多静脉入路腔内微创治疗下肢深静脉血栓和血栓后综合征单中心研究

Multi-approach endovenous techniques in the treatment of iliofemoral deep venous thrombosis and post- thrombotic syndrome

目的评价不同静脉入路的血管腔内技术在下肢深静脉血栓（DVT）和血栓形成后综合征（PTS）治疗中的应用价值。方法上海长征医院自2012年4月2013年5月共收治54例下肢DVT和PTS患者，其中下肢DVT39例，PTS15例；男33例，女21例，年龄45～72岁，平均年龄为（62±12）岁。所有患者均经彩色多普勒血管超声和（或）数字减影血管造影检查明确诊断。根据下肢深静脉顺行静脉造影检查情况，选择性采用4种静脉入路行导管直接溶栓术（CDT）、经皮穿刺球囊扩张（PTA）和支架成形术，其中经股静脉入路12例、胭静脉入路27例、大隐静脉入路9例、小隐静脉入路6例。术后随访内容包括患肢检查、凝血功能检测和测定国际标准化比值（INR），并行患肢彩色多普勒血管超声和（或）静脉造影检查。结果1例PTS患者因导线和导管无法穿过阻塞的髂静脉而导致治疗失败；余53例患者行介入手术治疗均获成功，治疗成功率为98．1％（53／54）。行CDT治疗的39例DVT患者的深静脉管腔通畅情况为3级15例（38．5％），2级19例（48．7％），1级5例（12．8％）；治疗后19例患者静脉造影检查示深静脉狭窄，同期行PTA治疗，其中15例经球囊扩张后狭窄解除不明显的患者再行支架成形术，共植入支架15枚。14例PTS患者行PTA、支架成形术，共置入支架18枚。53例患者共植入自膨式支架33枚，均经静脉造影检查示狭窄段解除，静脉通畅，且支架在位良好。5例患者行CDT后出现穿刺处或牙龈少量渗血，溶栓治疗结束后自行停止；1例患者行CDT后出现腹股沟穿刺点血肿，行加压包扎和溶栓药物减量后血肿逐渐消退。53例治疗成功的患者随访3～15个月，平均随访时间为（8．2±1．4）个月。随访期间无1例患者死亡和发生致死性肺动脉栓塞。彩色多普勒血管超声或静脉造影检查示血管通畅良好51例；1例左下肢DVT患者行CDT后2周左下肢小腿DVT形成，调整苄丙酮香豆素钠的剂量并予继续抗凝治疗1个月后复查血栓消失；1例PTS患者行支架植入术后1年发生支架远端狭窄，但无临床症状，继续随访观察。结论多种静脉入路为DVT和PTS的微创治疗提供了丰富的入路选择，可根据患者的病情选择合适的入路。胴静脉入路较为常用。

Objective To evaluate the value of multi-approach endovascular techniques in the treatment of iliofemoral deep venous thrombosis （DVT） and post-thrombotic syndrome （PTS）. Methods Fifty-four patients with 54 symptomatic limbs were identified by duplex scan and/or digital subtraction venography. Vascular access into the affected deep vein was achieved through four various approaches according to the evaluation of venography： transfemoral, transpopliteal, transankle （great saphenous vein [GSV] and small saphenous vein）. Thirty-nine patients received catheter-directed thrombolysis （CDT）, 24 patients with prartial lysis thrombosis and 15 PTS patients received balloon dilatation, and self-expanding stent was placed in 33 cases. All patients were followed for 3- 15 months. Clinical follow-up by the referring physician included physical exam, international normalized ratio （INR）, color duplex Doppler ultrasound （US） and（or） venography. Results The technical success rate was 98.1% （53/54）in our study. Four various approaches according to the evaluation of venography included., transfemoral （12/54）, transpopliteal （27/54）, transankle （great saphenous vein, [9/54] and small saphenous vein [6/54]）. In a total of 39 patients who received CDT, complete lysis was achieved in 15 cases （38.5%）, and partial lysis was achieved in 24 （61.5%）. The patients who had residual stenosis or PTS received balloon dilatation. Self-expanding stents were placed in 33 cases. The 53 patients were followed up for 3- 15 months, with a mean of （8.2 ±1.4） months. There was no perioperative mortality or symptomatic pulmonary embolism during follow-up. Color ultrasound or vein angiography showed that 51 cases had patent blood vessels. A patient with low limb DVT received CDT and 2 weeks later he developed deep venous thrombosis, which was resolved one month later after anti-coagulation treatment; another PTS patient developed distal stent restenosis one year after stenting, with no clinical symptom and was still followed up. Conclusion The results of this study indicate that the multi-approach endovascular technique is a safe and effective treatment of iliofemoral DVT and PTS. Every approach has its merits and the selection mainly depends on the specific circumstance of the patient. The popliteal vein approach is more widely used.