球囊扩张在隧道式透析导管更换术中的应用

Application of balloon dilatation during tunneled cuffed catheter replacement

目的探讨存在纤维鞘和(或)上腔静脉狭窄、闭塞时隧道式透析导管更换术中应用球囊扩张的指征和球囊直径的选择,并分析上腔静脉狭窄原因。方法回顾性分析近6年来隧道式透析导管更换术中应用球囊扩张的患者130例次,未应用球囊扩张导致导管置入困难的患者12例次,观察置管困难原因及处理过程。结果(1)事先未应用球囊扩张导致撕脱鞘置入困难的患者共68例次,导管留置总时间(导管在同一血管内纤维鞘中)2.5~16.0年,中位时间5.0年;(2)拔管困难患者12例,均出现撕脱鞘置入困难,应用球囊扩张纤维鞘后才能置入撕脱鞘;(3)奇静脉显影患者28例次,均伴有上腔静脉或者腔房交界处重度狭窄或闭塞病变,球囊扩张病变部位后置入导管23例次,导丝引导置入导管5例次;(4)扩张纤维鞘球囊直径范围6~12 mm;扩张上腔静脉和腔房交界病变球囊直径范围7~12 mm;(5)之前没有置管史,也没有更换过导管的21例患者中,原导管尖端在右心房的9例患者中有6例上腔静脉无明显狭窄,12例原导管尖端在腔房交界处和上腔静脉的患者均出现腔房交界处或上腔静脉狭窄;(6)所有病例术后均无血管破裂、症状性肺栓塞、感染并发症发生。结论(1)撕脱鞘置入困难是球囊扩张纤维鞘的绝对指征,拔管困难以及导管留置时间2.5年以上的患者可能需要球囊扩张纤维鞘后才能置入撕脱鞘;(2)上腔静脉近心端或腔房交界处中重度狭窄或闭塞尤其是伴有奇静脉显影的患者建议事先用球囊扩张病变部位后再置管;(3)扩张纤维鞘建议首选8 mm直径球囊,扩张上腔静脉和腔房交界狭窄,建议首选10 mm直径球囊,重度狭窄或闭塞病变需逐级扩张;(4)导管尖端放置在右心房时上腔静脉狭窄率更低。

Objective To explore the indication of balloon dilatation and the selection of balloon diameter during tunneled cuffed catheter replacement in the presence of fibroblastic sleeve and/or superior vena cava stenosis or occlusion and examine the causes of long fibroblastic sleeve formation and superior vena cava stenosis.Methods Over the past 6 years,130 patients with balloon dilatation and 12 patients with difficult catheterization due to no balloon dilatation were analyzed retrospectively.The causes and treatments of difficult catheterization were recorded.Results A total of 68 patients encountered difficulties of inserting peel-away sheath without balloon dilatation.Total median time of catheter indwelling(catheter in the same fibroblastic sleeve)was 5.0(2.5-16.0)years.In 12 patients with difficult extubation,peel-away sheath could be placed only after fibroblastic sleeve was expanded by balloon.Azygos vein imaging was performed in 28 patients with severe stenosis or occlusion of superior vena cava or cava atrial junction.Catheters were inserted 23 times after balloon dilation and 5 times under guide wire guidance.The diameter range of expanded fibroblastic sleeve balloon was(6-12)mm;The diameter of balloon for dilated superior vena cava and atria cava junction lesions ranged from 7-12 mm.Among 21 patients without a previous history of catheterization and not replacing,6/9 patients with original catheter tip in right atrium had no obvious stenosis of superior vena cava while 12 cases with original catheter tip placed at the junction of atria cava and superior vena cava had stenosis of junction of atria cava or superior vena cava.After operation,there were no vascular rupture,symptomatic pulmonary embolism or infection complications.Conclusion Difficulty of inserting peel-away sheath is an absolute indication of balloon dilatation of fibroblastic sleeve.Patients with difficulty in extubation and catheter retention for>2.5 years may need balloon dilatation of fibroblastic sleeve before inserting peel-away sheath.For patients with moderate/severe stenosis or occlusion at proximal end of superior vena cava or at the junction of cava and atrium,especially those with azygos vein development,expanding lesion site with balloon is preferred before catheterization.And 8 mm diameter balloon is recommended for expanding fibroblastic sleeve while 10 mm diameter balloon for expanding the stenosis at the junction of superior vena cava and atria cava.Severe stenosis or occlusive lesions should be expanded stepwise.Central vein stenosis rate with catheter tip in right atrium is lower.