Quaretti Pietro, Galli Franco, Fiorina Ilaria, Moramarco Lorenzo Paolo, Spina Monica, Forneris Giacomo, Torresi Mario, Bellazzi Roberto
1 Interventional Radiology Unit, Radiology Department, IRCCS Policlinico San Matteo, Pavia - Italy.
J Vasc Access. 2014 May-Jun;15(3):183-8. doi: 10.5301/jva.5000186. Epub 2013 Oct 31.
A long-term tunneled hemodialysis catheter can be difficult or impossible to pull out if a fibrin sleeve has attached it to the venous wall. We report the outcome of a refinement of Hong's technique for removing incarcerated catheters aimed at improving its feasibility and safety.
We applied a modification of Hong's technique in four patients (two males, age ranging from 51 to 68 years) with jugular twin hemodialysis catheters (five of eight lines incarcerated). Hong pioneered the technique of endoballooning to expand a stuck central venous catheter, thus freeing it from adhesions. In our technical refinement, we cut the catheter close to its venous entry point in order to facilitate pullout and inserted a valved introducer as access for guide wires as well as for inflations of the catheter balloon. A stiff guide wire was placed in the inferior vena cava to avoid potential damage to heart cavities. Dilation was monitored under fluoroscopy with constrictions showing points where the catheter was incarcerated. If adhesions persisted through the same introducer, endoluminal dilations were repeated with a larger diameter balloon until the catheter was released. New catheters can be positioned using the stiff guide wire already in place. All removals were carried out under local anesthesia in an angiographic room by interventional radiologists.
All catheters were successfully removed without complications. Average fluoroscopy time for removal was 12 minutes. In the case of a Tesio catheter removed after 12 years because of infection, a computed tomography scan 2 months later revealed persistence of a calcified fibrin sleeve in the vessel.
Hong's technique was confirmed to be a simple, safe and highly effective way to remove incarcerated long-term central venous catheters. The refinements we adopted made the procedure more flexible and possibly less prone to complications. By properly using ordinary tools available anywhere, Hong's technique could be considered Columbus' egg in this previously risky field.
如果纤维蛋白套将长期隧道式血液透析导管附着于静脉壁，拔出导管可能会困难甚至无法拔出。我们报告了对洪氏技术进行改进以取出嵌顿导管的结果，旨在提高其可行性和安全性。
我们对4例患者（2例男性，年龄51至68岁）的颈内双腔血液透析导管（8根导管中有5根嵌顿）应用了改良的洪氏技术。洪氏开创了球囊扩张技术来扩张卡住的中心静脉导管，使其从粘连中解脱出来。在我们的技术改进中，我们在靠近静脉入口处切断导管以利于拔出，并插入一个带瓣膜的导入器作为导丝进入通道以及导管球囊充气的通道。在 inferior vena cava 放置一根硬导丝以避免对心腔造成潜在损伤。在荧光透视下监测扩张情况，狭窄部位显示导管嵌顿的位置。如果通过同一导入器粘连仍然存在，则用更大直径的球囊重复腔内扩张，直到导管被松解。可以使用已就位的硬导丝来放置新的导管。所有取出操作均在血管造影室由介入放射科医生在局部麻醉下进行。
所有导管均成功取出，无并发症发生。取出的平均透视时间为12分钟。因感染在12年后取出的一根特西奥导管，2个月后的计算机断层扫描显示血管内钙化纤维蛋白套持续存在。
洪氏技术被证实是一种简单、安全且高效的取出嵌顿长期中心静脉导管的方法。我们采用的改进使该操作更灵活，可能也更不易发生并发症。通过合理使用各地都有的普通工具，洪氏技术在这个以前有风险的领域可被视为哥伦布的鸡蛋。
