 3.9%. After multivariate analysis, only catheter diameter remained significant. There were no thromboses in catheters 3 F or smaller. The thrombosis rate was 1% for 4-F catheters, 6.6% for 5-F catheters, and 9.8% for 6-F catheters. CONCLUSIONS: Thrombosis rate associated with PICCs was low (3.9%). The smallest acceptable catheter diameter should be used to decrease the incidence of venous thrombosis.     

Use of a Peripherally Inserted Central Catheter as a Conduit for Central Venous Access Across Thrombosed Great Veins

This report describes a technique of inserting an implantable venous access port (portacath) through a thrombosed and occluded vein employing a pre-existing peripherally inserted central catheter (PICC) as the route of access. The PICC was used as a conduit for venous access in a way that has not been described previously in the literature. This procedure was performed in a young patient with cystic fibrosis in an effort to prevent the use of his virgin contralateral veins, which might be used in the future.     

Institution of a Hospital-Based Central Venous Access Policy for Peripheral Vein Preservation in Patients with Chronic Kidney Disease: A 12-Year Experience

PurposeTo describe the implementation of nursing-based venous access team (VAT) and standardized interventional radiology (IR) protocols in accordance with Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines to provide central venous access while preserving peripheral veins in patients with chronic kidney disease (CKD).Materials and MethodsReview of peripherally inserted central catheter (PICC) and small-bore central catheter (SBCC) referral and placement data from VAT and IR databases was conducted over a 12-year period. SBCC referral was automatic for patients with creatinine levels ≥ 3 mg/dL or a renal transplant regardless of creatinine level unless dialysis was not planned. All SBCC insertions, regardless of referral source, were identified and reviewed, and SBCC placements prompted by K/DOQI PICC contraindication were identified. Catheter types, indications, access sites, technical success, and complications were ascertained.ResultsA total of 35,781 requests for PICC placement were made to the VAT; 1,889 (5%) were referred to IR for SBCC placement per institutional policy, and 2,200 SBCCs were attempted or newly placed during this period, 1,879 (85%) based on K/DOQI contraindications. Primary indication for SBCC placement was antibiotic therapy (59%). Access sites included right internal jugular vein (IJV) (70%), left IJV (24%), right external jugular vein (EJV) (3%), left EJV (2%), right common femoral vein (CFV) (0.3%), and left CFV (0.2%). Technical success rate of SBCC insertion was 99%. Six minor (0.3%) and three major (0.1%) complications occurred.ConclusionsAutomatic referral for SBCC placement in patients with CKD via VAT and IR protocols may eliminate PICC placement and thereby protect peripheral veins needed for hemodialysis. SBCC placement has high technical success and low complication rates.