D-二聚体监测在治疗急性髂股静脉血栓形成中的临床价值

The clinical value of monitoring plasma D-dimer concentrations in treating acute iliofemoral deep venous thrombosis

目的通过动态监测急性髂股静脉血栓形成抗凝、溶栓治疗过程中血浆D-二聚体值的变化,结合影像学表现,评价其临床价值。方法 2010年3月至2012年12月收治80例急性髂股静脉血栓形成患者,按治疗方法不同分为单纯抗凝组(A组)20例、置管溶栓组(CDT,B组)40例和顺行性溶栓组(C组)20例。为防止致命性肺栓塞(PE)发生,B、C组患者溶栓前均行下腔静脉滤器置入术。溶栓药物均采用尿激酶,总量均为50万u/d。用免疫比浊法测定三组患者治疗过程中各时间点(治疗前,治疗开始2、4、6、8 d,治疗结束时)的D-二聚体值,同时计算各时间点血栓溶解体积及血栓清除率,采用统计学方法评判D-二聚体的变化规律及D-二聚体与血栓溶解体积、血栓清除率的关系。结果 A、B、C组患者治疗前的D-二聚体均值分别为(0.83±0.21)μg/ml、(0.83±0.28)μg/ml、(0.82±0.20)μg/ml,治疗后分别为(0.30±0.98)μg/ml、(0.31±0.12)μg/ml、(0.33±0.11)μg/ml,与正常临界值(0.5μg/ml)比较,差异均有统计学意义(P<0.05)。三组间治疗前D-二聚体值比较差异无统计学意义(P>0.05),治疗结束时比较差异亦无统计学意义(P>0.05),其余各时间点三组间两两比较差异均有统计学意义(P<0.05)。三组治疗过程中各时间点血栓清除率两两比较差异有统计学意义(P<0.05)。从治疗全程看,D-二聚体值与血栓清除率无相关性(Pearson系数=0.028,P=0.538)。B、C组第2天的D-二聚体峰值与对应时间点血栓溶解体积呈直线相关关系(R2=0.970,P=0.000)。B、C组D-二聚体峰值与治疗结束后血栓清除率呈正相关(Pearson系数=0.547,R2=0.299,P=0.000)。B、C组在治疗第8天前有24例(40%)D-二聚体值已降至正常值范围,结合造影图像比较,其中5例在治疗第8天前血栓清除率已达100%,其余19例继续溶栓后血栓清除率较前(D-二聚体值降至正常值时所对应的血栓清除率)无明显变化。在第8天前未降至正常范围内的36例(60%),继续溶栓后血栓清除率继续增加。结论 D-二聚体的变化有助于及时发现再发血栓形成,对治疗效果起到预测作用,同时能为停止溶栓治疗提供参考依据。

Objective To assess the clinical value of monitoring plasma D-dimer concentrations by dynamically observing the changes of plasma D-dimer concentrations during the whole course of anticoagula- tion and thrombolysis for acute iliofemoral deep venous thrombosis as well as by analyzing imaging findings. Methods During the period from March 2010 to December 2012, a total of 80 patients with acuteiliofemoral deep venous thrombosis were admitted to the hospital. According to the therapeutic method used, the patients were divided into simple anticoagulant group （group A, n = 20）, catheter- directed intrathrombus thrombolysis group （groupB, n = 40） and anterograde thrombolysis via peripheral vein group（group C, n = 20）. In order to prevent the occurrence of fatal pulmonary embolism, preoperative implantation of inferior vena cava filter was employed in the patients of group B and C. Urokinase, as the thrombolytic drug, was used in all patients with the dose of 500,000 U/d. In all patients the D-dimer concentration was determined by immuno-turbidimetric method before the treatment, at 2, 4, 6 and 8 days after the treatment as well as at the end of the treatment. The dissolution volume and the clearance rate of the thrombus were measured at the same time. By using statistical method, the changing regularity of D-dimer concentration was observed and the correlation between the D- dimer concentration and the dissolution volume as well as the clearance rate of the thrombus was analyzed. Results The preoperative D-dimer concentration of group A, B and C was （0.83 ±0.21 ） μg/ml, （0.83 ± 0.28） μg/ml and （0.82 ±0.20） μg/ml respectively. The postoperative D-dimer concentration of group A, B and C was （0.30±0.98） μg/ml, （0.31 -＋ 0.12）μg/ml and （0.33 ± 0.11） μg/ml respectively. Compared to the normal 0.5 μg/ml borderline, the differences were statistically significant for all three groups （P 〈 0.05）. The differences in D-dimer concentration determined before the treatment as well as at the end of the treatment among the three groups were not significant （P 〉 0.05）. Significant differences in D-dimer concentration obtained at other points of time, i.e. at 2, 4, 6 and 8 days after the treatment, existed among the three groups （P 〈 0.05）. In each group, the D-dimer concentrations obtained at different points of time during the therapeutic course were significantly different between each other（P 〈 0.05）. In the whole therapeutic course, the D-dimer concentration bore no relationship to the clearance rate of the thrombus （Pearson ratio = 0.028, P = 0.538）. In group B and C, at the second day of the treatment the peak value of D-dimer concentration carried a linear relationship to the dissolution volume of the thrombus determined at the corresponding point of time （R2 = 0.970, P = 0.000）. The peak value of D-dimer concentration had a parallel relationship with the clearance rate of the thrombus determined after the treatment in both group B and C （Pearson ratio = 0.547, R2 = 0.299, P = 0.000）. Before the eighth day of the treatment, in 24 patients （40%） of group B and C the D- dimer level decreased to tire normal range. RefelTing to angiographic findings, tlre clearance rate of the thrombus was already up to 100% in 5 cases before the eighth day of the treatment, and in the remaining 19 cases the clearance rate of the thrombus showed no obvious further improvement with the continued thrombolysis. In the 36 patients （60%）, whose D-dimer level did not decrease to the normal range before the eighth day of the treatment, the clearance rate of the thrombus continuously increased with the thrombolysis. Conclusion The determination of the changes in plasma D- dimer concentration in the course of anticoagulation and thrombolysis therapy for acute iliofemoral deep venous thrombosis is very helpful in promptly detecting the recmTent thrombosis, in predicting the therapeutic effect as well as in providing reliable reference to end the thrombolvsis theraDv.（J Intervent Radiol. 2013. 22： 464-469）