【作者】 刘岩；

【导师】 刘凡；

【作者基本信息】 河北医科大学 ， 内科学， 2014， 硕士

【摘要】 目的：心内电生理检查、射频消融术、心脏起搏器植入术等心脏检查、治疗已被证明是诊断和治疗各种心律失常安全和有效的方法，并广泛应用于临床。锁骨下静脉是最常用的血管径路，随着起搏器技术的开展及广泛应用，双腔起搏器、三腔起搏器植入量越来越大，通过锁骨下静脉途径植入的电极也越来越多，并且目前植入的电极大多为粗且硬的双极电极，增加了锁骨下静脉“挤压综合征”的发生，经腋静脉途径穿刺是解决锁骨下静脉“挤压综合征”的有效方法，并且能有效避免气胸等并发症。本研究通过分析经肘正中静脉或头静脉穿刺行腋静脉造影患者腋静脉走行，研究腋静脉的体表标志。方法：对象：选择2012年3月至2013年12月于河北医科大学第二医院心内科因阵发性室上性心动过速行射频消融术（RFCA）及因病态窦房结综合征、房室传导阻滞、恶性心律失常、心衰行心脏起搏器植入（包括单腔起搏器、双腔起搏器、ICD及CRT）患者共115例（15～78岁）。其中男性56例，女性59例。行射频消融术（RFCA）者59例，行心脏起搏器植入术者56例。方法：入选患者呈平卧位，双上肢自然下垂并收拢于身体两侧，经肘正中静脉或头静脉穿刺，用一次性注射器迅速推注碘普罗胺注射液（370）约5ml，应用数字减影血管造影X线机（DSA）行腋静脉造影。X线透视下观察锁骨形态（即锁骨与水平线角度），腋静脉显影后以锁骨为标志，观察腋静脉走行并应用Archive Manager图像处理软件测量锁骨与水平线角度，腋静脉与锁骨角度，腋静脉出锁骨处与锁骨胸骨端距离。然后，以胸前区左锁骨下皮肤表面凹陷形成的三角最低点（A点）向下约1.2cm处（B点）定为腋静脉体表标志（见Fig.1）。为进一步确定B点在X线下与腋静脉重合，我们选取3M心电图电极片不透X线的钮扣作为腋静脉的体表标志点。电极片置于B点定标志后，经肘正中静脉或头静脉行腋静脉造影，观察腋静脉通过体表标志点的通过率。并分析不同性别、不同锁骨形态有无差异。统计方法：应用SPSS13.0软件包建立数据库，进行统计学分析。计量资料采用均数±标准差(x±s)表示，计数资料用百分比表示。不同性别、不同身体侧别患者的锁骨形态、锁骨与腋静脉角度及腋静脉出锁骨处与锁骨胸骨端距离的比较采用独立样本t检验，不同性别、不同锁骨类型，腋静脉通过体表标志比率的比较采用x2检验，两变量之间的相关性采用直线相关分析，数据以x±s表示，P＜0.05认为有统计学意义。结果：115例成功行腋静脉造影术患者，平均年龄为57.00±15.82岁（15～78岁）。其中男性56例（48.70%），女性59例（51.30%）；行射频消融术（RFCA）患者59例（51.30%），行心脏起搏器植入术患者56例（48.70%）；行左侧腋静脉造影患者76例（66.09%），行右侧腋静脉造影患者39例（33.91%）。115例成功行腋静脉造影患者均无并发症发生。锁骨与水平线角度平均为29.74±7.48°其中30°及以下（即锁骨水平）者共56例（48.70%），平均为23.30±4.44°，30.1°～45°（即锁骨上翘）者共59例（51.30%），平均为35.90±3.64°（见Fig.2）。其中男性平均为30.70±7.38°，女性平均为28.83±7.53°。左侧锁骨与水平线角度平均为29.50±7.48°，右侧锁骨与水平线角度平均为30.23±7.57°，不同性别、不同身体侧别比较均无统计学差异（P＞0.05）。锁骨与腋静脉角度平均为57.30±10.50°，男性平均为60.00±11.47°，女性平均为54.80±8.86°，二者比较有统计学差异（P＜0.05）。左侧锁骨与腋静脉角度平均为58.12±10.64°，右侧锁骨与腋静脉角度平均为55.71±10.17°，二者比较无明显统计学差异（P＞0.05）。锁骨与水平线角度与锁骨与腋静脉角度均符合正态分布，二者呈直线相关，相关系数r为0.373（P＜0.05），有统计学意义。腋静脉出锁骨处与锁骨胸骨端平均距离为54.74±11.10mm。男性平均为：57.86±9.15mm，女性平均为：51.77±12.02mm。二者比较有统计学差异（P＜0.05）。左侧腋静脉出锁骨处与锁骨胸骨端平均距离为55.50±11.54mm，右侧腋静脉出锁骨处与锁骨胸骨端平均距离为53.24±10.15mm。二者比较无统计学差异（P＞0.05）。腋静脉出锁骨处与锁骨胸骨端距离、锁骨和水平线的角度均符合正态分布，二者无线性相关关系，无统计学差异（P＞0.05）。经统计学分析，不同身体侧别锁骨形态、腋静脉均无统计学差异，故均选择患者左侧行腋静脉造影并观察腋静脉通过体表标志的通过率。电极片置于体表B点定标后行左侧腋静脉造影患者21例，其中锁骨与水平线角度30°及以下者共14例（66.67%），30.1°～45°者共7例（33.33%）。其中男性12例（57.14%），女性9例（42.86%）。腋静脉通过体表标志患者17例，其中锁骨与水平线角度30°及以下者共11例，30.1°～45°者共6例。其中女性7例（41.18%），男性10例（58.82%）。通过率为80.95%。不同性别、不同锁骨类型腋静脉通过体表标志的比率均无明显统计学差异（P＞0.05）。结论：本研究通过分析腋静脉造影成功患者X线影像学资料，发现腋静脉体表标志相对固定，以锁骨和B点为体表标志，腋静脉出锁骨处与锁骨内侧头距离平均为54.74±11.10mm，腋静脉与锁骨角度平均为57.30±10.50°，不同性别有统计学差异，不同身体侧别均无统计学差异。锁骨与水平线角度与锁骨与腋静脉角度，两者呈线性相关关系。且腋静脉均通过B点（不同性别、不同锁骨类型腋静脉通过体表标志的比率均无明显统计学差异，通过率为80.95%。更多还原

【Abstract】 Objective: Cardiac intervention therapy, such as cardiac electrophysio-logical study, radiofrequency catheter ablation and pacemaker implantation,has been proven to be a safe and effective method for diagnosis and treatmentof various arrhythmias, and has been widely used in clinic. Subclavian veinwas the most commonly used puncture pathway, with the extensivedevelopment and application of pacemaker technology, double chamberpacemaker, three chamber pacemaker has been widely implanted into patients,and most of electrodes are embedded through the subclavian vein. Currently,most of pacemaker electrodes are thicker and rigid bipolar electrodes, leadingto the increasing incidence of subclavian vein crush syndrome. The puncturepathway of axillary vein is an effective method to solve the "crush", and caneffectively avoid various complications, such as pneumothorax. In order tolocate the landmark of axillary venous, we plan to evaluate angiography of theaxillary vein pathway by median cubital vein or cephalic vein puncture.Subjects:115patients aged15-88years old of both sexes were enrolledinto this study between March2012and December2013at the SecondHospital of Hebei Medical University, including59patients with paroxysmalsupraventricular tachycardia for radiofrequency catheter ablation (RFCA),56patients with sick sinus syndrome, atrioventricular block, malignantarrhythmia, heart failure for pacemaker implantation (including singlechamber pacemaker, double chamber pacemaker, ICD, CRT).56cases wasmale,59cases was female.Methods: The patients who were supine with their upper limbs saggingnaturally on both sides of the body were punctured through median cubitalvein or cephalic vein and pushed iodine amine injection (370) about5ml foraxillary vein angiography using digital subtraction angiography X-raymachine（DSA）. Clavicle shape（the angle between clavicle and horizontal line）is observed under X-ray fluoroscopy. After developed，the shape ofaxillary vein is investigated and several indicators should be measured withthe Archive Manager image processing soft: the angle between clavicle andhorizontal line, the angle between axillary vein and clavicle, the distancebetween axillary vein starting and the sternal end of clavicle. Then, in thechest area，the nadir of left subclavian right-angled triangle formed by thesurface of the skin sag was point A，under vertical about1.2cm was point Bas the landmark of axillary vein (see Fig.1). In order to the point B can bedeveloped under X-ray, We adopt the electrode as the surface mark.Electrodes are marked at the point B，then the passing rate of axillary vein areobserved through landmark of body, and we analyze whether there issignificant difference between different gender and clavicle type.Statistical analysis: All data were represented as mean±SD or percent-age. All the statistical examinations were performed using either independentsamples t-test or Chi-squared test by SPSS13.0software. The correlationanalysis between two variables used rectilinear correlation. P<0.05wasconsidered statistically significant.Results: The average age was57.00±15.82years old (15～78years old)in115cases, including56males (48.70%) and59females(51.30%).The number of patients with implantation of RFCA was59cases (51.30%).The number of patients who have pacemaker implantation was56cases(48.70%). The number of patients who were made by axillary veinangiography on the left side of body was76cases (66.09%), The number ofpatients who were made by axillary vein angiography on the right side of bodywas39cases (33.91%). No complications occurred. The data showed that theangle between the clavicle and the horizontal line was29.74±7.48°on average,of which less than30°was56cases (48.70%) with23.30±4.44°on average, ofwhich30.1°~45°was59cases(51.30%) with35.90±3.64°on average. Theangle between the clavicle and the horizontal line was30.70±7.38°on averagein male,28.83±7.53°on average in female,29.50±7.48°on average on the leftside and30.23±7.57°on average on the right side. Both different side and different gender, the comparison of angle between clavicle and the horizontalline showed no significant difference (P>0.05). The angle between axillaryvein and clavicle was57.30±10.50°on average. The comparison of angle hada significant difference between male and female (60.00±11.47°vs.54.80±8.86°, P<0.05). The comparison of angle had no significant differencebetween left and right (58.12±10.64°vs.55.71±10.17°, P>0.05). There were arectilinear correlation between the angle of the clavicle and the horizontal lineand the angle of the axillary vein and the clavicle(r＝0.373P<0.05). Thedistance between axillary vein starting and the sternal end of clavicle was54.74±11.10mm on average. The distance is significantly different betweenmale and female (57.86±9.15mm vs.51.77±12.02mm, P<0.05), while therewas no significant difference between left and right (55.50±11.54mmvs.53.24±10.15mm, P>0.05). There was no rectilinear correlation between theangle of the clavicle and the horizontal line and the distance of the axillaryvein starting and the sternal end of clavicle (P>0.05). After analyzing the dataof the angle between the clavicle and the horizontal line, we found that therewas no difference in different gender and body side. So the axillary vein wasin different body side. We made axillary vein angiography all at the left side.The number of patients who were marked with electrodes, then, we madeaxillary vein angiography at the left side was21cases,of which less than30°were14cases (66.67%), of which30.1°~45°were7cases (33.33%), of whichmale were12cases(57.14%), female were9cases (42.86%). The number ofpatients whose axillary vein passing the landmark was17cases, of which theclavicle and the horizontal line angle less than30°were11cases, of which30.1°to45°were a total of6cases including7female（41.18%）and10male（58.82%）. The total passing rate was80.95%. The comparison of the rate ofpassing the landmark between different gender and clavicle type showed nosignificant difference.Conclusion: In this study, we found that the body surface mark of theaxillary vein puncture was relatively fixed. Marked by clavicle, the distancebetween axillary vein starting and clavicle medial head was54.74±11.10mm on average, the angle between clavicle and axillary vein was57.30±10.50°onaverage. Majority of patients’ axillary vein pass the point B (the comparisonof the rate of passing the body surface maker between different gender andclavicle type was no significant difference). There was a significant differencebetween different gender, while different side of the body had no statisticaldifference. There was a rectilinear correlation between the angle of theclavicle and the horizontal line and the angle of the axillary vein and theclavicle.更多还原