X线透视下直接经皮股静脉途径封堵未闭动脉导管的临床研究

目的:在熟练掌握常规操作的基础上,探讨以经胸超声心动图测量结果为依据,术中不做主动脉弓降部造影,直接在X线透视下行经皮股静脉途径封堵未闭动脉导管的可行性和安全性。方法:2018年8月至2019年5月共完成57例不造影、X线透视下直接经股静脉途径封堵动脉导管,患者均为体重≥7 kg、左向右分流、肺动脉端内径≥2 mm的非窗型动脉导管未闭(PDA)。57例患者中,儿童47例为儿童组,成人10例为成人组。术前常规心脏听诊,做心电图、X光胸片和经胸超声心动图协助诊断。除常规测量外,在胸骨旁大动脉短轴、高位胸骨旁大动脉和锁骨上窝大动脉这三个重点切面,以二维超声和彩色多普勒超声相结合,评价PDA的形态,测量肺动脉端最细处内径,并根据测量结果选择国产蘑菇型封堵伞,漏斗型PDA,封堵伞的肺动脉端内径为肺动脉端最细处内径(mm)×2+2 mm;管型PDA或体重较大者在此基础上增加2 mm。在X线透视下直接经皮股静脉途径放置封堵伞。术后以X线透视和经胸超声心动图评估封堵效果。结果:儿童组患者年龄0.9~13.7(3.0±2.4)岁,体重7.8~43.0(14.3±4.8)kg;动脉导管内径2.0~10.0(3.4±1.5)mm,封堵伞直径6~14(9.6±2.8)mm。成人组患者年龄22~66(37±15)岁,体重52~96(66±14)kg,动脉导管内径3.0~10.0(5.6±2.3)mm,封堵伞直径8~22(12.8±4.3)mm。儿童组在X线透视下重新放置原封堵伞和更换大一号封堵伞各1例;2例改股动脉途径封堵完成。余53例一次放置成功。术后早期及1个月随访无死亡、封堵伞移位、心律失常及血管损伤等并发症。结论:初步显示以经胸超声心动图结果为依据,术中在X线透视下直接放置封堵伞的简化操作模式可行且安全、有效。

Feasibility and Safety of Percutaneous Device Occlusion of the Patent Ductus Arteriosus Under X-ray Without Aortography

Objectives:We aimed to investigate the feasibility and safety of directly placing the patent ductus arteriosus(PDA)occluder by femoral vein approach under X-ray on the guidance of echocardiography without aortography.Methods:Patients with PDA diameter≥2 mm of non-window-type and hemodynamically left to right shunt,weighted above 7 kg were selected.The sizes of occluders were determined by the results of transthoracic echocardiography.Pre-operation examinations included cardiac auscultation,electrocardiogram,chest X-ray,transthoracic echocardiography and blood tests.In addition to routine calculations,the type and the narrowest site of PDA(D)was assessed and measured in the parasternal short axis view,high left parasternal view and suprasternal view of arteries,using both two-dimensional and color Doppler imaging by experienced physicians.These views were also used to evaluate the immediate results after occlusion.The size of the occluder was determined by the results of echocardiography,that is 2×D+2 mm for funnel type,2×D+4 mm for tubular type.The occluders were placed directly under the X-ray via the femoral vein without aortography.The results of occlusion were assessed by fluoroscopy and transthoracic echocardiography.Results:From August 2018 to May 2019,the occlusions were successfully performed in 47 children aged 0.9-13.7(3.0±2.4)years old,weighted 7.8-43.0(14.3±4.8)kg,and in 10 adults aged 22-66(37±15)years old and weighted 52-96(66±14)kg.The size of PDA and implanted occluders were 2.0-10.0(3.4±1.5)mm and 6-14(9.6±2.8)mm in the children group,and 3.0-10.0(5.6±2.3)mm and 8-22(12.8±4.3)mm in adult group,respectively.The occluder was resettled due to residual shunt in one infant,and changed a bigger size in another infant,both during the procedure.2 children were switched to femoral artery approach,as the PDA were too small to be passed.Occluders were properly placed once in the rest cases.There was no death,occluder migration,residual shunt,hemolysis or femoral vessel complication in the perioperative period or at one-month follow-up.Conclusions:The preliminary results show that our simplified option of device occlusion of PDAis feasible and safe in selected PDA patients.