Clinical application of central venous percutaneous transluminal angioplasty in the replacement of tunnel-cuffed catheter
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摘要:
目的 探讨经皮腔内血管成形术(percutaneous transluminal angioplasty, PTA)在导管相关中心静脉病变血液透析患者再置管中的临床应用。 方法 收集2018年1月—2019年12月浙江省台州医院收治的有导管相关中心静脉病变且需要使用带隧道和涤纶套的透析导管为血管通路的10例患者临床资料。所有患者经血管造影明确中心静脉狭窄的部位、范围、程度，行PTA治疗，再置入新的带隧道和涤纶套的透析导管，随访3~6个月观察患者临床疗效。 结果 所有患者扩张后中心静脉狭窄较前明显改善，顺利置入新的带隧道和涤纶套的透析导管，未发生手术相关并发症，如心律失常、心包填塞、球囊破裂，导管穿破中心静脉进入纵隔或者胸腔，致血胸、血气胸、纵隔血肿等并发症。术后X片提示导管位置满意。术后可立即应用导管行血液透析，观察5次血流量均可达到250 mL/min。术后随访3~6个月，所有患者透析时导管血流量均可达到250 mL/min，未出现导管功能不良及感染。 结论 当患者以带隧道和涤纶套的透析导管为长期血管通路，原带隧道和涤纶套的透析导管无法继续使用时，行血管造影，若存在严重的中心静脉狭窄，行PTA治疗后更换新的带隧道和涤纶套的透析导管较为安全，成功率高，为临床上该类患者建立血管通路提供新的思路。 Abstract:Objective To investigate the clinical application of percutaneous transluminal angioplasty (PTA) in catheter replacement of haemodialysis patients with catheter-related central vein disease. Methods Clinical data were collected from 10 patients admitted to the Taizhou Hospital of Zhejiang Province between January 2018 and December 2019 with catheter-related central venous disease and vascular access requiring tunnel-cuffed catheter (TCC). All patients underwent angiography to determine the narrow area, extent, degree of the narrow central veins, underwent PTA treatment, and then placed into the new TCC, followed-up 3 to 6 months to observe the patient's clinical efficacy. Results After dilation, the central-vein stenosis significantly improved in all patients compared with the previous. New TCC was successfully replaced, and no surgically related complications occurred, such as arrhythmic disorder, cardiac tamponade, balloon rupture, and catheter through the central vein into the mediastinum or chest resulting in haemothorax, haemopneumothorax, mediastinal hematoma, and other complications. Postoperative X-ray showed satisfactory catheter position. Immediately after the operation, catheters were used for haemodialysis, and blood flow reached 250 mL/min observed five times. The patients were followed up for 3-6 months after the operation. Catheter blood flow during dialysis reached 250 mL/min in all patients, and no catheter dysfunction or infection occurred. Conclusion When patients take TCC as a long-term vascular access and continued use of the original TCC is not possible, angiography should be performed. If there is serious central-vein stenosis, it would be safer to replace the new TCC after PTA treatment with a high success rate. This study provides a new idea for the clinical establishment of vascular access in such patients. -
Key words:
- Central vein /
- Percutaneous transluminal angioplasty /
- Dialysis catheter
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图 1 狭窄段血管在DSA下行PTA治疗并置入新的导管
注：A为造影提示患者右无名静脉节段性狭窄；B为对狭窄较明显位置先用直径6 mm球囊预扩张；C为PTA后置入新的透析导管，摄片提示导管末端位置在右心房。
表 1 10例中心静脉狭窄更换TCC导管患者手术资料
患者序号 性别 年龄(岁) 既往导管时间 换管原因 狭窄位置 球囊大小(mm×mm) 导管长度(cm) 1 女性 77 5年 流量差 右无名静脉 Gladiator 12×60 23 2 女性 72 10年 流量差 右颈内静脉、无名静脉 Gladiator 8×80 19 3 男性 77 ARROW管3周 严重类风湿，肘关节畸形，无法内瘘手术 右无名静脉至上腔静脉 Gladiator 10×80 19 4 女性 45 临时管2周拔除, ARROW管2周 腹膜炎改血透，情况差无法耐受内瘘手术 右颈内静脉、无名静脉 Gladiator 12×40 19 5 男性 54 1年 颜面水肿 右颈内静脉、无名静脉 MUSTANG 6×80 Gladiator 12×40 23 6 女性 75 7年 导管相关性感染 右无名静脉及上腔静脉节段狭窄 Gladiator 10×80 23 7 女性 82 10年 流量差 右无名静脉 Gladiator 10×80 23 8 女性 77 6年 流量差 上腔静脉 Gladiator 10×40 23 9 女性 56 2年 流量差 右无名静脉及上腔静脉 MUSTANG 5×80 Gladiator 10×80 23 10 男性 88 2年 原导管外接口乳化变薄易破裂，静脉压高 右无名静脉 Gladiator 10×80 Gladiator 12×40 23 
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