血液透析中心静脉导管相关右心房血栓诊治进展

Advance in diagnosis and treatment of hemodialysis catheter⁃related atrial thrombus

导管相关右心房血栓(CRAT)是中心静脉置管血液透析患者的少见并发症,包括附壁血栓和导管尖端血栓,其发生与导管尖端位于右心房内密切相关,导管尖端反复接触心房内壁、右心房血流动力学改变和全身高凝状态均可促进血栓形成。大多数CRAT无临床症状,部分患者因导管功能不良、心血管症状等不适就诊,若同时继发栓塞或感染等并发症则会引起严重临床不良后果甚至死亡。CRAT诊断主要依赖于经胸壁心脏超声、经食管心脏超声、电子计算机断层扫描血管造影、磁共振成像等影像学检查。治疗包括经导管靶向治疗、手术取栓、抗凝、全身溶栓和拔除导管等,应根据血栓大小、位置、患者全身情况和医疗机构技术条件实施个体化的治疗策略。本文就血液透析患者CRAT流行病学、分类、发生机制、临床表现及诊断、治疗的相关进展作一综述。

Catheter-related atrial thrombus(CRAT)is a rare complication in hemodialysis patients,which includes mural thrombus and catheter tip thrombus.CRAT is closely associated with positioning of the catheter tip in the atrium.Repeated mechanical trauma to the atrial wall from catheter tip,the fluid dynamics within right atrium and systemic hypercoagulable state can promote thrombosis.Most of patients with CRAT are asymptomatic,some cases presented with catheter malfunction,cardiovascular abnormalities and other discomforts.However CRAT might bring serious adverse and sometimes fatal events when complications such as embolism and infection occurred.It is mainly diagnosed by cardiac imaging studies including transthoracic echocardiography(TTE),transesophageal echocardiography(TEE),computed tomography angiography(CTA),magnetic resonance imaging(MRI).According to the size,location of thrombus,general condition of patients and available techniques in medical facilities,therapeutic strategies including catheter-directed therapy,surgical thrombectomy,anticoagulation,systemic thrombolysis,catheter removal and so on can be individually selected.This review summarized the epidemiology,classification,pathogenesis,clinical manifestations,diagnosis and treatments of CRAT in hemodialysis patients.