手动机械性血栓碎吸治疗急性下肢深静脉血栓疗效

The clinical effectiveness of manually mechanical aspiration thrombectomy for the treatment of acute deep venous thrombosis of lower extremities

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8～14 F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(χ2=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(χ2=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(χ2=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。

Objective To investigate the anatomical distribution of acute lower extremity deep venous thrombosis （LEDVT）, and to evaluate the medium-term and long-term clinical effectiveness of manually mechanical aspiration thrombectomy in treating acute LEDVT. Methods The clinical data of 745 patients with acute LEDVT, who were admitted to the hospital during the period from April 1998 to March 2011 and were treated with manually mechanical aspiration thrombectomy, were retrospectively analyzed. According to the anatomical distribution of the thrombi displayed on venography, the patients were divided into group A （central type, n = 258） and group B （mixed type, n = 487）. Implantation of inferior vena cava filter under local anesthesia via the femoral vein of the healthy limb was performed in all patients, which was followed by the insertion of an 8 - 14 F catheter sheath to the femoral vein of the affected limb and through it manuallymechanical aspiration thrombectomy was carried out. Coexisting common iliac vein stenosis or occlusion was found in 287 patients, and percu- taneous endovascular angioplasty aswell as stenting had to be employed. All patients were followed up for 16 - 147 months with a mean period of （46 ± 39） months. The clinical effectiveness of the two groups was evaluated according to the clinical symptoms and venographie findings. The results were statistically analyzed by using t and X^2 tests. Results At the time of discharge, the differences of circumference of the healthy limbs and the affected limbs measured at 15 cm above and at 15 cm below the knee were （1.34 ± 1.07）em and （0.93 ±0.52）cm respectively in group A, and were （2.89±1.53）cm and （1.72 ± 0.89）cm respectively in group B. The differences were statistically significant when compared with those determined before the treatment （t = 19.46,24.13;t = 16.14,17.79;both P = 0.000）. During the follow-up period, the circumferences of the affected limbs measured at 15 cm below the knee reduced to （0.53 ±0.42）cm in group A and to （1.42 ± 1.35）cm in group B, and statistically significant difference existed between the two groups （t = 13.38,P = 0.000）. The incidences of edema, pigmentation, ulcer were 27.91%（72/258）, 13.18%（34/258） and 0% respectively in group A, and were 35.12% （171/487）, 22.59% （110/487） and 2.46% （12/487） respectively in group B. The differences between the two groups were statistically significant（X^2 = 3.98, 9.58 and 5.00 respectively, P = 0.046,0.002 and 0,02 respectively）. The venous patency rate and the normal valve function rate in group A were 96,51% and 78.68% respectively, while those in group B were 78.03% and 56.47% respectively. The differences between the two groups were statistically significant （X^2= 52.70 and 40.57, both P = 0.000）. Follow-up results showed that the excellent effectiveness was obtained in 92.64% of patients in group A and in 65.09% of patients in group B. The difference between the two groups was statistically significant （X^2 = 67.58, P = 0.000）. Conclusion The use of manually mechanical aspiration thrombectomy for acute LEDVT should be judged by the anatomical distribution of the thrombi. Manually mechanical aspiration thrombectomy carries best effectiveness for LEDVT of central type, while manually mechanical aspiration thrombectomy combined with systemic thrombolytic medication can improve the clinical effect for LEDVT of mixed type. （J Intervent Radiol, 2013, 22： 020-026）