难治性血液透析相关锁骨下静脉闭塞的介入治疗

Endovascular intervention for refractory dialysis-related subclavian vein occlusion

目的本研究拟评估在维持性血液透析人群中难治性锁骨下静脉闭塞病变的介入治疗疗效。方法回顾性分析2019年6月~2021年6月在四川大学华西医院使用标准导丝导管技术无法再通的锁骨下静脉闭塞的24例血液透析患者资料,并根据不同的再通方式分为2组,第1组12例患者通过钝性撞击再通静脉闭塞,第2组12例患者使用尖针锐性再通术。2组患者静脉闭塞实现再通后,均辅以球囊血管成形术及必要时支架置入术。记录患者的一般资料、手术成功率和并发症,随访通路长期通畅情况。结果1组手术成功率100%(12/12),第2组的手术成功率91.67%(11/12),2组的锁骨下静脉闭塞病变再通手术成功率并无统计学差异(P=0.400),但第1组手术时间更短(t=3.333,P=0.003)、手术相关并发症发生率更低(P=0.027)。2组病灶临床特征分析显示,2组患者病灶平均闭塞长度更长[(34.0±6.82)mm比(25.0±6.99)mm,t=3.191,P=0.004],钙化比例更高(58.33%比16.67%,P=0.019)。在手术后通路通畅方面,手术后6个月初级通畅率分别为83.3%(第1组)和75.0%(第2组),12个月为58.3%(第1组)和50%(第2组)。Log rank检验显示2组的通畅率没有显著差异(χ^(2)=0.682,P=0.409)。结论钝性撞击法可以安全有效的处理难治性血液透析相关锁骨下静脉闭塞性病变,而尖针锐性再通术可作为补充治疗手段。

Objective To investigate the efficacy and safety of endovascular intervention for refractory subclavian vein occlusion(SVO)in hemodialysis patients.Methods Clinical data of the 24 patients failed to recanalize the SVO using standard guidewire and catheter techniques between June 2019 and June 2021 in our department were retrospectively studied.They were categorized into two groups:12 patients in group 1 undergone percutaneous transluminal venoplasty(PTV)via a blunt impingement technique,and 12 patients in group 2 undergone sharp needle recanalization.Technical success rate,fluoroscopy time in the procedure,perioperative complications,and patency rate were evaluated retrospectively.Result Comparison of the two groups reveals no significant difference in success rate(100%vs.91.67%,Fisher exact test,P=0.400).The operation time(76.08±11.72min vs.90.67±9.61min,t=3.333,P=0.003)and complication rate(8.34%vs.58.34%,P=0.027)were significantly less in group 1 than in group 2(P<0.05).Mean occlusion length was significantly longer in group 2 than in group 1(34.0±6.82mm vs.25±6.99mm,t=3.191,P=0.004).A higher percentage of calcified lesions was found in group 2(58.33%vs.16.67%,P=0.019).During follow-up(median 12 months),the primary patency rates were 83.3%in group 1 and 75.0%in group 2 after the operation for 6 months,and were 58.3%in group 1 and 50.0%in group 2 after the operation for 12 months.There was no statistically significant difference in patency rate between the two groups(c2=0.682,P=0.409).Conclusion It is effective and safe for interventionalists to use the blunt impingement technique to treat chronic SVO refractory to traditional procedures.The sharp needle recanalization method can be used as supplementary means.