经皮肱动脉穿刺技巧及其并发症的防治探讨

目的总结经皮肱动脉穿刺的临床经验,并探讨相关并发症发生的原因及其预防处理对策。方法回顾性总结因行血管腔内诊疗接受超声引导下肱动脉穿刺87例患者的临床资料。结果 87例患者在超声引导下行肱动脉穿刺均成功,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35例(39%)。16例(19例次)患者发生了并发症,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部位的解剖特点,掌握相应的操作技巧、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。     

肱静脉非超声引导下MST技术在外周血管条件差患者中的应用

目的总结非超声引导下运用MST技术在外周血管条件差患者中的应用经验。方法回顾性分析30例应用MST技术经外周置入中心静脉导管(PICC)患者的临床资料。结果 30例患者PICC均获成功,其中1次穿刺成功28例,2次成功2例。结论根据肱动脉与两条肱静脉伴行的局部解剖结构,确定穿刺部位,应用MST技术进行PICC置管,使新技术在没有置管专用血管超声仪的情况下,成功率高,经济,效果肯定。     

掌上无线超声引导桡动脉穿刺置管的护理配合

目的 总结掌上无线超声引导桡动脉穿刺置管的护理配合要点。 方法 对51例患者采用掌上超声定位桡动脉穿刺置管,护理配合包括患者准备、仪器及耗材等准备,Allen试验评估,穿刺中配合医生摆放穿刺体位、进行桡动脉穿刺配合,穿刺后护理及常见并发症处理等。 结果 51例均完成置管,其中一次穿刺成功44例（86.28%）,1例5次穿刺成功患者出现穿刺处血肿,其余患者未发生感染、血管痉挛、动脉血栓、神经损伤等并发症。 结论 高效、规范的护理配合可提高掌上无线超声引导桡动脉穿刺置管成功率,减少并发症。     

肱动脉入路在腔内治疗中的应用及穿刺并发症分析

目的探讨经肱动脉入路行动脉造影和动脉成形的适应证、并发症及其预防措施,以提高腔内治疗的成功率,降低肱动脉穿刺并发症发生率。方法回顾分析2007年1月～2011年12月采用Seldinger技术通过肱动脉穿刺行动脉造影及动脉成形86例106例次的临床资料。分析肱动脉入路的适应证、穿刺并发症及其形成原因、预防措施。结果通过肱动脉入路行动脉造影的成功率为100%(56/56),动脉成形的成功率为84.0%(42/50)。并发症发生率2.8%(3/106),为局部血肿(2例)和假性动脉瘤(1例)。结论肱动脉入路的适应证包括:股动脉无法穿刺,股动脉入路影响力量的传导,股动脉入路无法提供靶血管的受力点,锁骨下动脉开口的定位。本组肱动脉穿刺的并发症为血肿和假性动脉瘤。规范的穿刺及压迫止血技术、充分认识肱动脉解剖学特点可以减少肱动脉穿刺的并发症。     

心脏术后有创动脉压力监测中并发症的预防及护理

回顾性分析了225例心脏直视术后患者行有创动脉压力监测的护理经验.在局麻下行桡动脉置管术217例,肱动脉置管术6例,股动脉置管术2例.结果 9例发生置管并发症,其中导管堵塞5例,出血4例(穿刺处渗血2例,拔管后局部出血2例),无感染、血管堵塞、肢体肿胀、导管滑脱等其他并发症发生.提出有创动脉压力监测是心脏直视手术后重要的监测手段,如果护理不当会导致一系列并发症,影响监测质量.做好置管的护理,确保其测定的准确性,避免并发症的发生,是心脏手术成功的重要保证.     

彩色多普勒超声引导经皮肾穿刺避免损伤肾血管的临床应用价值

目的 探讨彩色多普勒超声在经皮肾取石术(percutaneous nephrolithotomy,PCNL)穿刺引导中避免肾血管损伤的临床应用价值.方法 分析2006年2月至2006年8月110例彩色多普勒超声引导的PCNL术,所有患者均进行黑白超声波与彩色多普勒超声探查并进行自身对照,先用黑白超声波设计入路,再在同一切面上使用彩色多普勒超声,若入路上有明显肾血管经过则重新调整入路,在彩色多普勒超声实时引导下穿刺进针.结果 110例患者彩色多普勒超声引导PCNL术均获成功.其中15例通过彩色多普勒超声检查发现原超声波设定入路上的肾血管并重新设定穿刺路径,有效避免直接损伤肾血管,占总例数的13.6%(15/110)(确切概率法P=0.035).所有患者术中术后均无大出血和动静脉瘘等严重并发症的发生.结论 彩色多普勒超声引导PCNL术中穿刺能确切避开肾血管,提高手术安全性和精确性,有效减少PCNL手术并发症.     

超声引导下腘动脉逆行穿刺在股浅动脉长段闭塞介入治疗中的应用

目的探讨超声引导下腘动脉逆行穿刺在股浅动脉长段闭塞介入治疗中的应用价值。方法分析本院2013年8月至2017年11月应用超声引导下腘动脉逆行穿刺后行双向内膜下血管成形术(SAFARI)或内膜下血管成形术(SIA)治疗的25例患者资料。患者均在超声引导下逆行穿刺腘动脉,然后介入引导下行SAFARI或SIA,比较患者手术前后症状及踝肱指数(ABI)的变化。结果 25例患者穿刺均获得成功,其中18例行SAFARI,7例行SIA,无严重并发症发生,7例患者腘动脉穿刺鞘未使用。ABI由术前平均0.37±0.19提高至术后1周的0.78±0.23,差异有统计学意义(P0.05)。手术时间为60~175分钟,平均(126±15)分钟,超声引导下腘动脉逆行穿刺时间为3~11分钟,平均(6±2)分钟。术中造影剂用量为40~125 ml,平均(75±15)ml。结论超声引导下腘动脉逆行穿刺后行SAFARI或SIA是股浅动脉长段闭塞介入治疗的一种新思路,能缩短手术时间、减少造影剂用量、降低射线接触量;但带来的收益与腘动脉穿刺点并发症带来的风险之间的利弊权衡,需进一步探讨。     

超声引导微通道经皮肾镜下碎石术的应用研究(附896例报告)

目的:探讨超声引导下行微通道经皮肾镜下碎石术(mini-PNL)治疗上尿路结石的可行性和优越性.方法:超声引导下行mini-PNL术共896例,其中肾鹿角形结石396例,肾盂结石350例,输尿管上端结石143例,移植肾结石7例.结果:896例患者中146例(16.3%)术前超声评估患肾积水较轻,而穿刺前输尿管插管,注生理盐水形成人工肾积水便于穿刺.872例(97.3%)患者1次穿刺成功,其余24例(2.7%)于一周后经第2次穿刺,22例成功,2例改行X线定位穿刺成功;碎石术中B超发现345例(38.5%)存在＞5 mm结石,在超声引导下定位并粉碎.术后每两周超声随访,1个月后,896例患者中823例(91.8%)结石完全清除,73例(8.2%)有残余小结石.并发症包括发热111例(12.3%),其中8例高热伴发菌血症败血症;出血138例(15.4%),其中2例发生下腔静脉损伤,但无严重出血发生;胸腔积液3例(0.3%);无腹腔内脏器损伤发生.结论:超声能对拟行mini-PNL术的病例作出准确判断,指导术前准备;术中超声引导可提高穿刺成功率,并有效避免血管及脏器损伤,避免大结石残留;术后可正确评估手术疗效.超声引导mini-PNL术治疗上尿路结石安全可行,适合在基层医院推广应用.     

10043例次经股动脉穿刺插管相关并发症分析

目的　总结经股动脉穿刺插管介入治疗的临床经验 ,并对各并发症发生的原因进行分析。　方法　采用Seldinger技术对 5 90 8例肝胆疾病患者共经股动脉穿刺插管行介入治疗 10 0 4 3例次。年龄5岁～ 86岁 ,平均 4 5 7岁 ,经股动脉穿刺插管 1次～ 13次 ,人均 1 7次。其中伴明显动脉粥样硬化 10 7例 ,双侧髂动脉严重钙化狭窄 2例。　结果　股动脉穿刺插管成功率为 99 8% ,首次插管第一针穿刺成功率为 95 % ,多次插管后第一针穿刺成功率为 76 %。并发症 2 78例 ,股动脉穿刺处局部出血或血肿 2 11例 (2 1% ) ;导丝或导管进入血管周围间隙 13例 ,进入下腔静脉 17例 ;动脉夹层 11例 ;术中股动脉痉挛 5例 ;导管未送入 18例 ,改对侧股动脉穿刺插管成功 16例 ,2例因双侧髂动脉严重钙化狭窄改肱动脉穿刺插管成功 ;下肢深静脉血栓形成 3例。未发生严重并发症及操作死亡。　结论　经股动脉穿刺插管是安全、便捷的有效途径 ,熟练掌握穿刺插管技术是减少各项并发症的关键。     

膝下动脉球囊血管成形术治疗重症下肢缺血的临床研究

目的 评价膝下动脉闭塞首选球囊血管成形术的临床治疗效果.方法 2005年12月至2009年5月,对于连续收治且符合手术指征的54例(61条肢体)膝下动脉重度狭窄或闭塞的重症下肢缺血患者,采用膝下动脉球囊血管成形术进行治疗.其中男性37例,女性17例,平均年龄66岁.术前踝肱指数平均0.43±0.27.根据病变部位选择手术方法,膝下动脉病变首选球囊血管成形术,合并髂股动脉病变同时进行血管重建(支架置入或动脉旁路术).结果 髂股动脉重建(28条肢体行支架置入,5条肢体行动脉旁路术)均一期成功.膝下动脉球囊血管成形术57条肢体获得一期成功,技术成功率93.4%.围手术期主要并发症为小腿血肿3例(4.9%),膝下截肢2例(3.3%).术后踝肱指数增加至0.86±0.21,与术前相比差异有统计学意义(P<0.01).本组平均随访时间(16±11)个月,一期通畅率61.1%,21条肢体发生再狭窄(38.9%),其中10条肢体再次接受外科干预,二期通畅率75.9%.截肢3条肢体,总的救肢率91.8%.结论 球囊血管成形术是治疗重症下肢缺血安全有效的方法,可以作为膝下动脉病变首选的外科干预手段.     

Brachial artery injury after cardiac catheterization

During a 3-year period, 12,158 cardiac catheterizations were performed via the brachial artery. During this same period, 106 patients were operated on for complications of brachial artery injury and/or thrombosis, an incidence of 0.9%. The indication for the cardiac catheterization was coronary artery disease in almost 92% of the patients. Early (less than 4 days) brachial artery repair was done in 90% of the patients. The operative findings were thrombosis (91%), intimal injury (54%), stenosis (13%), laceration and/or perforation (11%), and atherosclerotic plaque (6%). Because of vessel injury, localized resection was done in two thirds of the patients. Vascular continuity was obtained with axial reanastomosis in 45 patients and interposition vein graft in 26 patients. Primary lateral repair was performed in 23 patients (22%). Ninety-five percent (101 patients) had initial excellent results. Of the five patients who required reoperation, flow was restored in four patients. Thus, 99% of patients had restoration of a patent brachial artery. Contributing factors for brachial artery complications are "redo" catheterization, prolonged catheterization time, catheter change, brachial artery atherosclerosis, improper arteriotomy closure, experience of cardiologist, female patient, and failure to use heparin. Because of the unpredictability of ischemic symptoms occurring after brachial artery thrombosis, the need for bypass graft surgery when delayed, and the good results with early surgical intervention, early exploration of brachial artery complications after cardiac catheterization and appropriate repair are recommended.     

Catheterization of the radial or brachial artery in neonates and infants

Background : In neonates and small children, percutaneous insertion of arterial catheters may be very difficult because of the small diameter of the arteries. Multiple attempts at cannulation are common and may be a predictor of serious adverse events following arterial cannulation. As an endartery, the brachial artery is usually not recommended for cannulation. However, limited data exist about brachial artery catheterization in neonates and young children. In this retrospective study, we report our experience with arterial indwelling catheters placed in neonates and small children prior to surgery for congenital heart defects. Methods : We reviewed 1473 patient medical files containing information about 1574 arterial lines for perioperative and intensive care monitoring. Patient data (age and weight), cannulation characteristics (site, type, percutaneous or cut down insertion), duration of catheterization and complications were documented using the anesthesia and/or intensive care unit files. Patients were divided into three groups according to body weight. Group I: patients with a bodyweight up to 5 kg (n = 561), group II: bodyweight 5–10 kg (n = 615), and group III: bodyweight 10–20 kg (n = 297). Results : The vast majority of our patients had radial or brachial artery catheterization. In group 1, we placed 200 brachial artery lines. Radial artery insertion was more successful with increasing body weight. Two ‘cut downs’ were necessary to place the arterial cannula (0.3%). The mean duration of the arterial cannula in place was 5.8 + 4.3 days in group I, which was significantly longer than in group III (2.9 + 2.2 days). Multiple attempts at catheter insertion were required for 200 patients in group I (P < 0.05 compared with groups II and III). The number of guide wires used was similar in all study groups. Generally, we preferred 24 and 22 G catheters for cannulation. Serious complications such as permanent ischemic damage were not observed. Temporary occlusion of an artery occurred in five of 1473 patients. The rate of local infection was 0.5% in group I, 0.7% in group II and 2.3% in group III. Local hematoma were observed more frequently, but with no relevant consequences. Most of our patients were cannulated on the right side. In group I, 112 brachial artery catheters were placed. The greater the weight, the more radial catheters were used compared with a brachial approach. The mean functional time of the catheters (5.8 ± 4.3 days in group I) was significant shorter compared with patients from group III (2.9 ± 2.2 days). In 33.3% (n = 200) multiple punctures were needed to place a catheter in group I (P < 0.05 compared with the other groups) whereas the use of a guide wire was evenly distributed throughout the study groups. Small catheters (24 and 22 G) were preferred for most patients. In total only eight 20 G sized catheters were used in the children of group III. Conclusions : Even considering the nature of a retrospective study design, we conclude that the brachial artery could be considered for cannulation in neonates and small children.     

Technical problems and complications of axillary artery cannulation.

OBJECTIVE: Cardiopulmonary bypass via the axillary artery is frequently used especially in aortic dissections. With an increased use of this technique problems were recognized too. We describe the technical problems and complications associated with axillary artery cannulation. METHODS: Sixty-five patients underwent cannulation of the axillary artery. The indication for operation was acute aortic dissection type A in 57%, chronic aortic dissection in 8%, aortic aneurysm in 18%, pseudoaneurysm in 3%, and others in 14%. RESULTS: Technical problems and complications occurred in 14%, and in 11% the perfusion had to be switched to either femoral (n=5) or aortic cannulation (n=2). Arterial damage or dissection of the axillary artery or the aorta occurred in 0% of the sidegraft technique, whereas they were found in 9% with direct cannulation (P=n.s.). Cannulation problems or insufficient CPB flow due to a narrow vessel occurred in 0% of the sidegraft technique, whereas they were found in 4% with direct cannulation (P=n.s.). Malperfusion in aortic dissections occurred in 20% of the sidegraft technique, whereas they were found in 0% with direct cannulation (P=0.016). No postoperative complications related to axillary cannulation which were evaluated by clinical examination, such as brachial plexus injury, axillary artery thrombosis or local wound infection were observed. CONCLUSIONS: Although axillary artery cannulation is an attractive alternative to femoral cannulation there needs to be an alertness for technical problems. Different complications occur with either direct cannulation or the sidegraft technique and at present it remains the surgeons preference which technique for axillary artery cannulation is used.     

Is the axillary artery a suitable cannulation site in aortic surgery?

AIM: The axillary artery is currently gaining interest as an alternative to femoral artery cannulation in aortic surgery. It was the aim of our study to evaluate the feasibility, safety, and efficacy of axillary artery cannulation in a series of patients undergoing surgery of the ascending aorta and/or the aortic arch. METHODS: From 1998 to 2002 cardiopulmonary bypass (CPB) perfusion via the axillary artery was intended in 35 patients (28 male), median age 61 (22-77) years. The underlying disease was acute aortic dissection type A in 22/35 (63%), chronic aortic dissection type A in 2/35 (6%), ascending aortic aneurysm in 8/35 (22%), aortic regurgitation after previous ascending aortic replacement in 1/35 (3%), pseudoaneurysm after Bentall operation in 1/35 (3%) and coronary artery disease with severe arteriosclerosis of the aorta in 1/35 (3%). RESULTS: Conversion to femoral artery or ascending aortic cannulation was necessary in 3 patients. In the other cases, adequate CPB flows of 2.4 l/m2/min were achieved. In 1 case local dissection of the axillary artery occurred after emergency cannulation. No postoperative complications related to axillary artery cannulation, such as upper extremity ischemia, brachial plexus injury, or local wound infection occurred. No new postoperative stroke was noted, hospital mortality was 4/35 (11%) patients. CONCLUSION: Axillary artery cannulation is feasible in the majority of cases and seems to be a safe and effective method in surgery of the ascending aorta and aortic arch. Several disadvantages of femoral artery cannulation and perfusion can be avoided.     

Outpatient treatment of arterial inflow stenoses of dysfunctional hemodialysis access fistulas by retrograde venous access puncture and catheterization

OBJECTIVE: To determine the feasibility of endovascular treatment of inflow stenoses in arteriovenous fistulae (AVFs) through retrograde venous access catheterization. METHODS: We included all 22 dysfunctional AVFs with arterial inflow stenoses at access imaging between January 2002 and September 2006. Following retrograde venous access puncture, an interventional radiologist intended to cross the arteriovenous anastomosis and advance a catheter into the aortic arch. After depiction of the complete vascular access tree, angioplasty and/or stent placement was aimed for stenoses with a >50% luminal diameter reduction at digital subtraction angiography (DSA). RESULTS: In one radiocephalic AVF, a catheter could not be positioned into the aortic arch after retrograde venous access puncture. DSA depicted 28 inflow stenoses in the remaining 21 patients (11 radiocephalic AVFs and 10 brachiocephalic AVFs). Clinical improvement was obtained in 18 out of 19 patients with a technically successful intervention (<30% residual stenosis after angioplasty or stent placement). Following endovascular therapy, access flow of 12 patients with a low flow access improved from 431 +/- 150 ml/min to 818 +/- 233 ml/min, and four patients with steal symptoms became symptom free. One nonmaturing fistula could be salvaged by angioplasty, and access cannulation problems were solved in another patient following angioplasty. Brachial artery stent placement did not reduce steal symptoms in one case, whereas two patients, in whom stent placement was not thought desirable, showed a >30% residual arterial stenosis after angioplasty. No complications were observed at DSA and endovascular intervention. CONCLUSION: Retrograde venous access puncture and catheterization, as an alternative to a potentially more hazardous brachial artery or more invasive femoral artery approach, should be considered for the visualization of the arterial inflow and endovascular treatment of inflow stenoses.     

Arteriovenous fistula combined with brachial artery superficialization is effective in patients with a high risk of maturation failure

Objective

In patients with a high risk of fistula immaturity, we created arteriovenous fistulas (AVFs) combined with brachial artery superficialization. With this procedure, the superficialized arteries are used as drawing routes and the AVFs as returning routes. This is a technical report about AVFs combined with brachial artery superficialization.

Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement

Background

Ideal perfusion during ascending aorta-arch surgery should allow easy implementation of antegrade cerebral perfusion while avoiding atheroembolization or false lumen perfusion in dissections. We report favorable experience with direct axillary artery cannulation.

Methods

Between 1999 and 2003, 284 patients with a mean age of 62.2 years (25 to 85), underwent axillary artery cannulation using a right angle wire-reinforced catheter. During this interval, attempted axillary cannulation was abandoned in only 14 patients because of inadequate backflow or other complications. Eighty-five patients were female. Severe aortic arteriosclerosis or degeneration was present in 209, aortic dissection in 63, and Marfan disease or aortitis in 12. The Bentall procedure was done in 144 patients, arch replacement in 86, the Yacoub procedure in 18, thoracoabdominal aneurysm repair in 16, and coronary artery bypass grafting in 20. Reoperations were at 30.2%.

Results

Adverse outcome (hospital death or permanent stroke) occurred in 6.6% (n = 19). Thirteen patients (4.6%) died before hospital discharge, and 13 patients (4.6%; 9 of whom died) suffered permanent stroke. Transient neurologic dysfunction occurred in 9.2% (n = 26). Mean duration of hypothermic circulatory arrest, used in 246 patients, was 26 ±7 minutes. Mean duration of antegrade cerebral perfusion, used in 139 patients, was 47 ± 23 minutes. In 93%, the right axillary artery was cannulated. Complications included 2 cases (0.7%) of brachial plexus injury (one transient), and 3 (1%) of localized dissection.

Conclusions

Our results suggest that axillary artery cannulation, successful in 95% of patients, may be the optimal technique for reducing perfusion-related morbidity and adverse outcome in operations for acute dissection, atherosclerotic, and degenerative aneurysmal disease. It deserves serious consideration in all patients older than 65 requiring cardiopulmonary bypass.     

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.     

Usefulness of the axillary artery as vascular access for cardiopulmonary bypass

AIM: In this paper we report our clinical experience with extended utilization of axillary artery cannulation for cardiopulmonary bypass (CPB) and discuss the indications and the results of the procedure in terms of complications and usefulness. METHODS: Between January 1999 and May 2004, 26 patients underwent right axillary artery cannulation for CPB. Fifteen patients presented acute type A aortic dissection and were operated urgently. Axillary cannulation was also used in 11 elective cases: 3 reoperative coronary surgery, 3 valve redo-operations and 5 cases of aortic valve regurgitation+aneurysm of the ascending aorta. RESULTS: All axillary artery cannulations were successful (21 direct and 5 with a side graft) without neurologic or vascular injuries to the right upper extremities. Hospital mortality was 7.7% and included 2 patients operated in an emergency procedure because of acute type A aortic dissection. In all cases, this cannulation site provided adequate perfusion, with a range of peak flows from 4.1 to 5.7 L/min. CONCLUSION: Our preliminary results demonstrate that the right axillary artery may be considered an alternative cannulation site for achieving full CPB and providing antegrade flow, thus avoiding complications related to retrograde flow when femoral artery perfusion is performed. This safe and useful method may be used not only in aortic surgery but in other such complex cardiac procedures as redo-operations.     

Percutaneous catheterization of the deep brachial vein

50 attempts of deep percutaneous antecubital catheterization are reported. A tourniquet was applied to the upper arm and the medial deep brachial vein was punctured in a point immediately medial to the brachial artery, in the antecubital fossa. Venepuncture was successful in 88% of the cases (44 cases), catheterization possible in 72% of the cases (36 cases). The catheter reached the central venous compartment in 60% of the cases (30 cases). The only benign complication was injury to the brachial artery in 6 cases. Mean duration of catheterization was 20 days. This very easy and safe technique can be used when superficial veins are unusable and use of the deep central veins dangerous or impossible.