超声引导PDA封堵治疗

改良动脉导管未闭导管封堵法

TranscatheterclosingPDAguidedbytransthoracicechocardiography:Feasibilityandsafety福建医科大学附属协和医院心内科

福建省冠心病研究所

陈良龙UUFightingCVD背景/Background

传统的导管封堵治疗PDA法通常需穿刺股动、静脉，以建立输送轨道；并做降主动脉造影，以确定PDA形态、大小及选择合适的封堵器。Conventionally,trans-catheterclosingPDAusuallyneedspuncturingboththefemoralarteryandthefemoralveintocreateanoccluderdeliveringtrack,andperformingaorta-angiographytodeterminethemorphologyandsizeofPDAinordertoselectaproperoccluder.局限性/Limitations

通常，穿刺股动脉及股静脉并不困难；但是婴幼儿或体重低于4KG者，穿刺股动脉或/和股静脉可能会有困难；对于直径小的股动脉进行穿刺及插管操作可能造成血管损伤及相关并发症。Normally,puncturingthefemoralvesselsiseasy,butitmaybedifficultifthepatientsareinfantsortheirweightis

4Kg;moreover,puncturingandoperationmanipulatingmaydamagethefemoralarteryorintroducecomplications.局限性/Limitations

主动脉造影时需要注射造影剂，造影剂剂量较大时具有肾毒性；同时，X线造影时患者需要接受较高剂量的X线辐射。这对患者尤其是儿童是十分不利的。Opacificationmediuminjectedforaorta-angiographyhasrenaltoxicityifusedathighdosages;meanwhile,patientshavetoreceiveextraX-Rayradiationduringaorta-angiography.Thesemaybeharmfulforpatientsespeciallyforchildren.替代方法/Alternative鉴此，传统的导管PDA封堵术是否有改良或替代方法？不必穿刺股动脉不需做X线主动脉造影仅穿刺股静脉Inviewofthefacts，arethereanymodifiedtechniquesforsubstitutiontraditionalmethodsforclosingPDA?NofemoralarterypunctureNoaorta-angiographyOnlyfemoralveinpunctureAcasedemo

病例介绍UUFightingCVD技术操作-PDA测量、轨道建立

技术操作-封堵器定位、残余分流观察技术操作-封堵器主、肺动脉无占位技术操作-封堵器主动脉占位？技术操作-封堵器释放后Initiateexperience

初步经验UUFightingCVD目的/Objectives探讨在超声心动图引导下、不需做X线主动脉造影、不必穿刺股动脉、仅穿刺股静脉封堵治疗PDA的可行性及安全性。Weintroducedanovelmethodwhichrequirednoaorta-angiographyandnofemoralarterypuncture,onlyneededfemoralveinpunctureandechocardiographyguidingduringPDAclosingWetestedthefeasibilityandsafetyforthismethods.临床资料/PatientsdataPDA患儿27例，男12例，女15例，年龄4.6±2.9岁（1

8）岁，体重13.1±5.4Kg（3.7

23.5Kg）。其中，2岁以下婴幼儿6例，体重8.2±3.1Kg（3.7

13.8Kg）。Twenty-sevenptswithPDA(12malesand15females,agedat4.62.9years,weightedat13.15.4Kg)wereincludedinthestudy,amongwhom6ptsareinfantswithweightof8.2±3.1Kg(3.7

13.8Kg).临床资料/Patientsdata二维超声心动图封堵前测量PDA最窄处直径为5.9±1.5mm(3.2

7.8mm)，PDA长度9.7±3.6mm(6.7

13.2mm)。PDA具有较典型的漏斗部、且彩色多普勒血流显像提示PDA分流方向指向肺动脉外侧壁或中部。

Preoperatively,thenarrowestPDAdiameterwas

5.9±1.5mmwiththePDAlengthof9.7±3.6mmmeasuredby2DE,andCDFIrevealedthetypicalPDAshuntinginallpatients.方法/Methods仅穿刺股静脉、不穿刺股动脉，在X线透视下建立输送轨道；按术前超声测量的PDA最窄处直径的2倍选择Amplatzer封堵器，并根据术中CDFI实时监测结果进行适当调整。Weonlypuncturedthefemoralveinasanapproachforbuildingupanoccluderdeliveringtrackunderfluoroscopy;theAmplatzer

occluderwasselectedbasedonthenarrowestdiameterofPDAdeterminedby2DEandadjustedbyreal-timeCDFImonitoringwhenthedeliveringcatheterwascrossingPDA.方法/Methods封堵器离到位后若X线透视下有明显的“堆形腰”、2DE显示封堵器呈“工字形”且主、肺动脉侧均无占位，即开始应用CDFI连续监测分流阻断情况；通常封堵到位后即刻至30分钟内，CDFI显示PDA分流逐步至完全消失，此时可释放封堵器。Afterwellpositioningtheoccluder,ifX-rayshoweditataperedwaist,2DE&CDFIrevealeditanI-shapedappearancewithoutanyoccupationofaortaorpulmonaryartery,CDFIwasusedforcontinouslymonitoringtheshuntingalterations.Ifshuntingdisappearedgraduallyin30Min,theoccludercouldbesafelyreleased.

方法/Methods在下列情况下，需要更换封堵器：1、封堵器到位后X线透视下无明显的“堆形腰”，或封堵器严重变形，或轻度推拉即发生封堵器移位；2、彩色多普勒血流显像显示封堵器边缘性分流宽度

2mm、持续时间

30Min。Incaseofthefollowingsituations，theoccludershouldbereplaced：ifnotaperedwaistorseveredeformedwasfound；andifthemarginalshuntingwas

2mmand/orlasting30min。

结果/Results

本方法对27例PDA患儿封堵治疗的技术成功率100%，无围手术期严重并发症。超声引导PDA封堵治疗在封堵器选择、定位、分流监测方面准确可行，安全可靠。ThetechnicalsuccessrateforclosingPDAbythenewmethodwas100%in27patientswithoutanyperi-andpost-proceduralcomplications.Andechocardiographyguidingfordeviceselectingandpositioning,andshuntmonitoringisaccurate,feasibleandsafe.结果/Results

在封堵尝试中，首次封堵器选择太小而需要更换较大封堵器者4例次（14.8%），首次封堵器选择太大而需要更换较小封堵器者2例次（7.4%）。Basedonechocardiographiccriteria,requirementofdevicereplacingduetoincorrectorimproperselectionwas22.2%,with14.8%ofselectionoftoosmalleranoccluderand7.4%ofselectionoftoobiggeranoccluder.讨论/Discussion超声心动图可替代X线造影:PDA大小测量及封堵器选择封堵器定位、形态判断残余分流监测、封堵器更换主动脉、肺动脉占位Echocardiographysubstitutionforangiography:MeasuringPDAdiameterandselectinganoccluderPositioningtheoccluderandviewingitsshapeMonitoringresidualshunting,determiningreplacementofanoccluderInterrogatingoccluderoccupationinaortaandpulmonaryartery结论/Conclusion超声心动图引导、无X线造影的经股静脉PDA导管封堵术是安全可行的；因无需X线造影，无造影剂毒副作用、X线辐射减少；无需穿刺股动脉，适合在低体重或/和婴幼儿中应用，可最大程度减轻手术损伤。Echocardiogr