Matsuura John, Dietrich Anne, Steuben Stephanie, Ricker Jaren, Barkema Karla, Kuhl Taften
The Iowa Clinic, Cardiovascular Services, 5950 University Avenue, Suite 231, West Des Moines, IA 50266, USA.
J Vasc Access. 2011 Jul-Sep;12(3):258-61. doi: 10.5301/JVA.2010.6084.
Endovascular therapy for hemodialysis (HD) access is now performed in outpatient centers in a growing number of cities in the US. As patients live longer, we are facing a growing number of patients with central venous occlusion. We report our first three cases of mediastinal tunneled dialysis catheter placement in a clinic setting.
Between 15 November 2009 and 1 April 2010, three patients with central vein occlusion required tunneled HD catheter placement. Case #1 was a 60-year-old male with left subclavian and innominate vein occlusion from a defibrillator pacemaker and two previous right internal jugular tunneled dialysis catheters with occlusion of the right internal jugular vein. He lost right arm access after two failed arteriovenous fistulas (AVF) and an occluded upper arm AV graft. His last right external jugular catheter was removed for infection. Case #2 was a 72-year-old female with a thrombosed left upper arm and a right basilic vein AV access. She had a history of left leg deep vein thrombosis (DVT) and a vena cava filter. The left and right internal jugular veins were occluded as well as the left subclavian vein after stent placement. She required a tunneled HD catheter after a failed attempt at endovascular salvage of her right basilic AVF. Case #3 was a 78-year-old female who had been on HD for 4 yr. She refused AVF surgery and had four tunneled HD catheters removed for infection. She presented with bilateral internal jugular vein thrombosis and the removal of an infected right subclavian tunneled HD catheter. THE TECHNIQUE: The dialysis catheters were placed using standard C-arm fluoroscopy. We accessed the right femoral vein to pass a Berenstein catheter (Cordis, Inc, Warren, NJ) into the right innominate-subclavian vein junction. Using the catheter as a fluoroscopic target, a micropuncture needle was guided into the right innominate vein and a standard J-guidewire was used to dilate the mediastinal tract and place a new tunneled dialysis catheter.
In all three cases, the tunneled dialysis catheters were placed under local anesthesia with no intravenous sedation. No pneumothorax occurred and all three catheters were used for HD within 24 hr. Two catheters were removed at 3 and 4 months for infection. One catheter continues to function well.
As the lifespan of our dialysis patient population continues to improve, we will see an increasing need to perform complicated access procedures to maintain HD support. These three cases emphasize the value of the transmediastinal technique using basic C-arm fluoroscopy and a limited stock of basic catheters and guidewires.
在美国越来越多的城市，门诊中心现已开展用于血液透析（HD）通路的血管内治疗。随着患者寿命延长，我们面临着越来越多的中心静脉闭塞患者。我们报告在临床环境中首例三例纵隔隧道式透析导管置入术。
2009年11月15日至2010年4月1日期间，三名中心静脉闭塞患者需要置入隧道式HD导管。病例1是一名60岁男性，因除颤起搏器导致左锁骨下静脉和无名静脉闭塞，此前两根右侧颈内静脉隧道式透析导管也导致右侧颈内静脉闭塞。他在两次动静脉内瘘（AVF）失败和上臂AV移植物闭塞后失去了右臂通路。他最后一根右侧颈外静脉导管因感染被拔除。病例2是一名72岁女性，左上臂血栓形成，有右侧贵要静脉AV通路。她有左腿深静脉血栓形成（DVT）病史和腔静脉滤器。在置入支架后，左、右颈内静脉以及左锁骨下静脉均闭塞。在对其右侧贵要AVF进行血管内挽救尝试失败后，她需要一根隧道式HD导管。病例3是一名78岁女性，已接受HD治疗4年。她拒绝AVF手术，因感染已拔除四根隧道式HD导管。她出现双侧颈内静脉血栓形成，并拔除了一根感染的右侧锁骨下隧道式HD导管。技术：使用标准C形臂荧光透视仪置入透析导管。我们经右股静脉将一根贝伦斯坦导管（Cordis公司，新泽西州沃伦）送入右无名-锁骨下静脉交界处。以该导管作为荧光透视靶点，将一根微穿刺针导入右无名静脉，并使用一根标准J形导丝扩张纵隔通道，置入一根新的隧道式透析导管。
在所有三例病例中，隧道式透析导管均在局部麻醉下置入，未使用静脉镇静剂。未发生气胸，所有三根导管均在24小时内用于HD。两根导管在3个月和4个月时因感染被拔除。一根导管仍功能良好。
随着我们透析患者群体的寿命持续延长，我们将看到越来越需要进行复杂的通路手术以维持HD支持。这三例病例强调了使用基本C形臂荧光透视仪以及有限的基本导管和导丝库存的经纵隔技术的价值。
