Giebler R, Scherer R, Erhard J, Lange R, Paar D, Stöcker L
Institut für Anästhesiologie, Universitätsklinikum Essen.
Anaesthesist. 1996 Jan;45(1):59-65. doi: 10.1007/s001010050241.
Portofemoro-axillary bypass systems are commonly used to treat adverse haemodynamic effects during the anhepatic phase of orthotopic liver transplantation (OLT). However, low shunt flows may reduce the efficacy of these bypass systems. In order to improve veno-venous bypass management, a percutaneous cannulation technique (PCT) was used to insert large-bore catheters (21 F) into the left femoral and subclavian veins. This study prospectively addresses the complications of the PCT in 195 adult patients undergoing 203 OLTs.
The left femoral and subclavian veins were cannulated preoperatively with 21 F single-lumen catheters (DLP, Grand Rapids, MN, USA) using a Seldinger technique. Intra-operatively, the centrifugal pump (Biopump, Biomedicus, Minnesota, USA) and the portal part of the bypass were connected with the femoral and subclavian catheters. Coagulation profiles, shunt flows, haemodynamic parameters, and complications during OLT associated with the bypass system were recorded.
Percutaneous cannulation of the left subclavian and femoral veins was successful in 198 (97.6%) patients. Mean portofemoro-subclavian shuntflow was 4.3 (SD 1.3 l min-1). Although cardiac index (shunt 3.91 [SD 1.1] vs pre-shunt 4.42 [SD 1.0] l min-1 m-2, P < 0.05) and oxygen delivery (shunt 496 [SD 111] vs. pre-shunt 562 [SD 153] ml ml-1.m-2, P < 0.05) were not maintained at pre-shunt levels, renal perfusion pressure stayed above 50 mm Hg during the anhepatic phase. Two intra-operative air embolism (0.98%) and one myocardial infarction (0.49%) at the beginning of the anhepatic phase were observed. There were no bleeding complications.
The portofemoro-subclavian bypass can be performed by percutaneous cannulation without additional complications in patients undergoing OLT. Although haemorrhagic complications following central venous catheterisation are reported to occur in patients with haemostatic defects, none of them was observed in this study. Two events of air embolism and one cardiac arrest could not be related to the PCT. In conclusion, femoro-subclavian percutaneous cannulation is a simple, rapid, and safe alternative to commonly used veno-venous bypass systems.
门静脉-腋静脉转流系统常用于治疗原位肝移植（OLT）无肝期的不良血流动力学效应。然而，低分流流量可能会降低这些转流系统的疗效。为了改善静脉-静脉转流管理，采用经皮插管技术（PCT）将大口径导管（21F）插入左股静脉和锁骨下静脉。本研究前瞻性地探讨了195例接受203次OLT的成年患者中PCT的并发症。
术前采用Seldinger技术，用21F单腔导管（DLP，美国明尼苏达州大急流城）插入左股静脉和锁骨下静脉。术中，将离心泵（Biopump，美国明尼苏达州Biomedicus公司）和转流的门静脉部分与股静脉和锁骨下静脉导管相连。记录OLT期间与转流系统相关的凝血指标、分流流量、血流动力学参数和并发症。
198例（97.6%）患者经皮穿刺左锁骨下静脉和股静脉成功。门静脉-锁骨下平均分流流量为4.3（标准差1.3）升/分钟。虽然心脏指数（转流时3.91[标准差1.1]与转流前4.42[标准差1.0]升/分钟·平方米，P<0.05）和氧输送量（转流时496[标准差111]与转流前562[标准差153]毫升/分钟·平方米，P<0.05）未维持在转流前水平，但无肝期肾灌注压保持在50毫米汞柱以上。观察到无肝期开始时发生2例术中空气栓塞（0.98%）和1例心肌梗死（0.49%）。无出血并发症。
OLT患者可通过经皮插管进行门静脉-锁骨下转流，无额外并发症。虽然据报道有止血缺陷的患者会发生中心静脉置管后的出血并发症，但本研究中未观察到此类情况。2例空气栓塞事件和1例心脏骤停与PCT无关。总之，股静脉-锁骨下经皮插管是常用静脉-静脉转流系统的一种简单、快速且安全的替代方法。
