CT血管成像在血液透析患者肿胀手综合征诊治中的价值

Application of CT angiography in the diagnosis and treatment of swollen hand syndrome in hemodialysis patients

目的总结血液透析患者肿胀手综合征的CT血管造影表现及其在肿胀手综合征临床诊治中的应用。方法对2013年11月至2017年11月18例维持血液透析肿胀手综合征患者应用CT血管成像技术进行检查,并根据CT血管造影结果明确静脉病变部位、长度、程度、范围,采用球囊扩张成形术对病变部位进行治疗。总结其发病部位、影响因素。结果 18例CT血管成像诊断:头臂静脉狭窄6例,头臂静脉闭塞4例,贵要静脉完全闭塞1例,锁骨下静脉支架内血栓6例,上腔静脉与心房入口处狭窄1例。除1例曾行同侧心脏起搏器植入术外,有颈内静脉置管史患者(12例)内瘘术后发生肿胀手综合征的时间明显早于无置管史患者(5例),差异有统计学意义[(11.5±27.4)个月vs(38.5±27.9)个月,P<0.05;采用自然对数转换呈正态后行成组t检验]。球囊扩张成形术治疗结果,15例成功,术后狭窄静脉血管通畅,侧支循环消失;2例成形术失败后行血管支架植入术,术后血流通畅;1例因静脉闭塞时间长达3个月以上,介入治疗失败,改行股静脉长期留置导管维持血透治疗。结论肿胀手综合征主要病因是中心静脉狭窄、闭塞或血栓形成。中心静脉置管者更易发生中心静脉病变,肿胀手综合征症状出现更早。CT血管造影可清晰显示中心静脉狭窄、闭塞的程度及部位,可为临床治疗,特别是介入治疗提供很有价值的帮助。

Objective To summarize CT angiographic manifestations of swollen hand syndrome in hemodialysis patients and its application in the clinical diagnosis and treatment. Methods Eighteen maintenance hemodialysis（MHD） patients with swollen hand syndrome were examined by CT angiography from November 2013 to November 2017 and were treated by balloon dilatation angioplasty according to the findings of CT angiography for location,length,degree,range of the disease lesion. The location and influencing factors of the disease were summarized. Results CT angiography showed that there were 6 cases of venae brachiocephalicae stenosis,4 cases of venae brachiocephalicae occlusion,1 cases of complete occlusion of basilic vein,6 cases of subclavian vein stent thrombosis and 1 case of stenosis of superior vena cava and atrium entrance. Except 1 case undergoing ipsilateral cardiac pacemaker implantation,the time of occurrence of swollen hand syndrome was earlier in 12 patients with internal jugular vein catheterization than that in 5 patients without intubation history[（11. 5 ± 27. 4） months vs （38.5 ± 27.9） months,P〈0.05） ]. After treatment with balloon angioplasty,vascular patency of narrow vein vessels and disappeared collateral circulation were in 15 successful cases,postoperative vascular patency after vascular stent implantation were in 2 cases with failed angioplasty. The femoral vein catheterization for longterm hemodialysis was performed in 1 case suffering from occlusion for more than 3 months and failed intervention therapy.Conclusions The main cause of swollen hand syndrome is central venous stenosis,occlusion or thrombosis. Central venous lesions are more likely to occur in the patients with central venous catheters. The symptoms of swollen hand syndrome appear earlier. CT angiography can clearly show the degree and location of central venous stenosis and occlusion and provide valuable help for clinical treatment,especially for interventional therapy.