血液透析患者颈内静脉解剖变异及狭窄的影响因素分析

Analysis of potential predictors of internal jugular vein stenosis and the anatomic position in hemodialysis patients

目的探讨血液透析患者颈内静脉与颈总动脉的解剖位置关系,分析颈内静脉留置导管后的狭窄发生率及影响因素。方法本研究为单中心横断面研究,纳入广东省人民医院肾内科2017年8月至2018年6月收治的235例慢性肾脏病患者为研究对象,按照是否接受血液透析治疗分为透析组(n=187)和对照组(慢性肾脏病非透析患者,n=48)。收集患者年龄、原发病、深静脉置管病史、导管留置时间、透析龄等临床资料。采用多普勒超声仪检查所有患者颈内静脉与颈总动脉的位置关系,测量不同颈部解剖平面颈内静脉的横截面积,分析透析组颈内静脉狭窄的发生率。卡方检验比较分析不同年龄、有无导管留置史、导管留置时间、透析龄、有无糖尿病肾病等亚组间颈内静脉狭窄发生率的差异。结果多普勒超声检查结果显示,235例入选者中,在颈部平甲状软骨平面和锁骨上三角顶点平面,以颈总动脉为中心,颈内静脉与颈总动脉的解剖关系有4种:颈内静脉位于颈总动脉外侧、前外侧、前侧、内侧,分别占16.23%、36.52%、41.11%、3.14%。左右两侧、不同解剖平面及不同年龄段患者间的颈内静脉与颈总动脉解剖关系的差异有统计学意义(均P<0.05)。187例血液透析患者颈内静脉狭窄率为47.1%,年龄<65岁组(n=128)及年龄≥65岁组(n=59)的右颈内静脉狭窄发生率分别为66.4%和44.1%(P=0.004);有导管留置史组(n=151)与无导管留置史组(n=36)的颈内静脉狭窄发生率分别为49.0%和32.8%(P=0.018)。将年龄、有置管史2个变量纳入Logistic回归方程,分析结果显示,有置管史是发生颈内静脉狭窄的危险因素(OR=1.668,95% CI:1.083~2.568,P=0.020)。结论颈内静脉与颈总动脉的解剖关系存在变异性,颈内静脉狭窄是血液透析患者留置导管后常见的并发症,有颈内静脉置管病史是影响颈内静脉狭窄的危险因素。

Objective To identify the anatomical positional relation of the internal jugular vein and the common carotid artery, and investigate the predictive factors associated with the stenosis rate of the internal jugular vein after catheterization in hemodialysis patients. Methods A single-center cross-sectional survey study of 235 patients from the Department of Nephrology, Guangdong Provincial People's Hospital between August 2017 and June 2018 was performed. According to whether received hemodialysis treatment, The patients were divided into dialysis group (n=187) and control group (chronic kidney disease non-dialysis patients, n=48). Clinical data such as age, primary disease, history of deep vein catheterization, catheter indwelling time and dialysis age were collected. The positional relationship between the internal jugular vein and the common carotid artery was examined by Doppler ultrasound. Measure the cross-sectional area of the internal jugular vein in different neck anatomical planes and analyse of the incidence of internal jugular vein stenosis in the dialysis group. Chi-square test was used to compare the differences in the incidence of internal jugular vein stenosis between subgroups of different ages, with or without catheter retention, catheter indwelling time, dialysis age and presence or absence of diabetic nephropathy. Results Doppler ultrasonography showed that in the 235 patients, there were four types of anatomical relationship between the internal jugular vein and the common carotid artery in the plane of the flat thyroid cartilage and the apex plane of the upper clavicle. The internal jugular vein was located on the lateral, anterolateral, anterior and medial sides of the common carotid artery, accounting for 16.23%, 36.52%, 41.11% and 3.14% respectively. There were significant differences in the anatomical relationship between the internal jugular vein and the common carotid artery between the left and right sides, different anatomical planes and patients of different ages (P<0.05). The rate of internal jugular vein stenosis in 187 hemodialysis patients was 47.1%. The right internal jugular vein stenosis rate was 66.4% and 44.1% in the age<65 years old group (n=128) and age≥65 years old group (n=59), respectively (P=0.004). The rate of internal jugular vein stenosis was 49.0% and 32.8%(P=0.018) in the catheter placement group (n=151) and the catheterless retention group (n=36), respectively. Two variables including age and history of catheterization were included in the logistic regression equation. The results showed that the history of catheterization was a risk factor for internal jugular vein stenosis (OR=1.668, 95% CI 1.083-2.568, P=0.020). Conclusions There is variability in the anatomical relationship between the internal jugular vein and the common carotid artery. Internal jugular vein stenosis is a common complication after indwelling catheters in hemodialysis patients. The history of internal jugular vein catheterization is a risk factor affecting internal jugular vein stenosis.