急性下肢深静脉血栓形成的微创治疗

Minimally Invasive Therapy in Acute Deep Venous Thrombosis of Lower Extremities

目的探讨微创治疗急性下肢深静脉血栓形成(DVT)的临床效果和应用价值。方法回顾性分析我院1998年4月至2011年12月期间的911例急性下肢DVT患者的临床资料,男489例,女422例;年龄(58.72±11.95)岁(23～86岁)。左下肢568例,右下肢343例。中央型487例,周围型166例,混合型258例。局麻下经健侧股静脉植入下腔静脉滤器,患侧股静脉插入8～14 F鞘管机械性抽吸血栓。527例髂静脉合并髋下股静脉急性血栓,经健侧股静脉导丝抓捕技术辅助,在患侧置入翻山鞘管,依托鞘管支撑导丝轻柔地越过瓣膜插至患侧股浅静脉远端或腘静脉处,沿导丝置入直径10 mm球囊导管,DSA监视下将血栓拉至患侧髂静脉内,再经患侧股静脉进行机械性抽吸血栓。球囊拉栓前先经患侧股动脉穿刺,置入直径12 mm球囊至腔、髂静脉汇合处,充胀球囊阻挡回心血流,以防血栓脱落随血流进入腔静脉。结果本组911例中单纯取栓423例,取栓+腔内溶栓275例,取栓+腔内溶栓+PTA 91例,取栓+腔内溶栓+PTA+支架置入122例。平均住院时间为7.5 d。①出院时疗效:总介入治疗有效907例(99.56%),无效4例(0.44%)。911例患者均行机械性血栓抽吸术,疗效Ⅲ级者556例,Ⅱ级者142例,Ⅰ级者213例。213例Ⅰ级患者中91例因经济原因或恶性肿瘤晚期而仅行PTA治疗,122例行PTA+支架置入治疗。出院时患肢膝关节上、下15 cm处周径及健、患肢膝关节上、下15 cm处周径差均明显小于入院时(P<0.01)。27例术后抗凝溶栓治疗时出现轻度皮下瘀血、牙龈出血、鼻出血、血尿,调整药物后消失。全组未出现大出血、血管夹层等并发症。②随访疗效:6～12个月时,优714例(78.38%),良136例(14.92%),中57例(6.26%),差4例(0.44%)。13～24个月时,优691例(76.18%),良151例(16.65%),中65例(7.17%),差0例。65例出现阻塞,经再次PTA和支架置入,58例血流完全恢复,7例血流部分恢复但无对比剂滞留现象。25～36个月时,优681例(75.08%),良128例(14.11%),中98例(10.81%),差0例。98例肢体消肿不满意,行走后仍有胀痛感,但较术前显著好转,嘱患者长期穿血管弹力袜,未再介入性干预。结论急性下肢DVT的微创治疗,能更早解除静脉腔内栓塞,迅速恢复血流通畅,更大程度上保存静脉瓣功能,具有微创优势,并发症少,近、中期疗效显著。

Objective To discuss the clinical effect and value of minimally invasive therapy on lower extremity deep venous thrombosis（DVT）.Methods The clinical data of 911 patients with acute lower extremity DVT from April 1998 to December 2011 were analyzed retrospectively.There were 489 males,422 females;the age ranged from 23-86 years old with（58.72±11.95）years old.Five hundred and sixty-eight patients occurred on the left leg,343 patients on the right leg.There were 487 cases of central type,166 cases of peripheral type,258 cases of mixed type.All the patients were implanted inferior vena cava filter under local anesthesia,then inserted an 8-14 F catheter via the femoral vein of the affected limbs to suck mechanically thrombus.Five hundred and twenty-seven cases of iliofemoral vein thrombus were inserted into sheathing canal with the help of technique of guide wire griped.The guide wire could be plugged into femoral vein,even more far,with the help of sheathing canal.Following the guide wire,a diameter-10 mm balloon catheter was used to pull the thrombus to iliac vein,with the watching of DSA,so it could be sucked from iliac vein.Before sucking thrombus,a diameter-12 mm balloon was put into the confluence of inferior vena cava and iliac vein,in case of thrombus fall off with blood flow to block inferior vena cava.Results Among 911 patients,423 cases were only treated by sucking thrombus,275 cases sucking thrombus plus endovascular thrombolysis,91 cases sucking thrombus plus endovascular thrombolysis plus percutaneous transluminal angioplasty（PTA）,122 cases sucking thrombus plus endovascular thrombolysis plus PTA plus stenting,the average hospital stay was 7.5 d.① Discharge success rate：907（99.56%） cases were successful by interventional therapy,4（0.44%）cases were failed.Nine hundred and eleven patients were performed mechanical thrombus suction,which was 556 cases of gradeⅢ,142 cases of gradeⅡ,213 cases of gradeⅠ.Among 213 cases of gradeⅠ,there were 91 cases only underwent PTA treatment for economic reasons or advanced stage malignant tumors,122 cases underwent PTA plus stenting.The circumferences of affected limb and the differences of circumference of healthy and affected limbs knees above and below 15 cm at discharge were significantly smaller than those at admission（P0.01）.Twenty-seven cases underwent anticoagulation and thrombolytic therapy after operation,which occurred mild subcutaneous bleeding,gum bleeding,epistaxis,hematuria,and the symptoms were disappearance after adjusting drugs.All the patients did not appear to complications such as bleeding,vessel dissection.② Follow-up effective rate：After 6 to 12 months follow-up,there were 714（78.38%）cases of excellent,136（14.92%）cases of good,57（6.26%）cases of middle,4（0.44%）cases of poor.After 13 to 24 months follow-up,there were 691（76.18%）cases of excellent,151（16.65%）cases of good,65（7.17%）cases of middle;65 cases occurred restenosis that the PTA and stent placement was underwent again,blood flow of 58 cases completely restored,blood flow of 7 cases partly recovered,and the contrast agent didn’t retent.After 25 to 36 months follow-up,there were 681（75.08%）cases of excellent,128（14.11%）cases of good,98（10.81%）cases of middle;98 cases of limb swelling were not satisfied,and the patients still had a sense of pain after walking,but the symptoms obviously improved as compared with preoperative symptoms,the patients were advised to wear stretch socks with no further interventional therapy.Conclusions Minimally invasive therapy on lower extremity DVT can eliminate thrombus from venous cavity more early,restore the unobstructed flow instantly,preserve the function of venous valve in a greater degree.It has an advantage of minimally invasive,less complications,and notable clinic effect of short-term and medium-term follow-up.