前瞻性实施一种算法，以在危重病患者床边行血管内超声引导下滤器放置。

Prospective implementation of an algorithm for bedside intravascular ultrasound-guided filter placement in critically ill patients.

机构信息

Division of General Surgery, University of Alabama at Birmingham, Birmingham, Ala, USA.

出版信息

J Vasc Surg. 2010 May;51(5):1215-21. doi: 10.1016/j.jvs.2009.12.041. Epub 2010 Mar 11.

DOI:10.1016/j.jvs.2009.12.041

PMID:20223628

Abstract

BACKGROUND

Although contrast venography is the standard imaging method for inferior vena cava (IVC) filter insertion, intravascular ultrasound (IVUS) imaging is a safe and effective option that allows for bedside filter placement and is especially advantageous for immobilized critically ill patients by limiting resource use, risk of transportation, and cost. This study reviewed the effectiveness of a prospectively implemented algorithm for IVUS-guided IVC filter placement in this high-risk population.

METHODS

Current evidence-based guidelines were used to create a clinical decision algorithm for IVUS-guided IVC filter placement in critically ill patients. After a defined lead-in phase to allow dissemination of techniques, the algorithm was prospectively implemented on January 1, 2008. Data were collected for 1 year using accepted reporting standards and a quality assurance review performed based on intent-to-treat at 6, 12, and 18 months.

RESULTS

As defined in the prospectively implemented algorithm, 109 patients met criteria for IVUS-directed bedside IVC filter placement. Technical feasibility was 98.1%. Only 2 patients had inadequate IVUS visualization for bedside filter placement and required subsequent placement in the endovascular suite. Technical success, defined as proper deployment in an infrarenal position, was achieved in 104 of the remaining 107 patients (97.2%). The filter was permanent in 21 (19.6%) and retrievable in 86 (80.3%). The single-puncture technique was used in 101 (94.4%), with additional dual access required in 6 (5.6%). Periprocedural complications were rare but included malpositioning requiring retrieval and repositioning in three patients, filter tilt >/=15 degrees in two, and arteriovenous fistula in one. The 30-day mortality rate for the bedside group was 5.5%, with no filter-related deaths.

CONCLUSIONS

Successful placement of IVC filters using IVUS-guided imaging at the bedside in critically ill patients can be established through an evidence-based prospectively implemented algorithm, thereby limiting the need for transport in this high-risk population.

摘要

背景

尽管对比静脉造影是下腔静脉（IVC）滤器插入的标准成像方法，但血管内超声（IVUS）成像也是一种安全有效的选择，它允许在床边放置滤器，并且通过限制资源使用、转运风险和成本，特别有利于固定不动的重症患者。本研究回顾了在这一高危人群中前瞻性实施的 IVUS 引导下 IVC 滤器放置算法的有效性。

方法

使用现有的循证指南制定了重症患者 IVUS 引导下 IVC 滤器放置的临床决策算法。在定义的先导阶段（允许技术传播）之后，该算法于 2008 年 1 月 1 日前瞻性实施。使用公认的报告标准收集了 1 年的数据，并根据 6、12 和 18 个月的意向治疗进行了质量保证审查。

结果

按照前瞻性实施的算法定义，109 例患者符合 IVUS 指导下床边 IVC 滤器放置的标准。技术可行性为 98.1%。只有 2 例患者因床边滤器放置时 IVUS 可视化不足而需要在血管内套房进行后续放置。在其余 107 例患者中，有 104 例（97.2%）达到了技术成功的定义，即适当放置在下肾位置。21 个滤器为永久性（19.6%），86 个为可回收性（80.3%）。101 例（94.4%）采用单穿刺技术，6 例（5.6%）需要额外的双入路。围手术期并发症罕见，但包括 3 例需要取出和重新定位的定位不当、2 例滤器倾斜>/=15 度和 1 例动静脉瘘。床边组的 30 天死亡率为 5.5%，无滤器相关死亡。