介入性腔内机械性血栓碎吸及溶栓术治疗周围动脉急性血栓栓塞

目的探讨介入性腔内机械性血栓碎吸和局部溶栓术治疗周围动脉急性血栓栓塞的临床效果和应用价值。方法124例周围动脉急性血栓性阻塞患者接受DSA检查和介入性腔内机械性血栓碎吸联合局部溶栓术治疗。结果全组总的介入治疗成功率97.58%（121/124）。血管完全开通率82.26%（102/124）,部分开通率15.32%（19/124）,无效率2.42%（3/124）。部分开通的19例辅以PTA联合内支架植入术后血管完全开通。并发症发生率6.45%（8/124）。结论介入腔内机械性血栓碎吸和局部溶栓治疗周围动脉急性血栓闭塞疾病,疗程短、成功率高、疗效显著、并发症少,恰当辅以PTA和内支架植入可显著提高治疗成功率。     

介入性溶栓治疗动脉血栓19例报告

目的 探讨动脉血栓的介入性溶栓治疗的临床价值。方法 对19例动脉血栓病人采用选择性血管内溶栓及经皮穿刺血管成形术(PTA)。结果本组平均溶栓时间3.7 h,尿激酶平均用量45×10~5IU,溶栓治疗成功率94.74％(18/19),14例血管完全开通,4例部分开通,1例无效。4例PTA,2例明显改善。结论 动脉血栓的介入性溶栓治疗效果显著,可作为治疗血栓闭塞性疾患优先选择的方法。     

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目的 探讨直肠癌术后下肢深静脉血栓形成（ＬＤＶＴ）的原因及其防治。方法 回顾性研究自１９９１年１月至１９９９年６月间收治的８全针肠癌术后ＬＤＶＴ病人。结果 本组ＬＤＶＴ占同期深静脉全形成的２．１％（８／３８４）。占同期直肠癌手术治疗的１．２％（８／６５６）。左侧５例，右侧３例。术后早期发生的ＬＤＶＴ有７例，均为截石体位手术，平均发生于术后第１０天，另１例２年发生。本组病人早期祛聚、抗凝和溶栓治疗后     

下肢骨折术后急性深静脉血栓形成的治疗

目的 探讨下肢骨折及术后急性下肢深静脉血栓形成的治疗效果显著的方法。方法 设通常静脉滴注尿激酶、低分子右旋糖酐加复方丹参注射液１３例为对照组,设经导管静脉内尿激酶溶栓１１例为治疗组,行两组治疗对比。结果 治疗组的治愈率８１．８５％,总有效率１００％;对照组治愈率２３．１％,总有效率６９．２％,两者显著差异（Ｐ〈０．０５）。结论 经导管血管内溶栓方法,用药量少,直接栓内溶栓,加之机械性破坏血栓,溶栓     

肿瘤段切除,人工假体重建合并症的分析

作者对１６８例肿瘤扩大切除、人工假体重建术后的病例进行观察，随访１～９年，平均４．２年。发生术后合并症者３０例，其中术后感染２例，迟发感染６例，总感染率为４．８％；术后假体脱位３例（１．８％）；松动３例（１．８％）；肿瘤局部复发７例（４．２％）；肺转移１１例（６．６％），其中７例兼有肿瘤局部复发；假体排异反应１例。最后作者根据临床资料对上述主要合并症作了较为详细的分析讨论。     

经尿道前列腺电汽化术的合并症

报告５７例前列腺增生症患者在经尿道前列腺电汽化术（ＴＵＶＰ）治疗中发生６例次（１０．５％）合并症，其中ＴＵＲ综合征１例（１．８％），术后继发膀胱出血１例（１．８％），术后膀胱颈挛缩２例（３．５％）及尿道外口狭窄２例（３．５％）。分析了其发生原因并提出防治措施，所有患者预后良好     

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目的：提高胰腺癌的根治性切除率。方法：对１６例胰腺癌施行扩大切除术,即以Ｗhipple术或胰体尾部切除为基础,广泛清扫区域淋巴结,部分并受侵门静脉和（或）肠系膜上静脉（ＰＶ／ＳＭＶ）联合切除,结果：平均手术时间８．５h,平均术中输血１２５０mL。１４例合并受侵ＰＶ／ＳＭＶ联合切除,１１例（６８．８％）获根治性切除。术后发生并发症７例（４３．８％）,围手术死亡１例（６．２５％）,平均住院时间３５d,获根治性切除的１１例中,生存１／２－１年者２例,１－２年者８年,１例已存活３２个月,无复发迹象,结论：胰腺癌的扩大切除术是安全可行的,单纯是侵犯ＰＶ／ＳＭＶ的胰腺癌仍有２／３的可能获得根治性切除。     

直肠癌术后盆内灌注式化疗：（附41例临床报告）

为防治直肠癌术后盆内局部区域复发，采用盆内灌注式化疗新方法，术中贫内置管，术后早期反复盆内灌注５－ＦＵ进行盆内区域化疗，对我院４１例直肠癌根治术人进行了治疗和观察。结果显示：白细胞减少１例，恶性呕吐２例，会阴伤口延迟愈合２例，拖出肠段坏死１例，无吻合口瘘、盆内大出血、盆内感染等严重局部并发症，未见严重全身毒副作用。全部病例定期随访观察，局部复发４例（９．８％），肝转移５例（１２．２％），存活３４例     

硬脑膜静脉窦血栓诊治分析

目的观察经静脉窦机械碎栓、尿激酶局部血管内溶栓治疗颅内静脉窦血栓形成的疗效。方法回顾性分析比较全身肝素化常规治疗方法治疗10例患者,与血管内治疗方法即经静脉窦机械碎栓、尿激酶局部血管内溶栓的方法治疗14例硬脑膜静脉窦血栓患者的治疗效果。结果血管内治疗组平均住院16天,其中11例痊愈（颅内压转正常、无神经功能障碍）,3例好转（颅内压仍高,但较前有降低）;全身肝素化常规治疗组平均住院28天,5例临床症状改善,3例无变化,1例加重后转本院行血管内溶栓,死亡2例。结论经静脉窦机械碎栓、尿激酶局部血管内溶栓治疗颅内静脉窦血栓形成临床疗效确切、安全可靠。     

人工心脏瓣膜替换术后抗凝治疗并发症

自１９８０年至１９９２年１０月我们行人工心脏瓣膜替换术３７０例，康复出院３２９例，经３月至１２５月随访，有２例失访，共发生与抗凝治疗有关并发症１７例（５．２％或１．４８％病人－年），死亡１２例（３．６％或１．０３％病人－年），其中血栓栓塞６例（１．８２％），死亡３例（０．９１％）；抗凝出血１１例（３．３４％），死亡９例（２．７３％）。抗凝治疗并发症中出血明显多于血栓栓塞，并发症发生时间主要在术后３个月内（含术后９４天），占８９％。     

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??Endovascular management of aortoiliac occlusive disease with thrombosis: an analysis of 18 cases YE Meng??ZHANG Hao??HUANG Xiao-zhong, et al. Department of Vascular Surgery, Renji Hospital, Shanghai Jiaotong University??Shanghai 200001 ??China
Corresponding author??ZHANG Ji-wei??E-mail: zhangjiwei001@sina.com.cn
Abstract Objective To review the outcomes and safety of endovascular treatment of aortoiliac occlusive disease with thrombosis. Methods Between June 2006 and February 2008, 18 patients underwent treatment for occlusion of the aortoiliac arteries complicating with thrombosis at Renji Hospital of Shanghai Jiaotong University. Three patients underwent surgical thrombectomy with ad-junctive angioplasty; 9 patients underwent angioplasty secondary to thrombolysis; 6 patients underwent primary iliac angioplasty with adjunctive thrombolysis. Results The technical success rate was 83.3%. The postoperative mortality rate was 5.6%, and limb survival rate was 100%. With a mean follow-up period of 14.5 months (range from 12??26 months), 1-year primary patency, assisted patency rates and second patency were 69.2%, 84.6% and 92.3%. Compared with angioplasty secondary to thrombolysis, the period of thrombolysis and the volume of urokinase decreased significantly in the group underwent primary angioplasty with thrombolysis(P<0.05). Conclusion All the treatment are acceptable management strategies for aortoiliac occlusive disease with thrombosis. The appropriate choice of treatment depends on the severity level of the ischemia.     

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目的探讨应用导管接触溶栓治疗急性动脉闭塞性疾病的临床效果。方法回顾性分析2004年8月至2006年4月间中国人民解放军总医院应用导管接触溶栓治疗急性动脉闭塞性疾病8例临床资料。持续导管接触溶栓治疗后均行腔内球囊扩张成型或支架置入治疗。结果8例8条肢体均在局部麻醉经皮穿刺下完成,导丝均能通过闭塞段,并通过脉冲喷射技术给予50万单位尿激酶,使闭塞段通溶开一条缝隙。后续治疗中持续泵入尿激酶(50万~100万单位)18~40h后,造影复查有7例获得较满意的溶栓效果,并对考虑为引起闭塞的中重度狭窄病变处给予相应的处理(单纯球囊扩张3例次,合并支架治疗4例)。2例发生血栓移位堵塞远处血管,1例腔内治疗好转,另1例行胫后动脉切开取栓合并自体大隐静脉补片手术。8条肢体造影均可见病变血管恢复通畅,术后原症状均有不同程度的改善。无截肢(趾),无穿刺部位假性动脉瘤及血肿,无死亡、无溶栓相关的严重出血并发症等。结论溶栓治疗可以恢复缺血肢体的血流,与传统外科手术相比,溶栓治疗可有效恢复侧支循环的血流。在有必要进行外科手术重建血运时,溶栓治疗通常可以缩小手术的范围;并将急诊手术转化为择期手术。但是要注意溶栓治疗时血栓移位形成远端动脉栓塞的发生及处理。     

肝移植术后肝动脉血栓形成的溶栓治疗3例报道

目的 探讨肝移植术后肝动脉血栓形成的溶栓治疗价值。方法对50例同种异体肝移植病例，术后以彩色多普勒超声(CDI)定期监测肝动脉血流，怀疑肝动脉血栓形成(HAT)行动脉造影，确诊3例，即刻行介入溶栓治疗，经导管分别在20分钟内予尿激酶12．5万单位、30分钟内予尿激酶25万单位和肝素50mg，及4小时内注入尿激酶60万单位。结果3例溶栓治疗后，肝动脉均再通。1例因二次血栓形成再次溶栓成功。但均发生不同程度的腹腔内出血，1例保守治疗痊愈，1例经开腹手术止血后痊愈，另1例死于多器官功能衰竭。结论对怀疑HAT病例，应尽早行动脉造影。改进后的溶栓疗法有可能成为治疗HAT的可选择方法。     

Evaluation of thrombolysis in a porcine model of chronic deep venous thrombosis: an endovascular model

PURPOSE: The advancement of catheter-based interventions for vascular recanalization has underscored the need for an experimental animal model of vascular thrombosis that can be used for the evaluation of interventional therapies. In this model, a porcine model of deep venous thrombosis with a novel endovascular technique was described, and the efficacy of thrombolytic therapy with urokinase was evaluated. METHODS: An endovascular device that consisted of a tapered polytetrafluoroethylene graft attached within a self-expanding nitinol stent was delivered to bilateral common iliac veins in 20 pigs. Venous thrombosis occurred as a result of flow stasis created by the intrastent stenosis. Catheter-directed pulse-spray thrombolysis with urokinase (250,000 units) and heparin (5000 IU) was performed on one limb while the contralateral limb received control saline solution. Thrombolysis was performed in 1 hour (n = 4), 8 hours (n = 4), 3 days (n = 4), 7 days (n = 4), and 14 days (n = 4) after the stent-graft deployment. Venography and intravascular ultrasound were used to evaluate the efficacy of thrombolysis. Light microscopy was used for histologic analysis of the thrombus. RESULTS: Complete thrombolysis was achieved in groups with deep vein thrombosis that were younger than 1 day. Angioplasty of the tapered stent-grafts in the completely thrombolysed iliac vein was successful in restoring venous flow. The efficacy of thrombolysis in 3-day, 7-day, and 14-day groups was 86% +/- 7%, 73% +/- 13%, and 42% +/- 23%, respectively. The thrombolytic efficacy was enhanced to 92% +/- 16% and 86% +/- 18% (P <.05) in 3-day and 7-day groups, respectively, when doses of the pulse-spray thrombolysis were doubled. Increased dosages of the thrombolytic agent, however, did not significantly enhance the thrombus dissolution in the 14-day group. CONCLUSION: The thrombolytic efficacy of urokinase correlated with the chronicity of deep venous thrombosis in our model. An increased dose of urokinase may be used to enhance the efficacy of thrombolysis in a 1-week-old thrombus.     

手术取栓与药物溶栓治疗急性髂股型下肢深静脉血栓形成的疗效比较

目的 评估手术取栓加药物溶栓与单纯药物溶栓治疗急性髂股型下肢深静脉血栓形成的疗效.方法 回顾性分析175例髂股型下肢深静脉血栓形成患者的临床资料,依据治疗方式的不同分为取栓组与溶栓组;手术取栓组85例,其中合并髂总静脉狭窄或闭塞的46例,选择于术或介入治疗,术后给予尿激酶、低分子肝素治疗.采取药物溶栓抗凝治疗90例,仪给予尿激酶、低分子肝素治疗.治疗前两组患者年龄、病程、肿胀程度及伴随疾病比较,差异无统计学意义(P＜0.05).结果 治疗后1个月,手术取栓组治愈率71.8%(61/85),双下肢周径差手术组由(4.6±1.6)cm下降为(0.8±0.5)cm;溶栓组治愈率38.9%(35/90);双下肢周径差由(4.0±1.9)cm下降为(1.8±1.3)cm.平均随访(28±11)个月,随访率64.6%,治疗后12个月,双下肢周径差手术组下降为(0.4±0.3)cm,溶栓组下降为(0.9±0.7)cm,手术组治愈率86.0%(49/57),溶栓组治愈率53.6%(30/56);手术组的下肢深静脉血栓形成后遗症发生率低于溶栓组(P＜0.05),手术组的静脉瓣功能异常的发生率低于溶栓组(P＜0.05).结论 急性髂股型下肢深静脉血栓形成手术取栓加溶栓疗效优于单纯药物溶栓.     

经导管直接溶栓治疗下肢深静脉血栓形成的尿激酶量效分析

目的探讨经导管直接溶栓（CDT）治疗下肢深静脉血栓中尿激酶的合理用量。方法将拟接受CDT的90例DVT患者随机分为3组：A组用小剂量尿激酶溶栓（每日用量〈40万U）,B组用中等剂量（每日用量40万～80万U）,C组用大剂量（每日用量〉80万U）进行溶栓治疗。比较3组的溶栓效果、溶栓时间及出血情况。结果3组溶栓疗效差异有统计学意义（Hc=15．09,P〈O．05）,A组与B组疗效差异有统计学意义（t=1．99,P〈0．05）。3组溶栓时间差异有统计学意义（F=4．92,P〈0．05）。各组出血发生率差异无统计学意义（x^2=2．96,P〉0．05）,C组出血程度最重。结论CDT治疗DVT安全有效,每日尿激酶用量在40万U～80万U时溶栓疗效好,且出血发生率低。     

The safety,efficacy, and pharmacoeconomics of low-dose alteplase compared with urokinase for catheter-directed thrombolysis of arterial and venous occlusions

PURPOSE: The purpose of this study was to compare the efficacy, complications, and costs associated with low-dose (<2 mg/h) alteplase (tissue plasminogen activator [t-PA]) versus urokinase for the catheter-directed treatment of acute peripheral arterial occlusive disease (PAO) and deep vein thrombosis (DVT). MATERIALS AND METHODS: A retrospective review was performed during sequential time periods on two groups with involved extremities treated with either t-PA with subtherapeutic heparin (TPA group) or urokinase with full heparin (UK group) at a single center. Treatment group characteristics, success rates, complications, dosages, infusion time, and costs were compared. RESULTS: Eighty-nine patients with 93 involved limbs underwent treatment (54 with DVT, 39 with PAO). The treatment groups were statistically identical (TPA: 45 limbs; 24 with DVT, 53.3%; 21 with PAO, 46.7%; UK: 48 limbs; 30 with DVT, 62.5%; 18 with PAO, 37.5%). The overall average hourly infused dose, total dose, infusion time, success rates, and cost of thrombolytic agent were as follows (+/- standard deviation): TPA, 0.86 +/- 0.50 mg/h, 21.2 +/- 15.1 mg, 24.6 +/- 11.2 hours, 89.4%, $466 +/- $331; and UK, 13.5 +/- 5.6 (10(4)) U/h, 4.485 +/- 2.394 million U, 33.3 +/- 13.3 hours, 85.7%, $6871 +/- $3667, respectively. Major and minor complication rates were: TPA, 2.2% and 8.9%; and UK, 2.1% and 10.4%, respectively. No statistical differences in success rates or complications were observed; however, t-PA was significantly (P <.05) less expensive and faster than urokinase. CONCLUSION: Low-dose t-PA combined with subtherapeutic heparin is equally efficacious and safe compared with urokinase. Infusions with t-PA were significantly shorter and less expensive than those with urokinase.     

Thrombolysis for native arterial occlusions of the lower extremities: clinical outcome and cost

INTRODUCTION: Intra-arterial thrombolysis is commonly used as the initial treatment of acute or subacute lower extremity ischemia. METHODS: To evaluate the efficacy and cost of thrombolysis, we retrospectively analyzed 100 consecutive cases (87 patients) in which intra-arterial lysis (urokinase) was used as the initial treatment for native arterial lower extremity occlusive disease. The mean age of patients was 67 years, 57% of the patients were male, and preexisting peripheral vascular disease was present in 74%. Presenting symptoms were limb-threatening ischemia (53%) and claudication (47%). Acute symptoms (< 2 weeks' duration) were present in 48%. RESULTS: The 30-day morbidity rate was 31%, and four patients died. Complications were significant bleeding (23%), ischemic stroke (1%), and renal failure with (2%) and without (2%) dialysis. Concomitant angioplasty was performed in 63%. Complete or significant lysis as demonstrated with angiography was achieved in 75% of iliac, 58% of femoropopliteal, and 41% of crural vessels (P <.001). Within 30 days of lysis, 9% of patients underwent major amputation and 20% surgical revascularization (in 3 patients the extent of revascularization was lessened by the lytic therapy). Amputation-free survival was 83% and 75% at 6 months and 2 years, respectively. Relief of ischemia (defined as relief of claudication or limb salvage without major surgical intervention) was achieved in only 70% and 43% of patients at 30 days and 2 years, respectively (Kaplan-Meier analysis; mean follow-up, 31 months). Patients with aortoiliac disease had significantly better outcomes than those with infrainguinal disease (P =.03). Duration or type of presenting symptoms did not predict outcome. The cost of the initial hospitalization per patient for thrombolysis was $18,490. CONCLUSION: Thrombolysis can be as or more costly than surgery and is associated with a suboptimal outcome in a significant number of patients. These data lead us to caution against a uniform policy of initial thrombolysis for patients who present with lower extremity ischemia.     

Multimodal Percutaneous Intervention for Critical Venous Occlusive Disease

Critical deep venous thrombosis and occlusion constitutes a small percentage of patients with venous disease, who exhibit severe symptomatology. This study examined the results of multimodal percutaneous therapy for the treatment of complex critical venous thrombotic and occlusive disease. Twenty-five patients presented with critical venous thromboses or occlusions (11 with debilitating unilateral lower extremity edema causing ambulatory impairment, 2 with debilitating bilateral lower extremity edema, 3 with phlegmasia cerulea dolens, 2 with venous claudication, 2 with superior vena cava (SVS) syndrome with respiratory compromise, 4 with debilitating upper extremity edema, and 1 with renal insufficiency). Therapeutic modalities including thrombolysis, mechanical thrombectomy, percutaneous venoplasty and stent placement, temporary inferior vena cava filtration, and ultrasound guidance were used in all cases in conjunction with long-term systemic anticoagulation. The venous access site was determined by the anatomic location of the lesion and included popliteal, femoral, brachial, and lesser saphenous. Patients were followed with clinical exam and duplex surveillance. Resolution of symptoms was achieved in 18 of 25 patients (72%) and partial resolution occurred in 4 of 25 (16%). Failure of treatment identified as both lack of clinical response and evidence of continued venous thrombosis occurred 3 of 25 patients (12%). Restoration of arterial pulses and limb salvage was achieved in the three patients with phlegmasia cerulea dolens and acute limb-threatening ischemia. Both patients with SVC syndrome experienced resolution of respiratory compromise and facial edema. The mean length of follow-up was 11 ± 2.7 months. Complications included transfusion requirement (2), hematuria (2), retroperitoneal hematoma (1), and cellulitis (1). Acute critical venous thrombotic and occlusive disease is responsive to multimodal percutaneous treatment. The relief of pain and resolution of acutely life and limb-threatening conditions in this most severely symptomatic subset of patients represents the immediate goal of treatment.Presented at the Twenty-ninth Annual Meeting of the Peripheral Vascular Surgery Society, Anaheim, CA, June 4-5, 2004.     

左侧髂静脉压迫综合征的介入治疗

目的探讨介入治疗左侧髂静脉压迫综合征的疗效及安全性。方法本组27例,均经下肢深静脉造影或彩超确定诊断。13例发病在3周以内,表现为急性髂-股静脉血栓;14例发病超过3周,表现为慢性静脉阻塞。13例经健侧股静脉穿刺,14例经患侧腘静脉穿刺。11例溶栓前置入滤器,16例未置入滤器。均先行经导管溶栓治疗,之后7例行单纯球囊扩张术,20例球囊扩张后行内支架植入术。结果13例经健侧股静脉穿刺,导丝成功通过狭窄段8例,不能通过5例,改为造影导引下患侧腘静脉穿刺;14例直接行患侧腘静脉穿刺,在深静脉造影的导引下均穿刺成功。溶栓时间（85±16）h,尿激酶用量（300±32）万U。13例急性发作者血栓完全溶解,14例慢性者彩超报告管腔内见血流信号,提示血管部分再通。27例术后造影显示髂-股静脉血流通畅。随访时间6～26个月,平均11个月。19例静脉造影或超声显示髂-股静脉通畅,临床症状消失,8例深静脉造影或彩超提示髂-股静脉血流基本通畅,患者症状明显减轻,但仍存留肢体轻度肿胀。结论采用介入方法治疗左侧髂静脉压迫综合征,疗效确切,并发症少,可作为临床上治疗此类疾病的首选方法。