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急性下肢深静脉血栓形成(deep venous thrombosis,DVT)治疗的主要目的是尽早清除血栓、保护瓣膜功能,预防早期肺动脉栓塞(pulmonary embolism,PE)及后期血栓形成后综合征(post-thrombotic syndrome,PTS)的发生[1]。目前腔内导管溶栓(catheter-directed thrombolysis,CDT)所取得的临床疗效明显优于以往的抗凝、全身溶栓,被优先推选用于急性下肢DVT的治疗[2]。文献[3]报道深静脉血栓溶栓后造影发现髂静脉狭窄率达70%以上,保障髂静脉通畅对促进血液回流、缓解症状、预防血栓复发具有重要意义。本文就CDT或联合髂静脉球囊扩张支架植入术治疗急性髂股静脉血栓形成伴髂静脉狭窄病人的疗效作一探讨。
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收集2015年12月至2018年6月我科治疗的86例急性髂股静脉血栓形成病人,其中男46例,女40例,年龄21~74岁;左下肢71例,右下肢15例;病程均 < 2周(急性期);入院后均经下肢彩超或深静脉造影明确诊断为急性髂股静脉血栓形成,造影可见明显双轨征,经溶栓后存在严重髂静脉狭窄(狭窄率>50%);全组病人近期均不存在抗凝、溶栓禁忌证。86例中,单纯采用CDT治疗54例(对照组),CDT联合髂静脉球囊扩张支架植入术32例(观察组),2组一般情况差异均无统计学意义(P>0.05)(见表 1)。所有研究对象对检查和治疗均知情同意。
分组 n 年龄/岁 男 女 病程/d 左患肢 右患肢 膝上15 cm周径差/cm 观察组 32 56.2±13.4 18 14 4.1±1.7 27 5 6.3±2.7 对照组 54 54.8±11.5 28 26 3.9±1.5 44 10 6.1±3.0 t — 0.51 0.16△ 0.57 0.12△ 0.31 P — >0.05 >0.05 >0.05 >0.05 >0.05 △示χ2值 表 1 2组病人一般情况比较(x±s)
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溶栓治疗前常规预先放置下腔静脉滤器,采用Seldinger技术,经健侧股静脉穿刺行髂静脉及下腔静脉造影明确双肾静脉开口,并观察下腔静脉有无蔓延血栓,于肾静脉开口下0.5~1.0 cm处放置先键科技腔静脉滤器以预防PE发生。
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选择超声引导下以患侧腘静脉或胫后静脉直接切开为入路,置入6F鞘管,单弯导管导丝相互配合置入unifuse溶栓导管,将溶栓导管头端置于髂总静脉开口处,行深静脉置管溶栓治疗3~7 d(每8 h,经溶栓导管间断泵入尿激酶20万u,持续泵入肝素5 mg/h)。
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留置溶栓导管后定期复查下肢深静脉造影,溶栓治疗3~7 d后观察组同期选择直径为10~14 mm球囊扩张髂静脉,随后选择美国Bard公司生产的Luminexx支架或波科公司的Wallstent支架(直径12~14 mm)植入支撑狭窄或闭塞病变段髂静脉;除晚期肿瘤病人预期寿命短,脑梗死引发偏瘫长期卧床等再发血栓风险高的病人,其余大部分病人选择治疗后同期取出下腔静脉滤器。术后常规给予低相对分子质量肝素,3~5 d后过渡至口服华法林或直接选择利伐沙班抗凝治疗,国际标准化比值(international normalized ratio,INR)控制在1.8~2.5,出院后门诊定期随访。
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根据血栓清除程度将其分为3级[4]:Ⅰ级, < 50%溶解;Ⅱ级,50%~90%溶解;Ⅲ级,>90%溶解。按照PORTER等[5]提出的分段血管通畅度评分,血栓消除率=(溶栓前得分-溶栓后得分)/溶栓前得分。测量治疗前后健侧和患侧膝关节上15 cm处周径差,比较2组病人肢体肿胀缓解程度。
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术后第3、6、12、24个月,采用Villalta评分量表、Vcss量表评估PTS发生情况及静脉临床症状严重程度,如出现患肢胀痛、痉挛、肢体沉重感、感觉异常、皮肤瘙痒等症状,查体见胫前水肿、皮下硬结、浅静脉曲张、腓肠肌压痛、色素沉着、静脉溃疡等体征,将每一项症状分为1~3分,总分15分,若总分>5分,即诊断为PTS,并将5~14分为轻/中度PTS,≥15分或出现静脉性溃疡列为重度PTS[6]。Vcss量表每一指标根据严重程度评为0~3分,共30分,总分越高,说明病情越严重[7]。统计2组病人随访期间PTS发生情况及症状严重程度。利用彩色多普勒超声或深静脉造影检查评估观察组支架内通畅情况、有无支架断裂、支架移位情况。
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采用t(或t′)检验、秩和检验和χ2检验。
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2组CDT治疗血栓Ⅲ级消除率达82.6%(71/86),在溶栓时间、尿激酶用量、住院时间方面差异均无统计学意义(P>0.05)。观察组膝上15 cm周径差较对照组小(P < 0.05)(见表 2)。
分组 n 溶栓时间/d 尿激酶用量/(×105u) 膝上15 cm周径差/cm 住院时间/d 溶栓结果 Ⅲ级 Ⅱ级 Ⅰ级 观察组 32 4.5±1.2 27.0±7.2 2.5±1.2 10.4±3.5 26(81.3) 5(15.6) 1(3.1) 对照组 54 4.8±1.6 28.8±9.6 3.2±1.4 11.8±4.0 45(83.3) 7(13.0) 2(3.7) t — 0.92 0.92 2.36 1.64 0.22* P — >0.05 >0.05 <0.05 >0.05 >0.05 *示Hc值 表 2 2组临床结果比较(x±s)
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2组均表现为穿刺点处淤血瘀斑,偶发牙龈、小便发红等症状;均无症状性PE发生。观察组出血3例,对照组5例,差异无统计学意义(χ2=0.13,P>0.05);观察组穿刺点瘀斑4例,对照组7例,差异亦无统计学意义(χ2=0.07,P>0.05);2组肝素诱导的血小板降低均为2例,经停药、减药、碱化尿液等对症治疗后症状均缓解,无需给予特殊干预措施。
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截至随访终点,观察组血栓复发率(1例,3.1%)与对照组(5例,9.3%)差异无统计学意义(χ2=0.41,P>0.05)。随访3、6、12、24个月,观察组Villalta体征和症状评价、Vcss评分均低于对照组(P < 0.05~P < 0.01),而PTS的发生率差异无统计学意义(P>0.05)(见表 3)。
项目 n 3个月 6个月 12个月 24个月 Villalta体征评分 观察组 32 1.3±0.3 1.6±0.5 1.9±0.5 2.1±0.6 对照组 54 1.7±0.5 2.0±0.6 2.3±0.5 2.4±0.7 t — 4.64* 3.17 3.59 2.02 P — <0.01 <0.01 <0.01 <0.05 Villalta症状评分/分 观察组 32 2.3±0.5 2.8±0.6 2.7±1.0 2.5±0.6 对照组 54 2.8±0.8 3.6±0.7 3.5±1.2 3.2±0.8 t — 3.57* 5.39 3.17 4.28 P — <0.01 <0.01 <0.01 <0.01 Vcss评分/分 观察组 32 1.8±0.8 2.2±1.0 2.4±1.2 2.5±1.1 对照组 54 2.3±1.1 2.9±1.3 3.1±1.2 3.2±1.4 t — 2.24 2.62 2.61 2.42 P — <0.05 <0.05 <0.05 <0.05 PTS发生率 观察组 32 2(6.3) 3(9.4) 5(15.6) 6(18.8) 对照组 54 5(9.3) 8(14.8) 12(22.2) 13(24.1) χ2 — 0.01 0.20 0.55 0.33 P — >0.05 >0.05 >0.05 >0.05 *示t′值 表 3 2组随访结果比较(x±s)
导管溶栓联合支架植入术治疗急性髂股静脉血栓形成
Analysis of the efficacy of catheter-directed thrombolysis combined with stent implantation in the treatment of acute iliofemoral vein thrombosis
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摘要:
目的比较经导管溶栓联合髂静脉支架植入与单纯导管溶栓治疗急性髂股静脉血栓形成的效果。 方法选择经抗凝及导管溶栓治疗后存在严重髂静脉狭窄的急性髂股静脉血栓形成病人86例,其中32例经导管溶栓后,联合球囊扩张支架植入术开通髂静脉(观察组);另54例单纯行导管溶栓治疗(对照组)。统计血栓消除率、肢体肿胀缓解情况及围手术期并发症;术后第3、6、12、24个月分别采用Villalta评分量表和Vcss量表评估血栓形成后综合征(PTS)发生情况及静脉临床症状严重程度。 结果2组经导管溶栓治疗血栓Ⅲ级消除率达82.6%;溶栓时间、尿激酶用量、住院时间、围手术期并发症、PTS的发生率及血栓复发率差异均无统计学意义(P>0.05);观察组膝上15 cm周径差较对照组小(P < 0.05);随访3、6、12、24个月,观察组Villalta体征和症状评价、Vcss评分均低于对照组(P < 0.05~P < 0.01)。 结论经导管溶栓治疗急性髂股静脉血栓形成血栓清除率高,联合球囊扩张支架植入术开通髂静脉有助于改善症状,提高临床治疗效果。 Abstract:ObjectiveTo compare the effects between catheter-directed thrombolysis combined with iliac vein stent implantation and catheter-directed thrombolysis in the treatment of acute iliofemoral vein thrombosis. MethodsThe clinical data of 86 patients with acute iliofemoral vein thrombosis complicated with severeiliac vein stenosis treated with anticoagulation combined with catheter-directed thrombolysis were retrospectively analyzed.Thirty-two patients treated with catheter-directed thrombolysis combined with balloon dilatation and stent implantation to open iliofemoral vein and 54 patients treated with catheter-directed thrombolysis alone were divided into the observation group and control group, respectively.The thrombosis elimination rate, limb swelling relief and perioperative complications were counted.The occurrence of post-thrombotic syndrome(PTS) and severity of venous clinical symptoms in two groups after 3, 6, 12 and 24 months of operation were evaluated using Villalta scale and Vcss scale. ResultsThe elimination rate of grade Ⅲ thrombus in two groups by catheter-directed thrombolysis was 82.6%.There was no statistical significance in thrombolytic time, urokinase dosage, length of stay, perioperative complications, incidence of PTS and thrombus recurrence rate between two groups(P>0.05).The circumference difference of up 15 cm of knee in observation group was smaller than that in control group(P < 0.05).During the following-up 3, 6 12 and 24 months, the Villalta signs and symptoms evaluation and Vcss score in observation group were smaller than those in control goup(P < 0.05 to P < 0.01). ConclusionsThe thrombus clearance rate of catheter-directed thrombolysis in the treatment of acute iliofemoral venous thrombosis is high, which combined with opening iliofemoral vein with balloon dilatation and stent implantation can improve the symptoms and clinical therapeutic effect. -
表 1 2组病人一般情况比较(x±s)
分组 n 年龄/岁 男 女 病程/d 左患肢 右患肢 膝上15 cm周径差/cm 观察组 32 56.2±13.4 18 14 4.1±1.7 27 5 6.3±2.7 对照组 54 54.8±11.5 28 26 3.9±1.5 44 10 6.1±3.0 t — 0.51 0.16△ 0.57 0.12△ 0.31 P — >0.05 >0.05 >0.05 >0.05 >0.05 △示χ2值 表 2 2组临床结果比较(x±s)
分组 n 溶栓时间/d 尿激酶用量/(×105u) 膝上15 cm周径差/cm 住院时间/d 溶栓结果 Ⅲ级 Ⅱ级 Ⅰ级 观察组 32 4.5±1.2 27.0±7.2 2.5±1.2 10.4±3.5 26(81.3) 5(15.6) 1(3.1) 对照组 54 4.8±1.6 28.8±9.6 3.2±1.4 11.8±4.0 45(83.3) 7(13.0) 2(3.7) t — 0.92 0.92 2.36 1.64 0.22* P — >0.05 >0.05 <0.05 >0.05 >0.05 *示Hc值 表 3 2组随访结果比较(x±s)
项目 n 3个月 6个月 12个月 24个月 Villalta体征评分 观察组 32 1.3±0.3 1.6±0.5 1.9±0.5 2.1±0.6 对照组 54 1.7±0.5 2.0±0.6 2.3±0.5 2.4±0.7 t — 4.64* 3.17 3.59 2.02 P — <0.01 <0.01 <0.01 <0.05 Villalta症状评分/分 观察组 32 2.3±0.5 2.8±0.6 2.7±1.0 2.5±0.6 对照组 54 2.8±0.8 3.6±0.7 3.5±1.2 3.2±0.8 t — 3.57* 5.39 3.17 4.28 P — <0.01 <0.01 <0.01 <0.01 Vcss评分/分 观察组 32 1.8±0.8 2.2±1.0 2.4±1.2 2.5±1.1 对照组 54 2.3±1.1 2.9±1.3 3.1±1.2 3.2±1.4 t — 2.24 2.62 2.61 2.42 P — <0.05 <0.05 <0.05 <0.05 PTS发生率 观察组 32 2(6.3) 3(9.4) 5(15.6) 6(18.8) 对照组 54 5(9.3) 8(14.8) 12(22.2) 13(24.1) χ2 — 0.01 0.20 0.55 0.33 P — >0.05 >0.05 >0.05 >0.05 *示t′值 -
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