【摘要】目的探讨颈内静脉入路的带隧道中心静脉导管置管准确性和安全性的影响因素。方法回顾性分析2011年～2019年行颈内静脉带隧道中心静脉导管置入术的病例资料。收集人口学资料，手术相关资料，包括置管位置，是否用X线，置管失败原因，介入干预情况，干预失败原因等。研究主要终点是置管成功率和失败原因。结果1598例患者纳入分析，平均年龄(63.27±11.86)岁，男性659例 (41.2%)，X线使用率34.7%。总的置管成功率为95.4% (1525/1598)，用X线和未用X线的置管成功率为 97.8%比 94.2% (χ²= 11.292, P=0.001)。总体患者经右颈内静脉置管比经左颈内静脉置管的成功率高(96.6%比90.1%，χ²=22,375，P＜0.001)；未用X 线时，经右颈内静脉置管成功率高于经左颈内静脉(χ²=56,871，P＜0.001)；应用X 线后，经右颈内静脉和经左颈内静脉置管成功率无明显差异(χ²=1.424，P=0.233)。置管失败原因有导管尖端异位(包括导管尖端血管内异位和血管外异位)、非X 线下导丝置入受阻、介入开通中心静脉失败。导管尖端异位病例均未用X 线，占未用X 线人群的3.3%(34/1043)；未用X线，导丝置入受阻置管失败27 例；介入干预病例237 例，成功置管225 例，未开通中心静脉置管失败12例。多因素logistic 回归分析显示，经左颈内静脉置管(OR=1.700，95% CI：3.203～9.362，P＜0.001)和未用X 线置管(OR=1.653，95% CI：2.650～10.28，P＜0.001)是颈内静脉置管失败的独立危险因素。结论X 线的应用可以增加经颈内静脉置入带隧道中心静脉导管的成功率，经左颈内静脉置管与经右侧颈内静脉置管相比，应用X线获益更明显。
【Abstract】Objectives To explore the factors relating to success and safety of tunneled central venous catheterization via internal jugular vein. Methods We conducted a retrospective study on patients undergoing tunneled central venous catheterization via internal jugular vein during 2011 to 2019. Demographic information and operation-related data, including location of the catheter, utilization of X-ray examination, cause of catheterization failure, intervention method, cause of intervention failure, and many others were recruited. The main termination point of the study was the rate of successful catheterization and the cause of catherization failure. Results A total of 1,598 patients were included in this study, with the average age of 63.27±11.86 years old, 659 males (41.2%), and X-ray utilization rate of 34.7%. The overall rate of successful catheterization was 95.4% (1,525/1,598). The rates of successful catheterization with and without x- ray examination were 97.8% and 94.2% respectively (χ²=11.292, P=0.001). The rate of successful catheterization via right internal jugular vein was higher than that via left internal jugular vein (96.6% vs. 90.1%; χ²=22,375, P<0.001). In the patients X-ray examination was not used, the rates of successful catheterization via right internal jugularvein and left internal jugular vein were 95.9% and 76.8% respectively (χ²=56,871, P<0.001); while in the
patients X-ray examination was used, the rates of successful catheterization via right and left jugular veins had no difference (98.4% vs. 96.8%; χ²=1.424, P=0.233). The causes of catheterization failure included ectopic tip of the catheter (endovascular ectopic or extravascular ectopic tip of the catheter), obstruction of guide wire insertion without the help of X-ray examination, and failure of interventional central vein opening. X-ray was not used in all ectopic catheter tip cases, accounting for 3.3%(34/1,043) of the patients without X-ray examination. In patients without X-ray examination, catheterization failure due to obstruction of guide wire insertion was found in 27 cases. In the 237 cases interventional operation was performed to manage the catheterization failure, the catheterization was finally successful in 225 cases, and was failure in 12 cases. Multivariate logistic regression analysis showed that left internal jugular vein catheterization (OR=1.700, 95% CI: 3.203~9.362, P<0.001) and no X-ray examination during catheterization (OR=1.653, 95% CI: 2.650~10.28, P<0.001) were the independent risk factors for failure of the catheterization. Conclusion The application of X-ray examination can increase the success rate of tunneled central venous catheterization via internal jugular vein. X-ray examination was more advantageous when left internal jugular vein was used for the catheterization
[1] Sun L, Zou LX, Han YC, et al. Forecast of the incidence, prevalence and burden of end-stage renal disease in Nanjing, China to the Year 2025. BMC Nephrol. 2016,17(1):60.DOI:10.1186/s12882-016-0269-8.
[2] Agarwal AK, Haddad N, Boubes K. Avoiding problems in tunneled dialysis catheter placement. Semin Dial. 2019,32(6):535-540.DOI:10.1111/sdi.12845.
[3] Yevzlin AS, Song GU, Sanchez RJ, et al. Fluoroscopically guided vs modified traditional placement of tunneled hemodialysis catheters: clinical outcomes and cost analysis. J Vasc Access. 2007,8(4):245-251.
[4] Adeb M, Baskin KM, Keller MS, et al. Radiologically placed tunneled hemodialysis catheters: a single pediatric institutional experience of 120 patients. J Vasc Interv Radiol. 2012,23(5):604-612.DOI:10.1016/j.jvir.2012.01.075.
[5] Labriola L, Seront B, Crott R, et al. Superior vena cava stenosis in haemodialysis patients with a tunnelled cuffed catheter: prevalence and risk factors. Nephrol Dial Transplant. 2018,33(12):2227-2233.DOI:10.1093/ndt/gfy150.
[6] Adwaney A, Lim C, Blakey S, et al. Central Venous Stenosis, Access Outcome and Survival in Patients undergoing Maintenance Hemodialysis. Clin J Am Soc Nephrol. 2019,14(3):378-384.DOI:10.2215/cjn.07010618.
[7] Aurshina A, Hingorani A, Marks N, et al. Intraoperative venoplasty to facilitate placement of tunneled catheters for hemodialysis. Vascular. 2018,26(3):338-340.DOI:10.1177/1708538117728866.
[8] Muhm M, Sunder-Plassmann G, Apsner R, et al. Malposition of central venous catheters. Incidence, management and preventive practices. Wien Klin Wochenschr. 1997,109(11):400-405.
[9] Weber E, Liberek T, Wo?yniec W, et al. Catheter tip malposition after percutaneous placement of tunneled hemodialysis catheters. Hemodial Int. 2015,19(4):509-513.DOI:10.1111/hdi.12303.
[10] Li XY, Ye JB, Zhang LG, et al. Misplacement of Tunneled Hemodialysis Catheter into Azygos Vein: Left or Right Jugular Insertion Has Similar Susceptibility. Blood Purif. 2019,48(1):1-9.DOI:10.1159/000497231.
[11] Ho TB, Cusack R, Rhodes A, et al. Unsuspected cardiac tamponade following insertion of a haemodialysis catheter: a normal chest radiograph does not exclude a complication. Nephrol Dial Transplant. 2000,15(5):719-721.DOI:10.1093/ndt/15.5.719.
[12] Ou S, Deng M. Perforation of the left innominate vein during cannulation for haemodialysis. Nephrology (Carlton). 2013,18(8):580.DOI:10.1111/nep.12097.
[13] Gupta S, Gummalla KM, Punamiya SJ, et al. Perforation of left innominate vein during dialysis catheter placement. BMJ Case Rep. 2014 Oct 16. DOI:10.1136/bcr-2014-206870
[14] Winkes MB, Loos MJ, Scheltinga MR, et al. Dialysis catheter placement via the left internal jugular vein: risk of brachiocephalic vein perforation. J Vasc Access. 2016,17(4):e75-78.DOI:10.5301/jva.5000566.
[15] Zhang W, Liu T, Wang X, et al. Hemothorax caused by replacement of hemodialysis catheter: A case report. Hemodial Int. 2016,20(4):E7-e10.DOI:10.1111/hdi.12428.
[16] Turkyilmaz A, Karapolat S, Kilic M, et al. The Perforation of the Superior Vena Cava Secondary to the Left Subclavian Dialysis Catheter. Vasc Endovascular Surg. 2017,51(2):95-97.DOI:10.1177/1538574416689427.
[17] Zauk JE, Papadimos TJ. Lethal cardiac tamponade after misplacement of a dialysis catheter. Int J Crit Illn Inj Sci. 2018,8(4):216-217.DOI:10.4103/ijciis.Ijciis_18_18.
[18] Sulek CA, Blas ML, Lobato EB. A randomized study of left versus right internal jugular vein cannulation in adults. J Clin Anesth. 2000,12(2):142-145.DOI:10.1016/s0952-8180(00)00129-x.
[19] Xie P, Peng K, Zhang K, et al. Anatomy Revisited: Hemodialysis Catheter Malposition into the Chest. Blood Purif. 2019,47(1-3):58-61.DOI:10.1159/000493177.
[20] Moura F , Guedes F , Dantas Y , et al.Translumbar hemodialysis long-term catheters: an alternative for vascular access failure. J Bras Nefrol. 2019 Jan-Mar; 41(1): 89–94.DOI: 10.1590/2175-8239-JBN-2018-0080
[21] Rao PB, Singh N, Samson S. Central venous catheter malposition due to dialysis catheter: a case report. Korean J Anesthesiol. 2016,69(5):532-534.DOI:10.4097/kjae.2016.69.5.532.
[22] Angral R, Sabesan P, Natarajan K, et al. Inadvertent placement of left central venous catheter into left internal thoracic vein: a case report. Ann Card Anaesth. 2012,15(2):165-166.DOI:10.4103/0971-9784.95086.
[23] Vachharajani TJ, Vachharajani V. A circuitous detour. Kidney Int. 2011,79(12):1383.DOI:10.1038/ki.2011.52.
[24] 詹申,张丽红,杨涛,等.透析导管末端位置异常的原因分析与处理[J].中华肾脏病杂志,2013,29(10):784-785. DOI:10.3760/cma.j.issn.1001-7097.2013.10.011.
[25] Kute VB, Vanikar AV, Gumber MR, et al. Hemodialysis through persistent left superior vena cava. Indian J Crit Care Med. 2011,15(1):40-42.DOI:10.4103/0972-5229.78223.
[26] Bairy M, Prabhu R, Nagaraju SP, et al. The left mediastinal hemodialysis catheter. J Vasc Access. 2015,16(3):e75-76.DOI:10.5301/jva.5000321.
[27] Chintu MR, Chinnappa S, Bhandari S. Aberrant positioning of a central venous dialysis catheter to reveal a left-sided partial anomalous pulmonary venous connection. Vasc Health Risk Manag. 2008,4(5):1141-1143.
[28] He H, Li B, Ma Y, et al. Catheterization in a patient with end-stage renal disease through persistent left superior vena cava: a rare case report and literature review. BMC Nephrol. 2019,20(1):202.DOI:10.1186/s12882-019-1339-5.
