机械性经皮血栓清除术的研究进展

机械性血栓清除术是20世纪后期出现的一种新的治疗血栓的方法，由于其血栓清除时间短，且无溶栓替在大出血等特点，故在国内外广泛用于治疗血透通道、冠状动脉、肺动脉、下肢动静脉、TIPS血栓等。本文简要介绍机械性血栓清除术常用装置类型及原理、临床应用、影响疗效相关因素和并发症，并对其应用前景作一展望。     

AngioJet血栓清除装置治疗急性下肢深静脉血栓形成初步临床应用

目的 探讨AngioJet血栓机械性清除装置治疗急性下肢深静脉血栓形成(DVT)的效果和安全性.方法 回顾性分析2014年7月至2015年10月收治的55例急性下肢DVT患者临床资料,其中23例接受AngioJet血栓清除装置治疗(A组),32例接受置管溶栓治疗(B组).评价两组患者治疗期间应用尿激酶总量、溶栓时间、住院时间、消肿率及并发症发生情况.结果 A、B组患者尿激酶总用量分别为(106.09±61.92)×104 U、(204.38±108.27)×104 U,溶栓时间分别为(3.00±2.35)d、(5.11±2.57)d,住院时间分别为(7.39±0.94)d、(9.19±2.26)d,差异均有统计学意义(P值分别为0.001、0.003、0.001);患肢消肿率分别为(76.60±19.07)％、(73.59±25.22)％,并发症发生率分别为4.35％(1/23)、6.25％ (2/32),差异无统计学意义(P值均＞0.05).结论 AngioJet血栓机械性清除装置治疗急性下肢DVT可明显提高血栓清除效率,减少尿激酶用量,缩短药物溶栓时间及住院治疗时间,且疗效良好,值得临床上进一步推广应用.     

机械性血栓抽吸治疗中央型下肢深静脉血栓的临床疗效

目的探讨机械性血栓抽吸治疗中央型下肢深静脉血栓形成(lower extremity deep venous thrombosis,LED-VT)的临床疗效。方法回顾分析我院2005年4月～2009年1月236例急性中央型LEDVT病例的临床资料。经健侧股静脉置入下腔静脉滤器,患侧股静脉插入12～14F鞘管手动抽吸髂股段静脉血栓。112例合并髂静脉狭窄或闭塞患者,行PTA和支架置入术;术后辅以肝素抗凝治疗。结果出院时健、患肢膝上、下15cm处周径差降为(1.34±0.57)cm和(0.93±0.42)cm,与入院比较差异有统计学意义(t=19.37和23.99,P=0.00);随访16～48个月,中位随访35个月,随访率97.88%。术后36个月,水肿、色素沉着、溃疡等后遗症发生率:12.99%(30/231)、8.23%(19/231)、0%;静脉通畅率98.27%;随访疗效:优92.21%。支架置入术后12、24、36个月通畅率均100%。结论机械性血栓抽吸治疗中央型下肢深静脉血栓疗效显著,并发症少,住院周期短,能够明显降低后遗症的发生率。     

AngioJet机械性血栓抽吸联合导管接触溶栓治疗急性下肢深静脉血栓形成效果观察

目的 探讨经皮机械性血栓清除术(PMT)联合导管接触溶栓(CDT)治疗下肢深静脉血栓形成(DVT)的安全性和近期效果.方法 回顾性分析2017年1月至2018年12月徐州医科大学附属医院收治的56例急性中央型、混合型下肢DVT患者临床资料.其中28例接受AngioJet机械性血栓抽吸联合CDT治疗(A组),28例接受单...     

机械性血栓清除术联合同期髂静脉支架植入治疗合并左髂静脉受压综合征的急性下肢深静脉血栓形成

目的：评价经皮机械性血栓清除术联合同期髂静脉支架植入治疗合并左髂静脉受压综合征的急性下肢深静脉血栓（DVT）形成的可行性、安全性及有效性。 方法：选取2015年4月-2017年6月收治左髂静脉受压综合征伴急性下肢DVT的患者33例,发病时间6 h-14 d,平均年龄（57.97±14.44）岁。所有患者均在滤器保护下进行治疗。AngioJet血栓清除术、球囊扩张和髂静脉支架植入均在同期完成,术后保留鞘管予以溶栓治疗,每天复查造影,若血栓完全溶解,取出下腔静脉滤器并结束溶栓。术后第1、3、6、12个月进行门诊随访,行彩色超声和（或）下肢静脉造影检查了解下肢深静脉及髂支架内血流通畅情况。 结果：33例患者均同期完成手术,技术成功率100%,AngioJet抽吸时间为（224.70±72.78）s,溶栓时间（34.00±15.37）h,尿激酶用量（112.58±49.92）万U。33例患者同期植入髂静脉支架33枚。血栓清除率Ⅲ级患者29例,血栓清除率Ⅱ级患者4例。无出血、症状性肺栓等严重并发症发生。术后随访1例患者术后两月血栓复发,32例患者术后随访超声和（或）下肢静脉造影检查提示下肢深静脉及髂静脉支架内血流通畅。 结论：机械性血栓清除术联合同期髂静脉支架植入治疗合并左髂静脉受压综合征的急性下肢深静脉血栓形成是一种安全有效的方法。     

手动机械性血栓碎吸治疗急性下肢深静脉血栓疗效

目的 分析急性下肢深静脉血栓形成(lower extremity deep venous thrombosis,LEDVT)的解剖部位,评价手动机械性血栓碎吸治疗的中、长期疗效.方法 回顾分析1998年4月至2011年3月745例急性LEDVT机械性血栓碎吸治疗的临床资料.根据静脉造影显示的血栓解剖部位,分为中央型258例(A组),混合型487例(B组),经健侧股静脉安置下腔静脉滤器,患侧股静脉插入8～14F鞘管手动机械性碎吸血栓.287例合并髂总静脉狭窄或闭塞,采取经皮血管腔内成形术和支架植入处理.随访16～147个月,平均(46±39)个月,根据临床症状及造影复查,评价两组患者的治疗效果.结果 出院时健、患肢膝上、下15 cm处周径差A组分别为(1.34±1.07)和(0.93±0.52)cm,B组分别为(2.89±1.53)和(1.72±0.89)cm,与术前比较差异均有统计学意义(t=19.46、24.13,P=0.000、0.000和t=16.14、17.79,P=0.000、0.000).随访发现患肢膝下15 cm处周径差A组下降为(0.53±0.42)cm,B组为(1.42±1.35)cm,组间差异有统计学意义(t=13.38,P=0.000).水肿、色素沉着、溃疡等后遗症发生率A组分别为27.91％(72/258)、13.18％(34/258)、0％;B组分别为35.12％(171/487)、22.59％(110/487)、2.46％(12/487),组间差异有统计学意义(x2=3.98,9.58,5.00,P=0.046,0.002,0.025).A组静脉通畅率为96.51％,瓣膜功能正常率为78.68％,B组分别为78.03％和56.47％,组间差异均有统计学意义(x2=52.70、40.57,P=0.000、0.000).随访疗效A组优占92.64％,B组占65.09％,组间差异均有统计学意义(x2=67.58,P=0.000).结论 急性LEDVT机械性血栓碎吸治疗,应根据血栓解剖分布类型指导治疗方案的选择;中央型单纯机械性血栓碎吸治疗效果最好,而混合型应配合系统溶栓可提高疗效.     

流变血栓清除术治疗急性下肢深静脉血栓形成

目的　评价流变血栓清除术治疗急性下肢深静脉血栓形成的临床疗效与安全性。资料与方法　 17例 1周内的急性下肢深静脉血栓形成患者 ,其中血栓形成位于髂静脉 1例 ,髂股静脉 4例 ,股静脉 6例 ,股静脉 5例 ,静脉 1例。血栓长度 4～ 3 0cm ,平均 11.2 9± 5 .86cm。采用经皮穿刺方法 ,置入 6F或 8FOasis流变溶栓导管并与高压注射器连接 ,将生理盐水以 2 .5ml/s的流率和 5 171kPa的压力注入 ,行流变血栓清除术 ,观察血管开通、临床疗效以及并发症发生情况。结果　流变血栓清除术后 ,17例重建了前向血流 ,并清除了绝大部分血栓物质 ,技术成功率 (残留狭窄 <5 0 % )为 10 0 %。 15及 3 0天的初始血管开通率均为 10 0 % ,无严重并发症发生。结论　流变血栓清除术能迅速、安全、有效地清除下肢深静脉急性血栓     

AngioJet机械性血栓清除装置治疗急性肠系膜上动脉栓塞初步临床效果

【摘要】 目的 探讨AngioJet机械性血栓清除装置治疗急性肠系膜上动脉栓塞（ASMAE）的可行性、安全性和有效性。 方法 回顾性分析2017年4月至2020年1月收治的12例ASMAE患者。其中男6例,女6例,年龄为（74.4±10.5）岁;肠系膜上动脉起始段闭塞1例,中段闭塞7例,起始段＋中段闭塞4例。采用AngioJet装置实施肠系膜上动脉血栓清除,对治疗后还存在血管残余狭窄者予以球囊扩张成形和/或支架植入。术后早期根据症状、体证评估疗效,术后1、3、6 个月进行腹部增强CT检查评估肠系膜上动脉通畅情况。 结果 所有患者均顺利完成抽栓治疗,技术成功率100%。抽吸时间为30～161 s,平均（81.0±39.3） s;术中尿激酶用量（10～30）×104U,平均（15.8±6.7）×104U。8例肠系膜上动脉栓塞部位完全再通,4例行补充性球囊扩张和/或支架治疗后血管恢复通畅,其中2例单纯扩张、1例支架植入、1例球囊扩张结合支架植入。无动脉损伤和肾功能损害等并发症。临床有效11例,无效1例,死亡1例。术后第1、3、6个月门诊随访,患者无腹痛、黑便、腹泻等症状。11例患者CTA检查提示肠系膜上动脉管腔血流通畅,无狭窄/闭塞表现。结论 AngioJet机械性血栓清除装置治疗ASMAE方法安全可行,初步临床疗效满意。     

机械血栓清除术治疗急性下肢深静脉血栓患者围术期护理

目的 探讨机械血栓清除术治疗下肢深静脉血栓围手术期护理措施.方法 回顾性分析2015年1月至2016年2月,在血管外科行机械血栓清除术的9例患者的临床资料,总结其护理方法,探讨护理要点.结果 患者均成功完成机械血栓清除治疗,9例患者术后均恢复静脉血流.经过术后严密的治疗护理,患者下肢肿胀症状均明显改善(P＜0.05),无围术期并发症发生.结论 机械血栓清除术治疗下肢深静脉血栓围术期护理尤为重要,掌握护理重点,做好相应的护理措施,有助于患者病情恢复.     

Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis in the treatment of symptomatic lower extremity deep venous thrombosis

Purpose

To evaluate the efficacy of percutaneous mechanical thrombectomy (PMT) combined with catheter-directed thrombolysis (CDT) in the treatment of massive symptomatic lower limb deep venous thrombosis (DVT).

Materials and methods

One hundred and three clinically confirmed DVT patients were discharged from our institution. Sixteen patients with massive lower limb DVT were included in this retrospective study. After prophylactic placement of inferior vena cava filters (IVCFs), percutaneous mechanical thrombectomy (ATD, n = 10; Straub, n = 6) and catheter-directed thrombolysis were performed in all patients. Complementary therapy included percutaneous transluminal venous angioplasty (PTA, n = 3) and stent placement (n = 1). The doses of thrombolytic agents, length of hospital stay, peri-procedure complications and discharge status were reviewed. Oral anticoagulation was continued for at least 6 months during follow-up.

Results

The average hospital stay was 7 days. The technical success rate (complete and partial lysis of clot) was 89%, the other 11% patients only achieved less than 50% clot lysis. The mean dose of urokinase was 3.3 million IU. There were no significant differences of clinical outcome between the ATD and Straub catheter group. The only major complication was an elderly male who experienced a fatal intracranial hemorrhage while still in the hospital (0.97%, 1/103). Minor complications consisted of three instances of subcutaneous bleeding. No transfusions were required. Vascular patency was achieved in 12 limbs during follow-up. No pulmonary emboli occurred. There is one recurrent DVT 4.5 months after the treatment.

Conclusions

Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis is an effective and safe method for the treatment of symptomatic DVT. A randomized prospective study is warranted.     

骨折后下肢深静脉血栓形成系统溶栓与介入取栓的疗效比较

目的 探讨骨折后下肢深静脉血栓形成(lower extremity deep vein thrombosis,LEDVT)系统溶栓与介入取栓加溶栓的疗效比较.方法 回顾性分析我院2005年9月～2011年9月收治的创伤性骨折伴DVT231例患者资料.根据治疗方式的不同,分为A组介入取栓治疗和B组系统溶栓.介入取栓组135例,其中合并髂总静脉狭窄56例,选择介入治疗,术后给予肝素抗凝治疗.系统性溶栓组96例,采取经足背静脉尿激酶溶栓、皮下注射低分子肝素治疗.结果 A组植入永久性下腔静脉滤器40例,临时性下腔静脉滤器95例,27例合并髂静脉重度狭窄者行支架置入治疗.出院时健、患肢膝关节上、下15 cm处周径差A、B组明显小于入院时(P＜0.05),差异有统计学意义.而且A组的静脉瓣功能异常的发生率低于B组(P＜0.05),差异有统计学意义.结论 骨折后下肢深静脉血栓形成介入取栓疗效优于单纯药物溶栓.     

经腘静脉介入治疗下肢深静脉血栓形成

目的：探讨经腘静脉介入治疗下肢深静脉血栓的临床应用价值。方法：对32例下肢深静脉血栓形成患采用经患侧腘静脉入路综合性介入治疗，其中血栓抽吸18例，血栓消融28例，腔内血管成形29例，共植入血管支架42枚。结果：技术成功率为100％，治疗后闭塞血管开放，双下肢周径差＜1cm，下肢活动正常。结论：经腘静脉介入治疗下肢深静脉血栓操作简便、安全有效。     

经动静脉双路径同步治疗深静脉血栓临床应用

目的：评价经动静脉双路径同步治疗下肢深静脉血栓（DVT）的疗效。方法回顾性分析37例下肢深静脉血栓溶栓治疗患者,在行下腔静脉滤器置入术后,其中16例患者行动静脉双路径同步溶栓及抗凝治疗。21例患者行单纯患肢静脉溶栓导管置入或患肢足背静脉溶栓术。结果随访37例患者均未出现大出血和致死性肺动脉栓塞等严重并发症,20例患者下肢DVT完全或大部分溶解,13例部分溶解,4例仍较多血栓,但深静脉主干基本出现,有较多侧枝循环。其中动静脉同步溶栓治疗中,完全或大部分溶解12例,单纯静脉溶栓完全或大部分溶解的有8例。结论经动静脉双路径同步治疗下肢深静脉血栓是一种安全可行、疗效好、操作相对简单的方法,较单纯静脉溶栓时间缩短,尿激酶用量减少,而且静脉完全溶解率升高。     

The accuracy of MRI in diagnosis of suspected deep vein thrombosis: systematic review and meta-analysis

Magnetic resonance imaging (MRI) may be used to diagnose deep vein thrombosis (DVT) in patients for whom ultrasound examination is inappropriate or unfeasible. We undertook a systematic review of the literature and meta-analysis to estimate the diagnostic accuracy of MRI for DVT. We searched databases of medical literature and citation lists of retrieved articles. We selected studies that compared MRI with a reference standard in patients with suspected DVT or suspected pulmonary embolus, or high-risk asymptomatic patients. Data were analysed by random effects meta-analysis. We included 14 articles in the meta-analysis. Most compared MRI with venography in patients with clinically suspected DVT. The pooled estimate of sensitivity was 91.5% (95% CI: 87.5–94.5%) and the pooled estimate of specificity was 94.8% (95% CI: 92.6–96.5%). Sensitivity for proximal DVT was higher than sensitivity for distal DVT (93.9% versus 62.1%). However, pooled estimates should be interpreted with caution as estimates of both sensitivity and specificity were subject to significant heterogeneity (P<0.001). Individual studies reported sensitivity ranging from zero to 100%, while specificity ranged from 43 to 100%. MRI has equivalent sensitivity and specificity to ultrasound for diagnosis of DVT, but has been evaluated in many fewer studies, using a variety of different techniques.     

Adjunctive percutaneous mechanical thrombectomy for lower-extremity deep vein thrombosis: clinical and economic outcomes

PURPOSE: To assess the clinical and economic benefits of catheter-directed thrombolysis (CDT) alone versus CDT with rheolytic percutaneous mechanical thrombectomy (PMT) for lower-extremity deep vein thrombosis (DVT). MATERIALS AND METHODS: Consecutive patients with acute iliofemoral DVT treated with CDT with urokinase between 1997 and 2003 were identified. Demographic characteristics and clinical and economic outcomes were compared between patients treated with CDT alone versus CDT plus PMT. RESULTS: Twenty-six limbs in 23 patients received CDT with urokinase, whereas 19 limbs in 14 patients were treated with CDT plus PMT. Mean treatment duration for CDT was 56.5 +/- 27.4 hours, compared with 30.3 +/- 17.8 hours for CDT plus PMT (P = .001). Mean urokinase dose for CDT was 6.70 +/- 5.9 million U compared with 2.95 +/- 1.82 million U for CDT plus PMT (P = .011). Urokinase CDT achieved complete clot lysis in 80.7% of limbs (n = 21) compared with 84.2% of limbs (n = 16) treated with CDT plus PMT (P = .764). The incidences of major bleeding (CDT, 7.7%; CDT plus PMT, 5.3%; P = .749) and pulmonary embolism (CDT, 3.8%; CDT plus PMT, 5.3%; P = .818) were similar. The mean urokinase and PMT device cost for CDT alone was $10,127 compared with $5,128 for CDT plus PMT (P = .026). CONCLUSIONS: Percutaneous CDT with rheolytic PMT is as effective as CDT alone for acute iliofemoral DVT but requires significantly shorter treatment and lower lytic agent dose, resulting in lower costs. Randomized studies to confirm the benefits of pharmacomechanical thrombolysis in the treatment of DVT are warranted.     

Combined treatment of subacute and acute synthetic and venous bypass-graft occlusions with percutaneous mechanical thrombectomy and thrombolysis

Introduction

Percutaneous mechanical thrombectomy (PMT) is a third choice of treatment for acute arterial occlusions, in addition to thrombolysis and surgical thrombectomy. The aim of this retrospective study was to compare the combined treatment of PMT and local thrombolysis with thrombolysis therapy alone.

Materials and methods

Sixty-nine patients with acute (<14 days [n = 35]) or subacute (14–42 days [n = 34]) femoropopliteal bypass occlusions were treated with PMT combined with thrombolysis. Seventy-two patients with acute [n = 40] or subacute [n = 32] femoropopliteal bypass occlusions were treated with thrombolysis alone. The thrombolysis in myocardial infarction (TIMI) classification was used to assess the bypass occlusion. Local thrombolysis time and dosage, reopening time, time in the intensive care unit, necessary surgical re-interventions, and clinical outcome were compared between the 2 groups.

Results

The TIMI scores were significantly higher in the PMT plus thrombolysis group than in the thrombolysis group (acute occlusions 1188 versus 935, p < 0.001; subacute occlusions 935 versus 605, p < 0.001). The total urokinase dosage, the total hours of thrombolysis, time in the intensive care unit, and total hospital stay in the acute PMT plus thrombolysis group were significantly lesser than those in the thrombolysis group. After 24 h of treatment, the ankle-brachial index improved in all groups (p < 0.001): in the acute and subacute PMT plus thrombolysis group to 0.63 ± 0.14 and 0.43 ± 0.08, respectively; and in the acute and subacute thrombolysis group to 0.51 ± 0.11 and 0.41 ± 0.04, respectively.

Conclusions

PMT combined with thrombolysis is a safe and very effective therapy for acute and subacute femoropopliteal bypass occlusions compared to treatment with thrombolysis alone.     

经皮血栓碎吸联合血管成形治疗髂静脉压迫综合征并深静脉血栓形成

目的探讨经皮血栓碎吸联合血管成形治疗髂静脉压迫综合征并下肢深静脉血栓形成的临床效果。资料与方法回顾性分析184例髂静脉压迫综合征并下肢深静脉血栓形成的病例资料。经皮穿刺患侧股静脉,在导丝引导下采用12～14 F鞘管抽吸髂、股静脉内血栓;对于股、腘静脉血栓,利用Fogarty球囊导管将血栓碎解、拖拉至髂静脉内,再行机械性血栓抽吸术。对髂静脉严重狭窄或闭塞者,行经皮腔内血管成形术或支架置入治疗。结果本组血栓清除率Ⅲ级80.98%,Ⅱ级19.02%;出院时患肢膝上、下15 cm 周径为（43.9±4.7） cm、（31.5±4.1） cm,与入院时相比其间差异有统计学意义（t=6.43,t=5.79,均P=0.000）。随访6～24个月,治疗有效率为97.75%;178例支架置入病人术后6、12、24个月彩色多普勒超声或 DSA 复查,支架通畅率为97.19%、94.94%、92.13%。结论血栓碎吸联合血管成形治疗髂静脉压迫综合征并下肢深静脉血栓形成,其近、中期疗效显著,住院时间短,是一种安全有效的介入治疗方法。