胸部CT三维重建评估颈内静脉透析导管位置与通畅性关系

Three-dimensional reconstruction of chest CT to assess the relationship between internal jugular venous catheter location and patency

目的应用胸部计算机断层扫描(computer tomography,CT)三维重建技术评估颈内静脉透析导管尖端位置与临床效果的关系。方法实施单中心、回顾性、队列研究,复习所有右侧颈内静脉(right internal jugular vein,RIJV)置入透析用带隧道带涤纶套导管(tunneled cuffed catheter,TCC)手术后胸部CT并进行三维重建,以第4前肋上缘与胸骨右缘交界点为坐标原点,测量导管尖端空间位置,根据TCC是否需要溶栓治疗分为溶栓组和无溶栓组,对比2组临床参数、TCC尖端位置参数及TCC转归。结果共纳入47例患者,无溶栓组16例(34.04%),溶栓组31例(65.96%)。无溶栓组与溶栓组相比年龄较小(t=-2.860,P=0.006),C反应蛋白(CRP)水平较低(Z=-2.627,P=0.009),TCC管尖与原点垂直距离更大(t=2.108,P=0.041),TCC在血管内长度更长(t=3.617,P=0.001)。Logistic回归分析显示年龄(OR=1.069,95%CI:0.997~1.122,P=0.008)、CRP(OR=1.270,95%CI:1.009~1.598,P=0.030)和TCC在血管内长度(OR=0.967,95%CI:0.920~0.993,P=0.005)为是否溶栓的独立影响因素,以TCC在血管内的长度评估TCC不需要溶栓治疗的ROC曲线下面积为0.784(95%CI:0.634~0.931,P=0.002),最佳界值为80.6 mm,灵敏度和特异度均为100%。溶栓组发生TCC相关感染比率更高(χ^(2)=0.501,P=0.029)。结论RIJV入路的TCC在血管内的长度可用来评估长期通畅不溶栓的可能性,对老年、CRP大于正常值的患者应当进行预防性溶栓治疗,以延长TCC留置时间。

Objectives To assess the correlation between the tip position of the right internal jugular vein(RIJV)catheter and clinical effects through three-dimensional(3D)reconstruction of chest computer tomography(CT)images.Methods This was a single centered,retrospective and cohort study.Chest CT images of the cases with tunneled cuffed catheter(TCC)in RIJV were reviewed.When the tip position of TCC was measured,the convergence of upper edge of the 4th rib and the right border of sternum was defined as the ordinate origin.The patients were divided to group thrombolysis(group T)and group non-thrombolysis(group NT)according to whether thrombolytic therapy for TCC was required.Clinical parameters,the tip position of TCC and outcomes of TCC were analyzed.Results A total of 47 patients were enrolled in this study,with 16(34.04%)patients in group NT and 31(65.96%)patients in group T.Patients in group NT had younger age(t=-2.860,P=0.006),lower CRP level(Z=-2.627,P=0.009),longer vertical distance from tip of TCC to origin point(t=2.108,P=0.041),and longer length of TCC inside the vessel(t=3.617,P=0.001)as compared with those in group T.Logistic regression showed that age(OR=1.069,95%CI:0.997~1.122,P=0.008),CRP(OR=1.270,95%CI:1.009~1.598,P=0.030),and the length of TCC inside the vessel(OR=0.967,95%CI:0.920~0.993,P=0.005)were the independent risk factors for the requirement of thrombolytic therapy.When length of TCC inside the vessel was used to estimate the non-thrombolysis therapy for TCC,the best threshold length was 80.6 mm,the area under the curve of receiver operating characteristic(ROC)curve was 0.784(95%CI:0.634~0.931,P=0.002),and both the sensitivity and specificity were 100%.The prevalence of TCC-related infection was significantly higher in group T than in group NT(χ^(2)=0.501,P=0.029).Conclusion The length of TCC inside RIJV can be used to estimate the possibility of long-term patency of TCC without thrombolytic therapy.For elder patients or patients with CRP higher than normal level,preventive thrombolysis treatment should be considered to get a longer patency of TCC.