Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany.
Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany.
Catheter Cardiovasc Interv. 2018 Nov 1;92(5):E327-E332. doi: 10.1002/ccd.27601. Epub 2018 May 8.
"Blind" pericardiocentesis is the standard procedure for emergency pericardial drainage when ultrasound guidance is unavailable. Under these circumstances, puncture site and needle direction are exclusively oriented according to certain anatomic landmarks. In the literature, different techniques for this "blind" method have been described. Goal of this retrospective study was to compare the potential success and complication rate of 13 simulated puncture directions.
Simulated pericardiocentesis was performed in 150 CT scans from patients with moderate to severe pericardial effusions (greater than 1 cm distance between epicardium and pericardium). Thirteen different puncture techniques with varying puncture sites, direction of the puncture, and the angle were compared. A simulated pericardiocentesis was classified as "successful" when the effusion was reached. It was classified as "successful without a complication" when no adjacent structure was penetrated by the simulated puncture (lung, liver, internal thoracic artery, LAD, colon, and stomach). An attempt was declared as "unsuccessful" when the pericardial effusion was not reached at all, or the reached effusion measured less than 0.5 cm between the epicardium and pericardium at the location where the needle entered the pericardium.
A subxiphoidal puncture technique starting in Larrey's triangle (sternocostal triangle) and directed toward the left midclavicular point with a 30° inclination resulted in the highest success rate (131 of 150 cases = 87%). In parallel the lowest complication rate (7 of 150 = 5%) was found using this technique, as well. In contrast, pericardiocentesis performed using other puncture directions resulted in lower success (66%-85%) and higher complication rates (9%-31%).
This CT-based simulation study revealed that blind pericardiocentesis guided by anatomical landmarks only is best performed in a subxiphoid approach with a needle direction to the left midclavicular point with a 30° inclination. Nevertheless, injury of adjacent structures occurred frequently (5%) even when applying this puncture technique. Thus, blind pericardiocentesis can be performed with a high success rate and seems adequate to be performed under emergency conditions. However, planned procedures should be performed under image guidance.
在无法进行超声引导的紧急情况下，“盲目”心包穿刺术是进行紧急心包引流的标准程序。在这种情况下，穿刺部位和进针方向完全根据特定的解剖学标志来确定。文献中已经描述了这种“盲目”方法的不同技术。本回顾性研究的目的是比较 13 种模拟穿刺方向的潜在成功率和并发症发生率。
在 150 例中等至大量心包积液（心外膜与心包之间的距离大于 1 厘米）的 CT 扫描中进行了模拟心包穿刺术。比较了 13 种不同穿刺技术，包括不同的穿刺部位、穿刺方向和角度。当达到积液时，模拟心包穿刺术被分类为“成功”。当模拟穿刺术未穿透任何相邻结构（肺、肝、内乳动脉、LAD、结肠和胃）时，分类为“成功且无并发症”。当根本未达到心包积液，或在针尖进入心包的位置处，到达的积液在心外膜与心包之间的距离小于 0.5 厘米时，则宣布尝试“不成功”。
从拉雷三角（胸骨肋三角）开始，针尖指向左侧锁骨中线，与矢状面成 30°角的剑突下穿刺技术成功率最高（150 例中有 131 例成功，即 87%）。同时，该技术的并发症发生率也最低（150 例中有 7 例，即 5%）。相比之下，使用其他穿刺方向进行心包穿刺术的成功率较低（66%-85%），并发症发生率较高（9%-31%）。
这项基于 CT 的模拟研究表明，仅根据解剖学标志进行的盲目心包穿刺术，最佳的方法是在剑突下进行，针尖指向左侧锁骨中线，与矢状面成 30°角。然而，即使采用这种穿刺技术，也经常会损伤相邻结构（5%）。因此，在紧急情况下可以进行高成功率的盲目心包穿刺术，但计划进行的手术应在图像引导下进行。
