机械性血栓清除联合置管溶栓在下肢急性深静脉血栓治疗中的应用

目的探讨机械性血栓清除术(PMT)联合置管溶栓与单纯置管溶栓治疗下肢急性深静脉血栓的治疗效果与安全性。方法回顾性分析新疆维吾尔自治区人民医院血管外科2018年1月-2018年12月符合本研究纳入标准的69例下肢急性深静脉血栓患者的临床资料,其中男性35例,女性34例;平均年龄59岁,年龄范围20~80岁。按腔内溶栓方法不同,分为PMT联合置管溶栓组(n=38)及单纯置管溶栓组(n=31)。记录两组患者的溶栓时间、尿激酶用量、血栓清除率、患侧肢体周径变化值、围手术期间不良事件总数。患者出院后1个月、3个月、6个月时门诊复查下肢血管超声,检查并评估残余血栓溶解、血栓复发情况。计量资料以均数±标准差(Mean±SD)表示,采用t检验进行组间比较;计数资料采用百分比(%)表示,组间比较使用χ2检验。结果PMT联合置管溶栓组、单纯置管溶栓组溶栓时间分别为(3.7±2.1)d、(5.2±2.1)d,两组比较差异具有统计学意义(P=0.005),尿激酶用量分别为(225.0±122.3)万单位、(315.8±108.6)万单位,差异具有统计学意义(P=0.001)。PMT联合置管溶栓组Ⅰ级、Ⅱ级、Ⅲ级血栓清除率分别为18.4%(7/38)、73.7%(28/38)、7.9%(3/38);单纯置管溶栓组Ⅰ级、Ⅱ级、Ⅲ级血栓清除率为16.1%(5/31)、77.4%(24/31)、6.5%(2/31),比较两组患者Ⅰ级、Ⅱ级、Ⅲ级血栓清除率,差异均无统计学意义(P=0.803,P=0.720,P=0.818)。溶栓治疗48 h后,PMT联合置管溶栓组患侧大腿周径差为(2.16±0.87)cm、小腿周径差为(1.38±0.66)cm,单纯置管溶栓组患侧大、小腿周径差分别为(1.21±0.59)cm、(1.02±0.49)cm,两组患者溶栓治疗48 h后患侧大、小腿周径变化,差异具有统计学意义(P<0.001,P=0.014)。PMT联合置管溶栓组发生3例(7.89%)围手术期不良事件,单纯置管溶栓组4例(12.90%),差异无统计学意义(P=0.692)。两组患者共随访时间6个月,PMT联合置管溶栓组6个月随访率:71.05%(27/38),单纯置管溶栓组:64.52%(20/31),差异无统计学意义(P=0.532)。随访6个月期间PMT联合置管溶栓组血栓复发率为11.11%(3/27),单纯置管溶栓组为15.00%(3/20)。单纯置管溶栓组血栓复发率虽高于联合治疗组,但差异无统计学意义(P=0.693)。结论PMT联合置管溶栓与单纯置管溶栓治疗下肢急性深静脉血栓具有相似的临床效果,相比单纯置管溶栓,PMT联合置管溶栓可减少尿激酶剂量,缩短溶栓时间,具有短时间内缓解患肢肿胀的优势,近期随访疗效好。

Application of percutaneous mechanical thrombectomy combined with catheter directed thrombolysis in the treatment of acute lower extremity deep venous thrombosis

Objective To investigate and compare the efficacy and safety of percutaneous mechanical thrombectomy(PMT)combined with catheter directed thrombolysis and catheter directed thrombolysis alone in the treatment of acute lower extremity deep venous thrombosis.Methods Retrospective analysis of clinical data of 69 patients with acute lower extremity deep venous thrombosis who met the inclusion criteria of this study from January 2018 to December 2018 in department of vascular surgery,People′s Hospital of Xinjiang Uygur Autonomous Region was performed.There were 35 males and 34 females,with an average age of 59 years and an age rang of 20 to 80 years.Patients were divided into PMT combined catheter directed thrombolysis treated group(n=38)and catheter directed thrombolysis treated group(n=31)according to different methods of intra-luminal thrombolysis.The thrombolysis time,dosage of urokinase,thrombotic clearance rate,perimeter difference of suffered limb,and total number of adverse events during perioperative period between two groups were recorded.At 1 month,3 months,and 6 months after discharge,patients underwent an ultrasonographic examination of lower extremity vessels to check and evaluate residual thrombolysis and thrombosis recurrence by outpatient review.The quantitative data in the two groups were expressed as mean±standard deviation(Mean±SD),t test was used for comparison between groups.Enumeration data in the two groups were expressed as percentage(%)andχ2 test was used for comparison between groups.Results The thrombolysis time of PMT combined catheter directed thrombolysis treated group and catheter directed thrombolysis treated group were(3.7±2.1)d and(5.2±2.1)d,respectively.The differences between the two groups were statistically significant(P=0.005).The dosage of urokinase were respectively(225.0±122.3)×104 units and(315.8±108.6)×104 units,the differences were statistically significant(P=0.001).PMTⅠ,Ⅱ,Ⅲthrombus clearance rate in patients with PMT combined catheter directed thrombolysis treated group were 18.4%(7/38),73.7%(28/38),7.9%(3/38),while 16.1%(5/31),77.4%(24/31),6.5%(2/31)were observed in patients with catheter directed thrombolysis treated group,with no statistically significant difference between the two groups(P=0.803,P=0.720,P=0.818).After a period of 48h thrombolytic therapy,the cross-section diameters of suffered thigh and calf were(2.16±0.87)cm and(1.38±0.66)cm in PMT combined catheter directed thrombolysis treated group respectively.While the cross-section diameters of suffered thigh and calf were(1.21±0.59)cm and(1.02±0.49)cm in catheter directed thrombolysis treated group respectively.The differences in the cross-section diameters of suffered thigh and calf were statistically significant after a period of 48h thrombolytic therapy(P<0.001,P=0.014).Three cases(7.89%)had occurred adverse events during perioperative period in PMT combined catheter directed thrombolysis treated group,while there were 4 cases(12.90%)in catheter directed thrombolysis treated group,with no statistically significant difference between two groups(P=0.692).The six month follow-up rate of PMT combined with catheter directed thrombolysis treated group was 71.05%(27/38),while that of the catheter directed thrombolysis treated group was 64.52%(20/31),with no statistically significant difierence between the two groups(P=0.532).During the six month of follow-up,the recurrence rate of thrombus in PMT combined catheter directed thrombolysis treated group(3/27,11.11%)was lower than those patients in catheter directed thrombolysis treated group(3/20,15.00%),with no statistically significant difference between the two groups(P=0.693).Conclusions Compared with catheter directed thrombolysis treated group,PMT combined catheter directed thrombolysis treated group has a similar clinical efficacy for treatment of acute lower extremity deep venous thrombosis.PMT combined catheter directed thrombolysis treated group has advantages of reducing dosage of urokinase,shortening duration of thrombolysis time and relieving the swelling of suffered limb in a short time rather than catheter directed thrombolysis treated group.It shows a great result in the short term follow up.