X线透视下双骨性标志导引的腋静脉穿刺技术与意义

The technique of axillary vein puncture guided by double bony landm arks under X-ray fluoroscopy and its value

目的探讨X线透视下双骨性标志导引腋静脉穿刺的可行性和安全性及其在心脏起搏器植入中的临床意义。方法选择2016年8月后浙江省立同德医院需行心脏起搏器植入患者42例(腋静脉组),行腋静脉穿刺,将后前位X线透视下第二肋外缘作为经皮穿入点的骨性标志,毗邻锁骨下缘的第一肋外侧部分作为穿入腋静脉点的骨性标志,观察经皮腋静脉穿刺成功率,急性并发症和远期并发症,并与2016年8月前采用锁骨下静脉途径植入起搏器的42例患者(对照组)相比较。结果腋静脉组42例中成功穿刺41例(97.6%),无一例误穿入胸腔及气胸与血气胸发生,无一例误穿入动脉,随访期无锁骨下电极挤压综合征发生。对照组经皮锁骨下静脉穿刺42例,全部穿刺成功(100%),6例次误穿入胸腔(8.22%),与腋静脉穿刺组比较差异有统计学意义(χ~2=6.253,P=0.012),发生气胸2例(4.76%)患者,误穿入锁骨下动脉3例(7.14%),及时处理未造成明显不良后果,15个月后发生起搏电极挤压综合征1例(2.38%)。结论 X线透视下双骨性标志导引的经皮腋静脉穿刺是安全、有效和易行的起搏器电极植入途径。

Objective To investigate the feasibility and safety of axillary vein puncture guided by double bony landmarks under X-ray fluoroscopy and its clinical value in the implantation of cardiac pacemakers. Methods Axillary vein puncture was taken in 42 consecutive patients undergoing pacemaker implantation in Tongde hospital zhejiang province after August 2016. The outer edge of the second rib was used as a bony landmark for percutaneous puncture point and the outer part of the first rib below the clavicle was used as a bony landmark for puncture point of axillary vein in the fluoroscopic antero-posterior view. The incidence of acute complications and long-term complications were observed and compared with that of 42 patients implanted with pacemakers by subclavian venous access before the study in same hospital. Results Of 42 patients underwent percutaneous axillary vein puncture, 41 cases（97.6%）were successfully punctured without unintentional lung puncture, pneumothorax, hemothorax and unintentional puncture of the axillary artery and subclavian artery. No subclavian crush syndrome occurred during follow-up. 42 patients underwent subclavian vein puncture with all successful （100%）. An unintended lung puncture occurred in 6 case-times （8.22%）. There was a significant difference of it between the two groups（X^2=6.253,P=0.0124）. Two cases（4.76%）developed pneumothorax. An unintended subclavian artery puncture occurred in 3 cases （7.14%）without adverse outcomes. One patient （2.38%） developed subclavian crush syndrome during 15 months of follow-up. Conclusion Axillary vein puncture using double fluorouscopic bony landmarks is a safe, effective and easy approach for implantation of pacemaker leads.