Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
University of Kentucky College of Medicine, Lexington, KY.
J Vasc Surg Venous Lymphat Disord. 2022 Sep;10(5):1113-1118. doi: 10.1016/j.jvsv.2022.03.012. Epub 2022 May 10.
Thoracic central venous obstruction (TCVO) presents a challenging scenario for patients requiring central venous access. The inside-out technique for crossing occluded veins has been described; however, to date, case series have reported on a limited number of patients. The purpose of the present study was to evaluate the indications for, efficacy of, and outcomes with the inside-out technique at a single tertiary academic center, with close attention to the severity of TCVO using the Society of Interventional Radiology (SIR) TCVO classification.
Patients who had undergone central venous access using the inside-out technique were identified from August 2007 to May 2021. The patient demographics, procedure indication, procedural details, SIR TCVO classification, outcomes, and procedure-related complications were recorded. Statistical analysis was performed using analysis of variance.
A total of 221 patients (109 men [49.3%] and 112 women [50.6%]) had undergone 338 inside-out procedures. Of the 221 patients, 49 had undergone the procedure multiple times (25 two times, 11 three times, 13 more than three times). The average patient age was 54.7 ± 14.8 years. The indications (n = 362) for the procedure included dialysis access (n = 230; 63.5%), infusion of parenteral nutrition, antibiotics, chemotherapy, or other medication (n = 81; 22.3%), cardiac access (n = 39; 10.8%), and other (n = 12; 3.3%); more than one indication for 20 procedures. Type 1 SIR TCVO was found during 147 procedures (43.5%), followed by type 4 for 142 (42.0%), type 2 for 36 (10.7%), type 3 for 6 (1.8%), and unable to determine for 7 (2.0%). The access site was the right femoral vein for 322 procedures (95.3%), left femoral vein for 14 (4.1%), and transhepatically for 2 (0.6%). The exit site location was the right supraclavicular region for 274 (81.3%), right subclavicular for 52 (15.4%), left supraclavicular for 3 (0.9%), left subclavicular for 6 (1.8%), and not defined for 2 (0.6%). Types 3 and 4 were associated with longer fluoroscopy times and more contrast compared with types 1 and 2. The median follow-up and device duration was 56.0 days and 76.5 days, respectively. No differences were found in device duration between the SIR TCVO types. Removal of a catheter was documented for 166 patients. The indications for removal included infectious causes (non-catheter-related bacteremia, catheter-related infection or bacteremia) for 70 (42.1%), catheter malfunction for 34 (20.5%), new hemodialysis access for 19 (11.5%), no longer needed for 19 (11.5%), patient removal of the catheter by 13 (7.8%), and replacement of a temporary catheter with a tunneled device for 11 (6.6%). No procedural complications were associated with the inside-out technique or catheter removal.
For a variety of indications, we have shown that the inside-out technique is safe and effective for establishing central venous access in patients with TCVO and can be performed repeatedly. More complex obstructive patterns were associated with longer fluoroscopy times and greater contrast administration. Durability was primarily limited by infectious complications.
胸内中心静脉阻塞（TCVO）对需要中心静脉通路的患者构成了具有挑战性的情况。已经描述了用于穿过闭塞静脉的内翻技术；然而，迄今为止，病例系列报告的患者数量有限。本研究的目的是评估在一家三级学术中心使用内翻技术的适应证、疗效和结果，并密切关注使用介入放射学会（SIR）TCVO 分类的 TCVO 严重程度。
从 2007 年 8 月至 2021 年 5 月，确定了使用内翻技术进行中心静脉通路的患者。记录患者的人口统计学资料、手术适应证、手术细节、SIR TCVO 分类、结果和与手术相关的并发症。使用方差分析进行统计分析。
共有 221 名患者（109 名男性[49.3%]和 112 名女性[50.6%]）接受了 338 次内翻手术。在 221 名患者中，49 名患者多次接受该手术（25 次 2 次，11 次 3 次，13 次 3 次以上）。患者的平均年龄为 54.7±14.8 岁。手术适应证（n=362）包括透析通路（n=230；63.5%）、肠外营养、抗生素、化疗或其他药物输注（n=81；22.3%）、心脏通路（n=39；10.8%）和其他（n=12；3.3%）；20 例有多种适应证。在 147 例（43.5%）中发现 SIR TCVO 类型 1，其次是类型 4（142 例，42.0%）、类型 2（36 例，10.7%）、类型 3（6 例，1.8%）和无法确定（7 例，2.0%）。入路部位为右侧股静脉 322 例（95.3%），左侧股静脉 14 例（4.1%），经肝 2 例（0.6%）。出口部位位于右侧锁骨上区 274 例（81.3%）、右侧锁骨下区 52 例（15.4%）、左侧锁骨上区 3 例（0.9%）、左侧锁骨下区 6 例（1.8%）和未定义 2 例（0.6%）。类型 3 和 4 的透视时间和造影剂用量明显长于类型 1 和 2。中位随访和器械使用时间分别为 56.0 天和 76.5 天。SIR TCVO 类型之间的器械使用时间无差异。记录了 166 例患者的导管拔除。导管拔除的适应证包括感染原因（非导管相关菌血症、导管相关感染或菌血症）70 例（42.1%）、导管功能障碍 34 例（20.5%）、新的血液透析通路 19 例（11.5%）、不再需要 19 例（11.5%）、患者自行拔除导管 13 例（7.8%）和临时导管更换为隧道设备 11 例（6.6%）。内翻技术或导管拔除无手术并发症。
对于多种适应证，我们表明内翻技术在 TCVO 患者中建立中心静脉通路是安全有效的，可以重复进行。更复杂的阻塞模式与更长的透视时间和更多的造影剂使用有关。耐久性主要受感染并发症的限制。
