Department of Vascular Surgery, Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX.
Siemens Medical Solutions USA Inc., Malvern, PA.
J Vasc Surg Venous Lymphat Disord. 2022 Nov;10(6):1334-1342.e1. doi: 10.1016/j.jvsv.2022.06.013. Epub 2022 Aug 6.
The novel Surfacer Inside-Out recanalization technique facilitates right-sided central venous access in occluded vessels but carries a risk of arterial and pleural injuries. This article demonstrates how an advanced intraoperative imaging protocol can help to avoid these potential complications.
This retrospective review included patients undergoing the Surfacer Inside-Out central venous recanalization procedure between December 2017 and October 2021. The study sample comprised patients included in the SAVE-US trial at our site as well as patients treated after US Food and Drug Administration approval of the device. All procedures were performed using intraoperative cone-beam computed tomography (CBCT) angiography to map out the trajectory of the device through the mediastinum and supraclavicular space with fusion imaging for guidance. Procedures were aborted if CBCT findings predicted injury to arterial or respiratory structures. The intraoperative coronal and sagittal orientation of the device was compared to preoperatively predicted trajectory.
A total of 17 procedures were performed in 16 patients with end-stage renal disease and a mean age of 61 ± 11 years. Most patients presented a type 3 central venous occlusion (9/15). Successful recanalization was achieved in 14 of the 17 cases (82.4%) with no intraoperative complications. The procedure had to be aborted in 3 of the 17 cases based on intraoperative CBCT findings, which projected the device to perforate the right pleural space in one patient, the trachea and right subclavian artery in another, and the innominate artery in the third patient. The total radiation dose per procedure was 753 ± 346 mGy and the mean procedural time was 101.6 ± 29.7 minutes. A median of 2 (range, 1-5) intraoperative CBCT scans were performed per patient and accounted for 70% of the total radiation dose. Statistical analysis showed intraoperative CBCT findings to differ significantly from preoperative predicted values.
The nonsteerable and penetrating nature of the Surfacer device may lead to serious complications when performed under fluoroscopic guidance alone. Intraoperative CBCT with fusion overlay enhances the safety and effective use of this device and inside out crossing technique.
新型 Surfacer 内外贯通技术可辅助开通闭塞血管以建立右侧中心静脉通路，但存在动脉和胸腔损伤风险。本文旨在介绍一种先进的术中影像方案，以避免此类潜在并发症。
本回顾性研究纳入了 2017 年 12 月至 2021 年 10 月期间行 Surfacer 内外贯通中心静脉再通术的患者。研究样本包括本中心 SAVE-US 试验的患者以及该设备获得美国食品药品监督管理局批准后的患者。所有操作均采用术中锥形束 CT（CBCT）血管造影，以融合图像为指导，对设备通过纵隔和锁骨上区的轨迹进行成像。如果 CBCT 发现提示存在动脉或呼吸结构损伤，则中止操作。比较术中设备冠状位和矢状位与术前预测轨迹的关系。
共纳入 16 例终末期肾病患者（17 例操作），平均年龄 61±11 岁。大多数患者存在 3 型中心静脉闭塞（9/15）。17 例操作中，14 例（82.4%）成功开通，无术中并发症。基于术中 CBCT 结果，有 3 例操作需要终止：1 例患者预计设备会刺穿右侧胸腔，1 例患者预计设备会穿通气管和右侧锁骨下动脉，1 例患者预计设备会穿通无名动脉。平均每个操作的总辐射剂量为 753±346mGy，平均操作时间为 101.6±29.7 分钟。中位数为 2（范围 1-5）次术中 CBCT 扫描，占总辐射剂量的 70%。统计学分析显示，术中 CBCT 结果与术前预测值有显著差异。
在单纯透视引导下使用不可转向、穿透性的 Surfacer 设备可能会导致严重并发症。术中 CBCT 融合叠加可提高该设备及内外贯通技术的安全性和有效性。
