机械性血栓清除装置治疗深静脉血栓的临床研究现状

相对于传统溶栓治疗,机械性血栓清除术具有即刻恢复血流、缩短溶栓时间、减少溶栓剂剂量等优势,是治疗深静脉血栓最有前景的方案。本文就目前临床常用于深静脉血栓治疗的机械性血栓清除装置进行综述如下。     

Adjunctive techniques in percutaneous mechanical thrombectomy

Percutaneous mechanical thrombectomy is an established method in interventional radiology and refers to the removal of acute embolic or thrombotic occlusive material in arteries, veins, or vascular grafts using percutaneous transluminal methods. However, initial complete removal of occlusive material can be achieved only in a minority of patients. The amount of removed material varies with the age and composition of the occlusive material. To achieve sufficient revascularization, adjunctive use of a variety of percutaneous endovascular recanalization techniques is necessitated. Additional treatment with local intra-arterial fibrinolysis, balloon angioplasty, stent implantation, endoluminal atherectomy, and other measures results in primary technical success rates of 70% to 100% for revascularization of acutely occluded vessels. The above-mentioned different techniques should not be viewed as competitive treatment modalities, rather a synergistic approach should be offered. The aim of this report is to review different adjunctive techniques in percutaneous mechanical thrombectomy with emphasis on techniques, mechanisms of action, experimental and clinical results, potential complications, and their potential role in view of clinical pathways to treat acute limb ischemia.     

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.     

Mechanical thrombectomy of acute iliofemoral deep vein thrombosis with use of an Arrow-Trerotola percutaneous thrombectomy device

PURPOSE: To evaluate the immediate and 1-year clinical outcomes of mechanical thrombectomy with use of the Arrow-Trerotola percutaneous thrombectomy device (PTD) with or without low-dose urokinase in the treatment of acute iliofemoral deep vein thrombosis (DVT). MATERIALS AND METHODS: Mechanical thrombectomy with the PTD was performed in 25 patients with acute iliofemoral DVT. Thrombolytic therapy with low-dose urokinase was used in all patients without contraindications (n = 20). Other therapies used in combination included inferior vena cava filter insertion (n = 5), sheath aspiration thrombectomy (n = 25), and angioplasty and stent placement (n = 20). RESULTS: Initial technical and clinical success was achieved in all cases. In the 20 patients who had no contraindications to the use of urokinase, the dosage of urokinase did not exceed 1 million IU (range, 360,000-1,000,000 IU; mean, 640,000 IU). The mean time of urokinase infusion was 16 hours (range, 12-20). In five patients who had a contraindication to the use of urokinase, mechanical thrombectomy with the PTD was successful without the use of urokinase. There were no major complications. Primary patency of the stent-implanted common iliac vein segment was achieved at 1 year in 17 of 20 patients (85%). The overall 1-year clinical success rate was 92% (23 of 25 patients). Valvular insufficiency occurred in two patients (8%). CONCLUSION: The PTD is an effective mechanical thrombectomy device in the treatment of acute iliofemoral DVT with or without adjunctive urokinase thrombolysis.     

AngioJet血栓清除术治疗急性下肢深静脉血栓形成的术中护理实践

【摘要】 目的 总结AngioJet血栓清除术治疗急性下肢深静脉血栓形成（LEDVT）的术中护理配合经验。 方法 收集206例AngioJet血栓清除术治疗急性LEDVT患者的临床资料，患者均予以充分的术前准备和规范的术中护理配合，包括心理护理与术前访谈、手术器材及药品准备、手术配合、生命体征的观察、疼痛和体位变动护理、特殊用药护理、并发症预防术后处置及交接。结果 206例患者均顺利完成手术，即刻血栓清除评价:Ⅰ级9例，Ⅱ级82例，Ⅲ级115例。48例患者术中感觉不适主要为患肢胀痛、胸闷、心悸。12例高血压、5例低血压、6例窦性心动过速、145例血红蛋白尿患者，经及时护理干预后均缓解。所有患者在围手术期中均未出现急性肾功能损伤、无失血过多、症状性肺栓塞等严重并发症。 结论 完善的术前准备与高效而细致的术中配合是AngioJet血栓清除术安全、顺利完成的重要保障。     

Applications of percutaneous mechanical thrombectomy in transjugular intrahepatic portosystemic shunt and portal vein thrombosis

Portal vein thrombosis (PVT) is an uncommon cause for presinusoidal portal hypertension. PVT can be caused by one of three broad mechanisms: (1) spontaneous thrombosis when thrombosis develops in the absence of mechanical obstruction, usually in the presence of inherited or acquired hypercoagulable states; (2) intrinsic mechanical obstruction because of vascular injury and scarring or invasion by an intrahepatic or adjacent tumor; or (3) extrinsic constriction by adjacent tumor, lymphadenopathy or inflammatory process. Usually, several combined factors are necessary to result in PVT. The consequences of portal vein thrombosis are mostly related to the extension of the clot within the vein. Gastrointestinal bleeding from gastroesophageal varices is the most frequent presentation. Noninvasive imaging techniques are currently used for the screening of patients and the initial diagnosis of PVT. The invasive techniques are reserved for cases when noninvasive techniques are inconclusive, before percutaneous interventional treatment, or in preoperative assessment of patients who are candidates for surgery. Recanalization of the portal vein with anticoagulation alone may not be consistent or appropriate in highly symptomatic patients. Catheterization of the superior mesenteric artery (SMA) is helpful for diagnosis as well as for therapy by allowing the intra-arterial infusion of thrombolytic drugs in the same setting. Direct transhepatic portography allows precise determination of the degree of stenosis and extension within the portal vein, as well as pressure measurements. Thrombotic occlusions of the portal, mesenteric, and splenic veins can be managed by mechanical thrombectomy (MT) or pharmacologic thrombolysis. Underlying occlusions because of organized or refractory thrombus or fixed venous stenosis are best corrected by balloon angioplasty and stent placement. Access into the portal venous system can also be established through creating a transjugular intrahepatic portosystemic shunt (TIPS). Creating a TIPS is also important in the setting of PVT associated with cirrhosis to decompress portal hypertension and improve portal venous flow. PVT involving the portal, splenic, and/or mesenteric veins can also complicate a preexisting TIPS in which case the shunt can be readily used as therapy access. Several techniques may be used to recanalize the shunt and portal venous system, including thrombolytic therapy, balloon angioplasty/embolectomy, suction embolectomy, basket extraction of clots, and mechanical thrombectomy with a variety of devices. Advantages of MT include the potential to rapidly remove thrombus without the need for prolonged thrombolytic infusions, and reducing the potential life-threatening complications of thrombolytic therapy. Possible drawbacks include the risk of intimal or vascular trauma to the portal vein, which may promote recurrent thrombosis.     

Mechanical thrombectomy for the treatment of lower extremity deep vein thrombosis

Deep venous thrombosis (DVT) has potentially debilitating long-term sequelae if left untreated. Conventional treatment (systemic anticoagulation with heparin followed by coumadin or low molecular weight heparin) often does not adequately relieves clot burden or symptoms, and patients may be left with post-thrombotic syndrome. Although the advent of catheter-directed thrombolysis has markedly improved the treatment of DVT and long-term outcomes of patients treated for DVT, it remains only partially effective on subacute or chronic clot. Mechanical thrombolysis may work synergistically with catheter-directed thrombolysis to decrease clot burden, treatment time, and complication rates, thereby improving outcomes.     

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。     

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。     

A porcine deep vein thrombosis model for magnetic resonance-guided monitoring of different thrombectomy procedures

PURPOSE: To establish a porcine model of deep iliac vein thrombosis, which allows monitoring of thrombectomy and thrombolytic procedures by magnetic resonance imaging (MRI). MATERIALS AND METHODS: Deep iliac vein thrombosis was induced in 12 domestic swine using an occlusion-balloon catheter and subsequent injection of thrombin distal to the occluded vessel site. Thrombosis induction was successfully achieved in all animals after 1 hour as verified by MRI. In addition, x-ray fluoroscopy was performed for comparison. Subsequently, thrombectomy was performed using a Fogarty catheter, an Arrow-Trerotola percutaneous thrombolytic device as well as electrical discharge-induced shock waves. The latter procedure was carried out with and without additional administration of Actilyse. MRI and x-ray fluoroscopy were repeated to monitor therapy. RESULTS: After successful thrombosis induction within the deep iliac veins in all cases, thrombus material could be completely removed using the Fogarty catheter and the Arrow-Trerotola percutaneous thrombolytic device, whereas electrical discharge-induced shock wave failed to recanalize the occluded vessel even if additional Actilyse was administered. The actual burden of thrombotic material could be reliably visualized using MRI. CONCLUSIONS: A porcine model of deep iliac vein thrombosis model is presented, which permits reliable visualization of thrombotic material. This model might be a useful tool to compare different thrombectomy devices or to evaluate the effectiveness of new thrombolytic approaches.     

Iliocaval thrombosis: percutaneous treatment with hydrodynamic thrombectomy

Mechanical thrombectomy is of growing importance for the treatment of thrombus. Although there are numerous reports about dialysis fistulae and arterial thrombosis, venous applications are currently not well known. We report that an extensive venous thrombotic occlusion can be treated with mechanical thrombectomy, without additional local lysis. This report deals with the indication and technique of venous mechanical thrombectomy and discusses the possible applications. Received: 22 February 1999; Revised: 20 May 1999; Accepted: 29 July 1999     

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.     

Septic thrombosis of the inferior vena cava treated with percutaneous mechanical thrombectomy

The present report describes a patient with septic thrombosis of the inferior vena cava (IVC) related to a subhepatic abscess adjacent to the IVC. Despite prolonged antimicrobial therapy and systemic anticoagulation, sepsis and septic embolism persisted while the size of the thrombus increased. Percutaneous mechanical thrombectomy was performed, resulting in removal of the infected thrombus and complete clinical recovery.     

Catheter-directed thrombectomy and thrombolysis for acute renal vein thrombosis

PURPOSE: To evaluate the technical success and clinical outcome of the percutaneous treatment of acute renal vein thrombosis (RVT). MATERIALS AND METHODS: Retrospective review was conducted of all patients with acute RVT treated with percutaneous catheter-directed thrombectomy with or without thrombolysis at one institution between 2000 and 2004. Demographics, comorbid conditions, and clinical outcomes associated with therapy were assessed. RESULTS: Seven thrombosed renal veins in six patients (mean age, 51.5 +/- 18.8 years) were treated with percutaneous catheter-directed thrombectomy/thrombolysis. Thrombosed renal veins included two allografts and five native veins, and diagnosis was confirmed in all cases by direct renal venography. Inferior vena cava thrombosis was the cause of RVT in one patient, and glomerulopathy was the cause in the remaining patients. Percutaneous mechanical thrombectomy was performed in all cases, and five renal veins were additionally treated with thrombolysis for a mean duration of 22.1 +/- 21.0 hours. Restoration of flow to renal veins was achieved in all thrombosed renal veins. Clinical improvement occurred in all patients: the mean serum creatinine level improved from a preoperative level of 3.3 +/- 1.92 mg/dL to a postoperative level of 1.92 +/- 1.32 mg/dL (P = .008). Mean glomerular filtration rate improved from a preoperative level of 30.8 +/- 23.0 mL/min per 1.73 m(2) to 64.2 +/- 52.4 mL/min per 1.73 m(2) (P = .04). There were no pulmonary emboli or hemorrhagic complications, and no RVT recurrence was documented during a median follow-up of 22.5 months. CONCLUSIONS: Percutaneous catheter-directed thrombectomy with or without thrombolysis for acute RVT is associated with a rapid improvement in renal function and low incidence of morbidity. It is feasible for native and allograft renal veins and should be considered in patients with acute RVT, particularly in the setting of deteriorating renal function.     

Aspiration catheter for percutaneous thrombectomy: clinical results

The clinical application of an aspiration thrombectomy system is presented. The system consists of a 7-F Teflon catheter with a rotating coaxial propeller-tipped wire. Thrombectomy was successful in treating occlusion of two femoropopliteal arteries and one hemodialysis implant but was not completely successful in a draining shunt vein. Preliminary results are encouraging; mechanical thrombectomy may offer an alternative to local lysis therapy.     

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.     

Pharmacomechanical thrombectomy of acute deep vein thrombosis with the Trellis-8 isolated thrombolysis catheter

PURPOSE: To evaluate the performance of the Trellis-8 isolated thrombolysis catheter during single-session pharmacomechanical thrombectomy (PMT) combined with low-dose thrombolysis with tissue plasminogen activator (TPA) in the treatment of patients with acute deep vein thrombosis (DVT) and multiple comorbidities. MATERIALS AND METHODS: Retrospective analysis was performed of 19 consecutive patients with acute above-knee DVT treated by PMT with the Trellis device followed by venous angioplasty and stent placement. Isolated thrombolysis with low-dose TPA was used with all patients. Concurrent therapies included retrievable inferior vena cava filter insertion (n = 4). The primary endpoint was restoration of rapid inline venous flow; the secondary endpoint was thrombus clearance. RESULTS: Restoration of rapid inline venous flow was achieved in all cases; thrombus removal was less than 50% in one case (4%), 50%-95% in 18 cases (82%), and at least 95% in three cases (14%). The median administered dose of TPA was 13.4 mg per patient. The mean treatment time was 91 minutes per limb (range, 61-129 min), with a mean of 21 minutes per thrombosed segment (range, 8-31 min). There were no major complications. Primary patency rate of the treated venous segments at 2 days was 86% (n = 19) and the primary assisted patency rate was 100% at 30 days. Two patients died of advanced malignancy at 17 and 24 days. CONCLUSIONS: The Trellis system was an effective method for the treatment of acute DVT. Based on the present data, the Trellis system could prove to be a safe and feasible single-session PMT method for the treatment of acute DVT in a broader patient population and warrants further investigation in a large-scale study.     

Clinical and economic evaluation of the Trellis-8 infusion catheter for deep vein thrombosis

PURPOSE: To summarize the preliminary experience with the Trellis-8 infusion catheter (TIC) in the treatment of deep venous thrombosis (DVT) and compare the outcome to that with catheter-directed thrombolysis (CDT) by using a meta-analysis of published reports. MATERIALS AND METHODS: Technical success, bleeding complications, and costs for patients treated with the TIC for DVT were reported through a voluntary, company-sponsored registry. Technical success was classified by using the National Venous Registry grading scale for DVT lysis (<50% lysis = grade I, 50%-99% lysis = grade II, and 100% lysis = grade III). The cost of treatment with the TIC was based on equipment (catheters) needed to perform the intervention, thrombolytic agents used, bleeding episodes, procedure time in the angiography and/or interventional suite, and monitoring time in a critical care unit. Outcomes with the TIC were compared against outcomes with CDT by using literature-derived outcomes derived from a meta-analysis. RESULTS: Thrombolytic doses and infusion durations were less with TIC than with conventional CDT. Grade II and III lysis was achieved in 93% of patients treated with the TIC and 79% of patients treated with CDT (P = .03). Major hemorrhage was reported in none of the TIC patients and in 8.5% of patients treated with CDT (P < .001). The per-patient cost of therapy was $3,697 for TIC and $5,473 for CDT (P = .03). CONCLUSIONS: Thrombolysis in DVT with the TIC is associated with a greater technical success rate, a lower rate of bleeding, and a lower cost than that reported for CDT. These preliminary results indicate that further evaluation of the TIC in the treatment of DVT is warranted.