Fraser Amy, Brenner Daniel S, Coghlan Matthew, Andrade Heather, Haouili Maya, Carlos William Graham, Jackson Edwin
Internal Medicine Residency Program, Indiana University School of Medicine, Indianapolis, IN, USA.
Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
POCUS J. 2025 Apr 15;10(1):83-87. doi: 10.24908/pocusj.v10i01.18071. eCollection 2025 Apr.
Each year, more than 200,000 thoracentesis and percutaneous chest tube thoracostomy procedures are performed in the United States [1-4]. In both procedures, the initial step involves advancing a needle over the superior aspect of the rib into the intercostal space to access the pleural cavity. Traditional teaching suggests that this technique avoids the neurovascular bundle, which is typically shielded by the inferior border of the rib. However, this technique does not guarantee safety. Computed tomography studies have shown that the intercostal arteries (ICAs) are highly tortuous, with positions that can vary significantly within the intercostal space [5-7]. This variability can lead to ICA laceration even with an optimal traditional technique [8-9]. Significant hemorrhage into the pleural space may initially go unnoticed but can progress to hemorrhagic shock or even tension hemothorax physiology [10-12]. Improved procedural guidance is needed to enhance safety and achieve the goal of zero patient harm. We propose the DIVOT (Doppler Imaging for Vascular Orientation in Thoracic procedures) protocol using a combination of high-frequency linear ultrasound, color, and Power Doppler (PD) to identify an ICA and its collaterals before needle insertion. This can reduce the risk of accidental vascular injury during thoracentesis or percutaneous chest tube thoracostomy.
在美国，每年进行超过20万次胸腔穿刺术和经皮胸管胸腔造口术[1-4]。在这两种手术中，初始步骤都是将针从肋骨上缘推进到肋间间隙以进入胸膜腔。传统教学认为，这种技术可避免神经血管束，因为神经血管束通常被肋骨下缘遮挡。然而，这种技术并不能保证安全。计算机断层扫描研究表明，肋间动脉（ICA）高度迂曲，在肋间间隙内的位置变化很大[5-7]。即使采用最佳的传统技术，这种变异性也可能导致ICA撕裂[8-9]。胸膜腔内的大量出血最初可能未被注意到，但可能进展为失血性休克甚至张力性血胸[10-12]。需要改进手术指导以提高安全性并实现零患者伤害的目标。我们提出了DIVOT（胸腔手术中血管定位的多普勒成像）方案，该方案结合高频线性超声、彩色和能量多普勒（PD）在插入针之前识别ICA及其侧支。这可以降低胸腔穿刺术或经皮胸管胸腔造口术期间意外血管损伤的风险。
