经小腿深静脉途径导管溶栓术治疗急性混合型下肢深静脉血栓形成

Clinical Curative Effect of Catheter-Directed Thrombolysis via Calf Veins for Acute Mixed Lower Extremity Deep Venous Thrombosis

目的探讨经患肢小腿深静脉导管溶栓术(CDT)治疗混合型下肢深静脉血栓形成(LEDVT)的临床疗效。方法搜集2014年1月至2017年12月采用小腿深静脉穿刺CDT治疗混合型LEDVT的患者,对其溶栓效果和临床疗效进行回顾性分析。6个月时下肢静脉造影观察髂股静脉主干通畅性,最近一次随访使用Villalta评分评估血栓形成后综合征(PTS)的发生率及严重程度。结果经患肢小腿深静脉CDT治疗混合型LEDVT 23例,胫后静脉切开插管2例,经皮穿刺13例,胫前静脉经皮穿刺8例。髂总静脉、髂外静脉、股总静脉、股浅静脉、腘静脉及小腿深静脉段的平均血栓清除率分别为(68.87±28.78)%、(77.30±26.17)%、(79.00±30.13)%、(67.00±30.35)%、(88.83±21.89)%和(58.09±29.70)%。CDT后发现髂静脉残余狭窄12例,则经同侧股/腘静脉穿刺行经皮血管成形术1例,髂总静脉-髂外静脉支架置入术11例。CDT术后24~48 h患肢软组织张力不同程度减轻,出院时患肢与健肢周径差同术前比较有显著性差异(P<0.05)。溶栓期间没有症状性肺栓塞(PE)和大出血的发生,发生小的出血并发症3例(13.04%),采用停止溶栓保守治疗后好转。随访时间6~36个月,平均(14.96±7.24)个月。随访期间有1例患者因华法林抗凝不规范再发髂股静脉深静脉血栓形成(DVT),经颈内静脉CDT治疗。6个月时,下肢静脉造影显示髂股静脉主干继续保持通畅的患者有17例(73.91%),6例表现为慢性股静脉和髂静脉阻塞,股/腘静脉残留血栓同出院时比较有进一步减少的患者8例。PTS发生率为26.1%(6/23),其中轻度5例,中度1例。结论经小腿深静脉入路CDT治疗混合型LEDVT是一种可行、有效、安全的方法,在常规入路CDT有困难时,可先选择小腿深静脉CDT溶栓,为择机开通髂、股静脉做准备。

Objective To study the clinical efficacy of catheter-directed thrombolysis(CDT)via calf veins in the treatment of mixed lower limb deep venous thrombosis(LEDVT).Methods From January 2014 to December 2017,the patients with mixed LEDVT treated by CDT via calf vein were reviewed.And the effects of thrombolysis and clinical efficacy were analyzed retrospectively.The patency of the iliofemoral vein was investigated by venography at 6 months.The incidence and the severity of post-thrombotic syndrome(PTS)was evaluated by Villalta score at the last follow-up.Results 23 cases of mixed LEDVT were treated with CDT via ipsilateral calf veins.Through the posterior tibial vein,incision and intubation was performed in 2 cases and percutaneous puncture in 13 cases.Percutaneous puncture of the anterior tibial vein was performed in 8 cases.The average thrombus clearance rates of common iliac vein,external iliac vein,common femoral vein,superficial femoral vein,popliteal vein and calf vein were(68.87±28.78)%,(77.30±26.17)%,(79.00±30.13)%,(67.00±30.35)%,(88.83±21.89)%and(58.09±29.70)%,respectively.12 cases were developed residual stenosis in the iliac vein after CDT.Then percutaneous angioplasty was performed through ipsilateral femoral/popliteal vein in 1 case and stent implantation via common iliac vein/external iliac vein in 11 cases.The tissue tension of the affected limbs was alleviated 24 to 48 hours after CDT.And the difference of circumference between the affected limb and the healthy limb at discharge was significantly different from that before operation(P<0.05).There was no symptomatic pulmonary embolism(PE)and massive hemorrhage during thrombolysis.Minor bleeding complications occurred in 3 cases(13.04%),which were improved after stopping thrombolysis.The follow-up period was 6 to 36 months(14.96±7.24 months).During the follow-up period,one patient had recurrent iliofemoral DVT due to inadequate warfarin anticoagulation then CDT was performed through internal jugular vein.At 6 months,venography showed that the main iliofemoral vein maintained patency in 17 cases(73.91%),and 6 cases showed chronic obstruction of the femoral vein and the iliofemoral vein.The residual thrombus of femoral-popliteal vein in 8 cases was further reduced compared with that at discharge.The incidence of PTS was 26.1%(6/23),including mild in 5 cases and moderate in 1 case.Conclusion CDT via calf veins approach is a feasible,effective and safe treatment method for mixed LEDVT.When CDT is difficult through the routine approach,CDT via calf veins can be selected to restore patency to the iliofemoral vein.