摘要
目的探讨血液透析患者颈内静脉穿刺置管时导丝意外嵌顿右心房的紧急处理方法及其临床效果。方法回顾性分析浙江大学医学院附属第一医院2011年1月至2018年7月期间行颈内静脉穿刺置管时发生导丝意外嵌顿右心房的5例血液透析患者的临床资料,2例完全嵌顿患者均在导丝送入颈内静脉约20 cm时发现导丝嵌顿,导丝推送及回退均失败,导丝无法移动;3例逆行性嵌顿患者导丝可继续送入,但反复退至约18 cm处嵌顿。所有发生导丝嵌顿患者,立即转至放射导管室行CT血管造影(CTA)或数字减影血管造影(DSA)明确导丝嵌顿部位,显示导丝均嵌顿在右心房近瓣膜附近区域。DSA下分别采用导丝取芯抽丝法、多功能血管造影(multipurpose angiography,MPA)导管导丝末端套取法和手法导丝调整术进行紧急处理。结果 1例完全嵌顿患者采用离断导丝取芯抽丝术成功治疗,DSA下颈内静脉重新穿刺置入临时导管。1例完全嵌顿和1例逆行性嵌顿患者采用MPA导管沿导丝套取导丝末端,使导丝扭曲变形的"J"形末端完全进入导管后将导丝随造影导管一起退出右心房;2例逆行性嵌顿患者在DSA下经过反复推进导丝,旋转调整导丝"J"形末端方向后再反复做导丝退出操作后,顺利退出右心房;此4例患者在嵌顿导丝取出后,利用保留的导丝调整方向后重新置管。结论颈内静脉穿刺置管出现导丝意外嵌顿右心房时,在DSA下通过离断导丝取芯抽丝术、MPA导管导丝末端套取术和手法调整术进行紧急处理,均能使导丝解除嵌顿退出右心房,并顺利完成置管,取得较好疗效。对导丝完全嵌顿患者,MPA导管导丝末端套取术的操作相对简单,并且安全有效。
Objective To investigate the emergency treatment and clinical effect when the guidewire stuck in the right atrium during central vein catheter placement for hemodialysis.Methods Five cases with guidewire stuck in the right atrium during central vein catheter placement for hemodialysis from January 2011 to July 2018 admitted into the First Affiliated Hospital of Zhejiang University were retrospectively analyzed.In two cases,the guidewires were found completely stuck when the insert depth was about 20 cm.The guidewires were not able to move forward nor backward.In the other three cases,the guidewires could be moved forward but not backward with the insert depth at about 18 cm.All patients received emergent computed tomography angiography(CTA)or digital subtraction angiography(DSA)imaging.Images showed that the guidewires were stuck in the right atrium near the ventricular valve.The guidewire core drawing method,the multipurpose angiography(MPA)catheter capturing method and the manual guidewire adjusting method were used for emergent treatment.Results One patient with completely stuck guidewire was successfully treated with guidewire core drawing method and the temporary central vein catheter catheterization through the internal jugular vein was performed under DSA.In a completely stuck case and a retrogradely stuck case,the J-shaped ends of the warped guidewires were captured into the MPA catheter,and the guidewires were then withdrawn from right atriums along with the contrast catheter.In the other 2 retrogradely stuck cases,under DSA,the guidewires were repeatedly pushed,the direction of J-shaped ends was manually adjusted,and then the guidewires were repeatedly pushed and pulled until catheters can be pulled out of the right atriums.The later 4 cases had permanent central vein catheter placement with the same guidewire after the stuck guidewires were withdrawn from the right atrium and readjusted.Conclusions All three methods can successfully solve the emergent situation of the stuck guidewire in the right atrium.For patients with completely stuck guidewires,the MPA catheter capturing method can be simpler,safer,and more effective.
作者
何永春
蒋华
张萍
雷欣
谢文卿
陈江华
He Yongchun;Jiang Hua;Zhang Ping;Lei Xin;Xie Wenqing;Chen Jianghua(Kidney Disease Center,the First Affiliated Hospital of Zhejiang University,Hangzhou 310003,China)
出处
《中华肾脏病杂志》
CAS
CSCD
北大核心
2020年第6期424-428,共5页
Chinese Journal of Nephrology
基金
国家重点研发项目(2018YFC1314003)
浙江省科技计划项目公益技术应用研究(分析测试)(2017C37097)
国家公益性行业科研专项(201502010)。
关键词
肾透析
导管
留置
颈静脉
导丝嵌顿
紧急处理
Renal dialysis
Catheters
indwelling
Jugular veins
Guide wire stuck
Emergent treatment
