超声与血管造影结合优化经腋静脉路径置入中心静脉导管技术的探讨

Optimization of axillary vein catheterization combined with angiography and ultrasound

目的(1)通过分析腋静脉CT血管造影(CTA)影像特征,探讨经腋静脉路径置入中心静脉导管的安全穿刺方向;(2)结合CTA,探讨超声引导下腋静脉穿刺技术的优化。方法(1)确定腋静脉穿刺的安全方向。回顾性分析2016年8-12月南昌大学第二附属医院100例患者的颈部至颅底CTA检查影像资料,依托清晰的腋静脉造影技术,通过分析腋静脉与腋动脉、胸壁、锁骨及第一肋骨之间的解剖位置关系,明确腋静脉穿刺的安全方向。(2)优化穿刺方法。回顾性分析2017年1月至2018年4月于南昌大学第二附属医院接受腋静脉穿刺的住院患者120例,根据随机数字法将患者分为观察组(60例)和对照组(60例)。观察组使用超声平面内和平面外技术相结合的技术,沿安全穿刺方向进针。对照组仅利用超声平面内技术实时引导穿刺针进行腋静脉穿刺。观察比较两组患者不同穿刺方法的操作时间、一次穿刺成功率、术中鞘管脱落率及气胸等并发症发生率。结果(1)通过对腋静脉CTA的影像分析发现,腋静脉走行大多表现为与腋动脉伴行,行于腋动脉内侧,与胸壁贴近;在锁骨下延续为锁骨下静脉时,则开始与腋动脉分开。(2)120例患者中,观察组与对照组比较,穿刺所用时间短[(10.20±2.50)min比(16.60±2.02)min,P=0.026],一次穿刺成功率高(78.33%比58.33%,P=0.038),差异均有统计学意义。两组患者早期并发症发生率(3.33%比5.00%,P=0.128)与术中鞘管脱落率(1.67%比3.33%,P=0.512)比较,差异均无统计学意义。结论(1)腋静脉的安全穿刺方向为第一肋骨下沿以上部分和腋动脉内侧所围成的区域。(2)使用优化后的穿刺方法行经腋静脉路径置入中心静脉导管在一次成功率和操作时间上都优于对照组,而且没有发生严重并发症(血胸、气胸、神经损伤等),是一种理想的腋静脉安全穿刺技术。但该技术的安全性和可靠性还要经过临床应用得到进一步验证。

Objective(1)By analyzing the image characteristics of axillary vein computed tomography angiography(CTA),to explore the saf e puncture direction of central venous catheter placement through the axillary vein route;(2)Combined with CTA,to explore the optimization of ultrasound-guided axillary vein puncture technology.Methods(1)to determine the safety direction of the axillary venipuncture.From August to December 2016,the imaging data of CTA between the neck to the cranial base CTA of 100 patients from the emergency department,neurosurgery,cardiology and other departments of the Second Affiliated Hospital of Nanchang University were retrospectively analyzed.With the clear axillary venography,the anatomical relationship between the axillary vein and the axillary artery,the chest wall,the clavicle and the first rib were analyzed and the safety direction of the axillary venipuncture was clearly defined.(2)Optimize the puncture method.A retrospective analysis of 120 patients who received axillary vein puncture in the emergency department,neurosurgery,cardiology and other departments of the Second Affiliated Hospital of Nanchang University from January 2017 to April 2018 was performed,and the patients were divided into observation group(60 cases)and control group(60 cases)according to random number method.The observation group f irst used the ultrasound out-of-plane technique to mark the direction of the axillary vein on the body surface,and then used the ultrasound in-plane technique to guide the puncture needle for axillary vein puncture in real time.The control group only used the ultrasound in-plane technique to guide the puncture needle in real time for axillary vein puncture.The puncture time,the success rate of one puncture,the rate of intraoperative sheath detachment and the incidence of complications such as pneumothorax were compared between the two groups.Results(1)The imaging analysis of the axillary vein CTA found that most of the axillary veins tended to accompany the axillary artery,running inside axillary artery and were close to the chest wall.When subclavian vein continues into subclavian vein,it begins to separate from axillary artery.(2)Among the 120 patients,compared with the control group,the observation group had a shorter puncture time[(10.20±2.50)min vs.(16.60±2.02)min,P=0.026],and the one-time puncture success rate was higher(78.33%vs.58.33%,P=0.038),the difference was statistically significant.The incidence of early complications in the two groups(3.33%vs.5.00%,P=0.128)]and the intraoperative sheath detachment rate(1.67%vs.3.33%,P=0.512),the difference was not statistically significant.Conclusions(1)The safe puncture direction of the axillary vein is the area enclosed by the upper part of the lower edge of the first rib and the inner side of the axillary artery.(2)Using the optimized puncture method to insert a central venous catheter through the axillary vein route is superior to the control group in terms of one-time success rate and operation time,and no serious complications(hemothorax,pneumothorax,nerve injury,etc.)occur.It is an ideal technique for the safety of the axillary venipuncture.The safety and reliability of the technology will be further verified through clinical application.