RU2613562C1 - Method of access to large veins of upper extremities (vbasilica and vcephalilca) for carrying out diagnostic and therapetic interventional interferences - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to X-ray endovascular diagnostics and treatment, anesthesiology and emergency medicine, cardio-vascular surgery, cardiology. On the side of supposed operational access internal catheter is installed into superficial vein of arm accessible for puncture. Then to estimate anatomical features of venous bed phlebography of arm is performed, in which purpose tourniquet, which prevents blood outflow by venous system of arm, is applied on upper third of shoulder, and 1-2 ml of X-ray contrast medication is introduced through earlier installed intravenous catheter, after which by analysis of phlebograms puncture area of lateral or medial subcutaneous vein of arm is determined. Under control of fluoroscopy after infiltration anesthesia of skin puncture of vein in selected area is realised with needle. Guide is introduced through needle in vein lumen. Skin cut performed on needle. Introducer for carrying out intervention is installed by means of guide. Diameter and length of introducer are selected taking into account area and character of supposed intervention.

EFFECT: method ensures conditions for safe performance of diagnostic and medicinal interventional interferences on heart and vessels of small and large circles of blood circulation.

3 cl, 2 ex, 3 dwg

Description

FIELD OF THE INVENTION

The invention relates to medicine, namely to endovascular diagnostics and treatment, anesthesiology and intensive care, cardiovascular surgery, cardiology, and can be recommended for implementation in clinical practice of angiography laboratories, cardiovascular, anesthesiology and cardiology departments (any departments in clinics equipped with angiographs).

State of the art

The prior art method for catheterization of the deep veins of the upper extremities, in particular by introducing a radiopaque preparation into the radial artery, followed by its accumulation in the system of superficial and deep veins of the upper extremities (Pancholy SB, Sweeney J. A technique to access difficult to find upper extremity veins for right heart catheterization: the levogram technique. Catheter. Cardiovasc. Interv. 2011 Nov. 1; 78 (5): 809-812).

However, the known method requires catheterization of the radial artery, exposing it to the risk of thrombotic occlusion. In addition, deep vein puncture is performed into the venous phase after the contrast medium is injected into the arterial bed, i.e. after the accumulation of contrast medium in the entire venous system of the upper limb, which significantly reduces the degree of visualization of the target vein.

The prior art also discloses a method for catheterizing central veins under ultrasound duplex scanning (Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, Reeves ST; Councils on Intraoperative Echocardiography and Vascular Ultrasound of the American Society of Echocardiography. Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2011; 24: 1291-318).

However, the known method requires an expert-class ultrasound device and, no less important, a highly qualified specialist who knows the technique, because to perform successful catheterization of the vessel while tracking the relative position of the ultrasonic sensor and the puncture needle, a quick and confident interpretation of two-dimensional images of the vessels and their surroundings is required structures consisting of daily practice and experience.

Disclosure of invention

The objective of the invention is to develop methods for quick access to one of the veins of the upper limbs of large caliber (v.basilica or v.cephalica).

The technical result achieved is the provision of conditions for the safe performance of diagnostic and therapeutic interventions on the heart (sounding of the right heart, interventional correction of cardiac arrhythmias, correction of MPP and MJP defects, isolation of the left atrial ear with atrial fibrillation) and blood vessels of the small and large circle of blood circulation ( catheterization of the right heart, angiopulmonography, balloon angioplasty of the pulmonary arteries, radiofrequency denervation of the pulmonary arteries, implant tion cava filter, etc.).

The proposed method has two main technical methods, the first of which is the phlebography of the upper limb through a pre-installed intravenous catheter, followed by analysis and the selection of the most suitable as operative access for performing interventional intervention of the main vein. In this case, an intravenous catheter can be installed by paramedical personnel outside the x-ray in any saphenous vein of the upper limb accessible for catheterization.

The second basic technique is to puncture the target vein under fluoroscopy control. This becomes possible due to the application of a turnstile on the upper third of the shoulder, which prevents the outflow of venous blood, which leads to the accumulation of a contrast agent in the venous system of the hand and good visualization of the target vessel even with a minimum volume of 1-2 ml.

The choice of the optimal vein for operative access on the basis of phlebography data allows the safe use of instrument sizes from 3-4 Fr for diagnostic tests up to 20 Fr (depending on the diameter of the punctured vein) when performing endovascular operations on the heart and blood vessels.

Operational access through the main veins of the upper limbs makes it possible to safely perform a wide range of diagnostic and therapeutic interventions on the heart and blood vessels and can serve as a full-fledged alternative to using the central veins (jugular, subclavian, femoral) as an access, associated with a rather high risk of complications.

SUMMARY OF THE INVENTION

The first step in performing prompt access to the medial or lateral saphenous vein of the arm is to insert an intravenous catheter into any upper limb vein accessible for puncture along the palmar or dorsum (in the elbow, forearm, shoulder, hand). An intravenous catheter is inserted by a nurse with peripheral vein puncture skills in the clinical unit or in the intensive care unit (ICU) / intensive care unit (IDU) as part of the preoperative preparation of the patient for endovascular intervention. Under sterile conditions, an intravenous catheter should be installed on the side of the intended surgical access through the main vein. Then the patient is transferred to an X-ray room, where after antiseptic treatment and isolation of the surgical field according to generally accepted provisions, the second stage is performed - an angiogram of the veins of the upper extremities.

A turnstile is placed on the upper third of the shoulder, which prevents the outflow of blood through the venous system of the arm. Phlebography is performed through a pre-installed intravenous catheter to assess anatomical features (1-2 ml of a radiopaque drug is administered). When analyzing the obtained angiogram, the optimal main vein is determined, which is suitable for use as an operative access when performing an intervention.

The next step is the puncture of the optimal vein under the control of fluoroscopy. For puncture and catheterization of deep veins, standard kits for radial access “Transradial Kit” of the company “Cordis Jonson & Jonson” (USA), “Radiofocus” of the company “Terumo” (Japan) and “Prelude” of the company “Merit Medical” (USA) are used. Due to the fact that the contrast agent is injected directly into the venous system, and the outflow from it is blocked by the turnstile, a high concentration of the radiopaque preparation is created in the target vessel, which leads to its very good visualization, which lasts long until the turnstile is removed from the shoulder. An infiltration anesthesia of the skin is performed with 1-3 ml of a 2% lidocaine solution in the area of the proposed puncture. Vein puncture is performed with an open-type needle (a needle for introducing a conductor) with a diameter of 21G, then a conductor with a diameter of 0.021``, 45 cm long, is inserted through the needle into the lumen of the vessel, a skin incision is made on the needle (the needle in this case is a guideline for making an incision) and an introducer is installed diameter and length required for interventional intervention. Next, the main stage of the intervention is performed. At the end of the procedure, the introducer sheath is removed immediately and an aseptic pressure bandage is applied.

The invention is also illustrated in a series of illustrations:

In FIG. Figure 1 shows a good visualization of large caliber v.basilica when a contrast medium is injected into the cubital vein against the background of a turnstile superimposed on the upper third of the arm.

In FIG. Figure 2 shows a good visualization of the main veins of the right hand (v.basilica, v.cephalica, v.brachialis) with the introduction of contrast medium into the cubital vein against the background of the turnstile superimposed on the upper third of the shoulder.

In FIG. 3 depicts angiopulmonography of the left lung performed by access through v.cephalica.

Clinical example No. 1.

Patient M., 46 years old; diagnosis: idiopathic pulmonary hypertension; recurrent pulmonary embolism. A 20G intravenous catheter is installed in the right cubital vein. To determine the optimal vein suitable for surgical access, an angiogram of the veins of the right upper limb was performed. A puncture of the medial saphenous vein of the shoulder (v.basilica) was performed and an introducer with a diameter of 8 Fr. was installed. A phased balloon vasodilation of the branches of the pulmonary artery of the C9 segment on the left was performed with the achievement of good filling of the distal bed and contrasting of the outflow along the pulmonary veins. The intervention went without complications.

Clinical example No. 2.

Patient I., 35 years old; diagnosis: Chronic thromboembolic pulmonary hypertension. A 20G intravenous catheter is installed in the right cubital vein. An angiogram of the veins of the right upper limb was performed. A puncture of the lateral saphenous vein of the shoulder (v.cephalilca) was performed and an introducer with a diameter of 6 Fr. was installed. Probing of the right heart and angiopulmonography were performed. The intervention went without complications.

Claims (3)

1. A method of access to the large veins of the upper extremities (v.basilica and v.cephalilca) for diagnostic and therapeutic interventions, characterized in that an intravenous catheter is placed on the side of the intended surgical access into the superficial vein of the arm accessible for puncture, then to assess anatomical of venous rust features, a hand phlebography is performed, for which a turnstile is placed on the upper third of the shoulder, which prevents the outflow of blood through the venous system of the hand, and 1-2 ml of radiopaque of the parathon through a previously installed intravenous catheter, after which, by analyzing the phlebograms, the area of puncture of the lateral or medial saphenous vein of the arm is determined, then, under the control of fluoroscopy after infiltration anesthesia of the skin, the puncture of the vein is performed with a needle, then a conductor is inserted through the needle into the vein lumen, then by needle they perform a skin incision, and an introducer sheath is installed along the conductor to perform the intervention, the diameter and length of the introducer sheath being selected taking into account the region and nature of confusion. 2. The access method according to claim 1, characterized in that an open-type needle with a diameter of 21G and a conductor with a diameter of 0.021 "and a length of 45 cm are used. 3. The access method according to claim 1, characterized in that when performing skin infiltration anesthesia, 1-3 ml of a 2% lidocaine solution is administered.

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