【摘要】目的探讨股静脉留置带隧道带涤纶套导管(tunneled cuffed catheter，TCC)在血液透析中的应用。方法选取2016 年1 月～2017 年12 月同济大学附属杨浦医院肾内科42 例使用TCC 及32 例颈内静脉留置TCC 行血液透析的尿毒症患者，观察2 组导管的使用情况。结果4 周和24 周时2 组患者的尿素清除指数无统计学差异(t 值分别为0.429,1.231；P 值分别为0.670,0.225)；4 周、12 周、24 周和36周时股静脉组导管功能不良发生率明显升高(χ2 值分别为5.891，51.080，20.857，24.000；P 值分别为0.017，＜0.001，＜0.001，＜0.001)，使用小剂量尿激酶(5000IU/ml)封管后2 组的血流量均能满足透析需求；股静脉组有3 例发生导管相关性感染，颈内静脉组无；2 组均无深静脉血栓发生。6 个月后，股静脉组需要的尿激酶剂量明显升高；尿素清除指数较前明显下降(t=3.351，P =0.002)，与颈内静脉组相比明显下降(t=3.810，P=0.001)；感染及静脉血栓发生率升高。结论对需中心静脉导管过渡的患者，短期(＜24 周)透析使用股静脉TCC 能达到良好的透析效果，可避免中心静脉狭窄，不影响患者建立自体动静脉瘘或人工血管动静脉瘘。
【Abstract】Objective To investigate the application of indwelling tunneled cuffed catheter (TCC) in femoral vein for hemodialysis. Method Forty-two patients with TCC indwelling in femoral vein and 32 patients with TCC indwelling in internal jugular vein for maintenance hemodialysis during January 2016 to December 2017 were enrolled in this study. The applications of these catheters were analyzed. Results There was no significant difference in urea clearance index between the two groups using the catheters for 4 and 24 weeks (t=0.429, P=0.670 for 4 weeks; t=1.231, P=0.225 for 24 weeks). The incidence of catheter dysfunction was obviously higher in femoral vein group than in internal jugular vein group (χ2=5.891, P=0.017 for 4
weeks; χ2=51.080, P=0.000 for 12 weeks; χ2=20.857, P=0.000 for 24 weeks; χ2=24.000, P=0.000 for 36 weeks); but the blood flow of the two groups still met with the dialysis requirement after sealing the catheters with a low dose of urokinase (5000 IU/ml). Catheter- related infection developed in 3 cases in femoral vein group, but not found in internal jugular vein group. No deep vein thrombosis occurred in both groups. After 6 months in femoral vein group, the dose of urokinase increased obviously, urea clearance index decreased significantly (t=3.810, P=0.001) lower than that in internal jugular vein group (t= 3.810, P=0.001), and the rate of infection and venous thrombosis increased. Conclusion TCC indwelling in femoral vein for a short period of time (<24 weeks) can be used in patients requiring a transitional blood access for hemodialysis. This method
avoids central venous stenosis and does not interfere with the establishment of autologous arteriovenous fistula or arteriovenous fistula graft.
1.Eggers PW.Has the incidence of end-stage renal disease in the USA and other countries stabilized?[J].Curr Opin Nephrol Hypertens, 2011, 20(3):241-245.
2.乔勤,顾波.我国与全球终末期肾脏病的流行现状[J].中国血液净化,2014,13（10）：729-732.
3.Vascular Access Work Group.Clinical practice guideline for vascular access[J].Am J Kidney Dis.2006,48（S1）:S1-322.
4.中国医院协会血液净化中心管理分会血液净化通路学组.中国血液透析用血管通路专家共识.中国血液净化，2014,13（8）：549-558.
5.王海燕.肾脏病学[M].第三版.北京：人民卫生出版社，2008：1939.
6.2011 update Japanese Society for Dialysis Therapy Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis.Therapeutic Aphersis and Dialysis 2015;19(Supplement 1):1-39.
7.梅长林.上海市肾内科质控手册[M].53-58.
8.中华医学会外科学分会血管外科学组.深静脉血栓形成的诊断和治疗指南（第2版）.中华外科杂志，2012,50（7）：611-614.
9.王梦迪，张凌，刘鹏，等.终末期肾脏病患者初次血液透析血管通路应用的多中心调查[J].中华肾脏病杂志，2016,32（6）：418-424.
10.Ravani P,Palmer SC,Oliver MJ,et al.Associations between hemodialysis access type and clinical outcomes:a systematic review[J].J Am Soc Nephrol,2013,24(3):465-473.
11.刘志敏，袁茹.尿毒症患者三种血管通路对血液透析效果的对比分析[J].内蒙古医学杂志，2017,49（11）：1289-1290.
12.韩琳，周蓉，张芸，等.血液透析患者临时中心静脉置管感染的相关因素分析[J].中国血液净化，2014,13（1）：46-48.
13.邝湖，何奕初，陈桂梅，等.血液透析中心静脉留置导管不同置管方式[J].齐齐哈尔医学院学报，2016,37（11）：1494-1495.
14.邱丽，姜斌，肖剑.血透用中心静脉置管相关性感染的临床研究[J].中国中西医结合肾病杂志，2016,17（1）：58-59.
15.中国医师协会肾脏病医师分会血液透析充分性协作组.中国血液透析充分性临床指南.中华医学杂志，2015,95（34）：2748-2753.
16.Oguzkurt L，Tercan F，Torun D，et al.Impact of short-term hemodialysis catheters on the central veins:a catheter venographic study[J].Eur J Radiol，2004,52:293-299.
17.Agarwal AK，Patal BM，Haddad NJ.Central vein stenosis：a nephrologist’s perspective[J].Semina Dial，2007,20:53-62.
18.刘波，诸一吕，施向东. 长期颈内静脉置管致中心静脉狭窄诊治分析[J].中华肾脏病杂志，2013,29（11）:860-861.
