目的：为临床提供一种操作简便、并发症少、易于掌握与标准化的输液港植入方法。方法：搜集我院2014年3月—2017年10月期间行输液港植入并资料完整的223例患者的临床资料，按照植入方式不同分为“可视化组”（超声引导与X线定位104例）及“盲穿组”（119 例）。采用χ2检验，对比分析“可视化组”与“盲穿组”中的一次穿刺成功率、误穿动脉次数、气胸例数、导管外血栓例数、夹闭综合征例数、导管位于T5~T7例数、导管内血栓例数、导管内感染例数、港体感染例数及切口裂开例数之间有无统计学差异。结果：可视化组中一次穿刺成功率高于盲穿组一次穿刺成功率（P=0.016）。可视化组无误穿动脉病例，盲穿组有10例误穿动脉（P=0.007）。可视化组无气胸病例出现，盲穿组有3例气胸，需置管抽气（P=0.25）。可视化组未发现导管外血栓形成，盲穿组中有14例导管外血栓形成（P<0.001）。可视化组104例均通过锁骨下静脉穿刺无夹闭综合征，盲穿组119例中有15例为锁骨下静脉穿刺置管而出现1例夹闭综合征（P=0.126）。可视化组104例导管末端均位于上腔静脉与右心房连接处（T5~T7），盲穿组119例术后X线确定仅有86例导管末端位于T5~T7（P<0.001）。可视化组104例均无导管内血栓形成，盲穿组有11例导管内血栓形成（P=0.001）。可视化组出现2例导管内感染，盲穿组出现12例输液港导管内感染（P=0.012）。可视化组无港体感染，盲穿组出现1例港体感染（P=1.0）。输液港切口裂开不愈合，在盲穿组中出现2例，可视化组中出现1例（P=1.0）。结论：采用超声引导穿刺保证极高的穿刺成功率，减少了穿刺并发症，同时术中Ｘ线定位可保证导管末端位于上腔静脉与右心房连接处，实现了输液港植入的全程可视化，不仅使静脉输液港植入简单、精准，而且还可以降低近、远期相关并发症的发生。
Abstract
Objective: To evaluate the effectiveness and safety of ultrasound(US)-guided vein puncture and fluoroscopy localization for a totally implantable venous access port(TIVAP) implantation. Methods: We reviewed the medical records of 223 patients who underwent TIVAP at our hospital between March 2014 and October 2017. 104 with ultrasound-guided puncture and fluoroscopy localization(visual group) and 119 following anatomical landmarks(blind-puncture group). Puncture-related complications including short-term and long-term complications were analyzed. Results: Primary success rate was higher in visual group than blind-puncture group. Verified by fluoroscopy, all the end of catheters were successfully located at the junction of the superior vena cava and the right atrium(between the fifth thoracic vertebra (T5) and T7) in visual group, versus 86 cases in blind-puncture group. Several complications observed in blind-puncture group were arterial puncture(10 patients), pneumothorax(3 patients), thrombosis outside the catheter(14 patients), thrombosis inside the catheter(11 patients) and pinch-off syndrome(1 patients). None complications mentioned above were observed in visual group. In addition, intraductal infection was observed in 2 patients in visual group, comparing 12 patients in blind-puncture group. Infection of port body was not observed in visual group, versus 1 case with blind technique. Rupture of incision was found in 1 case in the visual group, versus 2 cases in blind-puncture group. Conclusions: US-guided vein puncture for TIVAP is easier for the operator and safer for the patient than blind technique by exposing anatomical structures. Verified by fluoroscopy, all the end of catheters are successfully located at the junction of the superior vena cava and the right atrium, reduces short-term and long-term complications.
关键词
导管 /
留置
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参考文献
[1]Niederhuber JE, Ensminger W, Gyves JW, et al. Totally implanted venous and arterial access system to replace external catheters in cancer treatment[J]. Surgery, 1982, 92(4): 706-712.
[2]Tabatabaie O, Kasumova GG, Eskander MF, et al. Totally Implantable Venous Access Devices: A Review of Complications and Management Strategies[J]. Am J Clin Oncol, 2017, 40(1): 94-105.
[3]Ma L, Liu Y, Wang J, et al. Totally implantable venous access port systems and associated complications: A single-institution retrospective analysis of 2 996 breast cancer patients[J]. Mol Clin Oncol, 2016, 4(3): 456-460.
[4]Hüttner FJ, Bruckner T, Alldinger I, et al. Frequency of pneumothorax and haemothorax after primary open versus closed implantation strategies for insertion of a totally implantable venous access port in oncological patients: study protocol for a randomised controlled trial[J]. 2015, 31(16): 128.
[5]Sun Y, Zhou T, Li Y, et al. Clinical application of totally implantable central venous port[J]. 2014, 52(8): 608-611.
[6]Paleczny JI, Bany-Jafernik B, Gazurek K, et al. Long-term totally implantable venous access port systems—one center experience[J]. Anaesthesiol Intensive Ther, 2013, 45(4): 215-222.
[7]Wu S, Huang J, Jiang Z, et al. Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices: a meta-analysis of comparative studies[J]. BMC Cancer, 2016, 16(1): 747.
[8]中华医学会外科学分会乳腺外科学组. 乳腺癌植入式静脉输液港临床应用专家共识及技术操作指南（2017版）[J]. 中国实用外科杂志，2017，37（12）：1377-1382.
[9]浙江省植入式静脉输液港协作组. 植入式静脉输液港（浙江）临床应用多学科专家共识[J]. 实用肿瘤杂志，2018，33（1）：17-24.
[10]中心静脉通路上海协作组. 完全植入式输液港上海专家共识[J]. 介入放射学杂志，2015，24（12）：1029-1033.
[11]Arzu GD, Coccolini F, Rossi M, et al. An entirely echo-guided technique for totally implantable access port positioning[J]. Indian J Surg, 2014, 76(3): 204-206.
[12]Cavallaro G, Sanguinetti A, Iorio O, et al. Ultrasound-guided vein puncture versus surgical cut-down technique in totally implantable venous access devices(TIVADS): a prospective comparative study on safety, efficacy and complications[J]. Int Surg, 2014, 99(4): 475-478.
[13]Ahn SJ, Kim HC, Chung JW, et al. Ultrasound and fluoroscopy-guided placement of central venous ports via internal jugular vein: retrospective analysis of 1254 port implantations at a single center[J]. Korean J Radiol, 2012, 13(3): 314-323.
[14]Marcy PY, Lacout A, Figl A, et al. Letter to the Editor re: "Outcome analysis in 3160 implantations of radiologically guided placements of totally implantable central venous port systems": observations about right internal jugular access[J]. Eur Radiol, 2011, 21(10): 2166-2167.
[15]Teichgrber UK, Kausche S, Nagel SN, et al． Outcome analysis in 3160 implantations of radiologically guided placements of totally implantable central venous port systems[J]． Eur Radiol, 2011, 21(6): 1224-1232．
[16]张欣贤，李炯，唐永，等. DSA引导下婴幼儿经颈内静脉输液港植入的应用[J]. 影像诊断与介入放射学，2016，25（4）：327-330.
[17]Oner B, Karam AR, Surapaneni P, et al． Pneumothorax following ultrasound-guided jugular vein puncture for central venous access in interventional radiology: 4 years of experience[J]． J Intensive Care Med, 2012, 27(6): 370-372．
[18]Lamperti M, Bodenham AR, Pittiruti M, et al. International evidence-based recommendations on ultrasound-guided vascular access[J]. Intensive Care Med, 2012, 38(7): 1105-1117.
[19]Aitken DR, Minton JP． The "pinch-off sign": A warning of impending problems with permanent subclavian catheters[J]． Am J Surg, 1984, 148(5): 633-636.
[20]Sundriyal D, Jain S, Manjunath S. "Difficult to flush chemoport: an important clinical sign"[J]. Indian J Surg Oncol, 2014, 5(4): 307-309.
[21]Yeung CW, Cheung WW, Leung AY, et al. Spontaneous central venous catheter fracture: relevance of the pinch-off sign[J]. J Hosp Med, 2010, 5(4): E33.
